Corporate Compliance

Use indicators to evaluate physician performance

Healthcare Auditing Weekly, October 5, 2003

Quality of care ranks as one of the government's top focus areas for this year. The Office of Inspector General's (OIG) latest focus is on physician privileging, which affects quality of care. As the OIG investigates quality oversight and privileging, hospitals should incorporate similar reviews into their compliance plans. Start by taking advantage of your organization's peer review process.

Your peer review panel should review the following indicators when evaluating physician performance:

·  Rule indicators identify a practice or general rule of medicine that physicians should follow. If a physician does not follow these rules, he or she should be educated about the standard of practice, even if a patient has not been harmed. This feedback process allows you to encourage physicians to follow established best practices.

·  Significant event indicators refer to cases that are complicated and therefore most easy to identify. These indicators are most often examined during the traditional peer review process and require chart review.

·  Rate indicators can be used to determine whether a physician's rates fall within the norm or best practice area. For example, you can gather very little helpful information from examining only one obstetrician's (OB) rate for caesarian sections. Instead, the peer review panel should compare the individual practitioner's rate against those of his or her peers. If the OB's rate falls within an acceptable range compared to other OBs on staff, there is no need to review his or her charts.

For more on ensuring quality of care, order the book "Compliance Troubleshooter: Tackling the Top 10 Compliance Challenges." This book features information on the False Claims Act, outlier payments, quality of care, economic and traditional credentialing criteria, the Emergency Medical Treatment and Labor Act (EMTALA), nonphysician practitioners, billing and documentation, outpatient prospective payment system, the Stark physician self-referral law, and inpatient compliance issues. Click here for more information or to order.


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