Medical Staff

Create a performance improvement culture

Medical Staff Leader Insider, August 24, 2005

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Dear Medical Staff Leader:

Physician performance feedback reports are only effective when the medical staff adopts a culture that accepts the validity of such reports and acts on them. Medical staff leadership must support the implementation of effective data collection systems and secure medical staff buy-in. To create a culture that accepts ongoing performance feedback data, deal with the issue of how the data will be used before distributing the reports. Remind the medical staff that

  • performance data are not only for reappointment-such data are part of an ongoing effort to improve the care provided by individuals and by the organization as a whole. Moreover, not all performance feedback data will be used for reappointment. For example, resource data that could be considered economic credentialing should be clearly labeled as "not for use in reappointment."
  • performance data will be provided systematically and in a timely manner to the staff.
  • the distribution and discussion of performance feedback data will be part of a collegial and helpful process. Reports are not designed simply to identify areas of poor performance and assign blame. In fact, data that vary from the target rate aren't always indicators of poor performance. These variations should prompt the organization and the physician to ask why the individual data differ. Also, physicians should be encouraged to express any concerns or questions they have about data.
  • performance data will recognize both excellence and opportunities for improvement. Praise excellent performance in public, but comment about lapses in performance in private. Never display to the entire organization performance data that includes each physician's name. If a physician's performance data vary significantly from target rates, work with the physician to individually make improvements.

    However, don't wait for the culture to change before distributing performance feedback reports. Distributing the reports is part of changing the culture. We have found that having a one-year grace period, in which reports are distributed but no actions are taken, allows physicians time to understand the data.

    That's all for this week!

    All the best,

    Robert Marder, MD

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