Peer Review Monthly: No data is useful data
When defining indicators to measure physician competence, medical staffs have stumbled on the question: Is “zero” really data? The answer is yes—with some caveats that depend on the type of indicator and the nature of the physician activity.
Indicators measure a patient event or practice activity. The way to decide if a lack of data is meaningful is to ask these two key questions:
- Was there an opportunity for Dr. X’s patients to have that event?
- Did Dr. X have the opportunity to perform that activity?
These events or activities can be related either to a specific privilege or the physician’s overall participation in patient care.
Examples of privilege-specific activities include unexpected deaths related to a procedure or the core measure related to congestive heart failure that requires physicians to order specific medications at discharge. Examples of more general participation in patient care include compliance with blood use criteria, infection control precautions, or the medical staff’s code of conduct.
When using privilege-specific indicators to measure physician competence, the medical staff can include “zero data” in the physician’s profile if the physician has no negative events or compliance failures while practicing those privileges. For general care indicators, the medical staff can include zero data in the physician’s profile if the physician provided care in the hospital and/or interacted with hospital staff and did not have any non-compliance issues and did not receive complaints from patients or staff.
However, if an indicator does not apply to that physician’s privileges or specialty, the medical staff should not include zero data on that physician’s profile. This means that profiles need to be specific to each physician. For example, it makes no sense to include unexpected mortality or blood use indicators on a pathologist’s profile.
If a physician has privileges but does not exercise them, the medical staff should not include those privilege-specific indicators on the physician’s profile. For example, if the physician has privileges for vascular surgery but has not performed any vascular procedures during the profile period, the physician’s profile cannot indicate zero mortalities because there was no opportunity for patient mortalities. In those cases, the medical staff should explore the physician’s non-use of the privilege to see if he or she should maintain them.
Robert Marder, MD, CMSL
Vice president
The Greeley Company