Medical Staff

Ask the expert: Who should set physician performance targets?

Medical Staff Leader Connection, November 4, 2009

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When determining what data to collect to evaluate physician competence, it is critical that the medical staff sets targets for excellent and acceptable performance. This is generally done by the medical staff quality committee, which asks each department for recommendations for specialty-specific indicators. The medical staff quality committee then determines as a whole the non-specialty related measures (i.e., appropriateness of blood usage or inpatient complaints). Then, these recommendations are sent to the medical executive committee (MEC) for approval. This way, when physicians fall outside the targets and begin to challenge them, medical staff leaders will be able to explain that these are medical staff targets, not those of the quality office or administration.

This week’s question and answer are adapted from Effective Peer Review: A Practical Guide to Contemporary Design, Second Edition, by Robert J. Marder, MD, CMSL; Mark A. Smith, MD, MBA, CMSL; and Richard A. Sheff, MD, CMSL.



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