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What to include in physician feedback reports

Medical Staff Leader Connection, June 21, 2006

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Since there is currently no standard performance feedback report from which to work, many healthcare organizations find themselves wondering exactly what types of information to include. Although each organization must decide for itself what physician data it will continually monitor, all reports should contain at least the following basic elements:

• provider data
• comparative data
• explanation of the data 

Within elements one and two above, organizations must make a distinction between two types of data-activity data and performance data. The two data types are often confused, which diminishes the usefulness of feedback reports.

Activity data refer to how much work (e.g., admissions, procedures, image interpretations) the physician completes within a given time period. Performance data indicate how well the physician does his or her work (e.g., clinical outcomes, patient satisfaction ratings).

Unfortunately, in an attempt to impress JCAHO surveyors with long, seemingly detailed physician reports, hospitals often lump activity data and performance data together, which makes it difficult to determine a physician's true performance. For example, activity data can show how many deliveries an obstetrician performed in a year. But what does that data really communicate? Activity data become performance data only when an organization approves and implements specific privileging criteria that state physicians must perform a minimum number of procedures within a certain time frame.

Consider, for example, coronary artery bypass grafts (CABGs). If a hospital determines that a cardiovascular surgeon must perform 100 CABGs a year to maintain his or her privileges because that number of procedures is statistically linked to better outcomes, it should include that activity in the physician's performance report.

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