Review acute care events to identify improvement opportunities
The movement of care from the inpatient setting and the rise of clinically integrated networks (CIN) have resulted in an increasing need to push the evaluation of physician quality into these new territories. The challenge is to understand how to systematically measure and evaluate physician competency when care is provided outside the hospital or when physicians are accountable to an organization apart from the medical staff.
The data source issue begins with what you can obtain from the hospital via a sharing agreement and what you can obtain from the ambulatory care setting that would provide a complete picture of a physician’s performance. Because the options are similar regardless of whether the entity is an employed ambulatory care group, independent group practice, or CIN, for purposes of this discussion, we will refer to any of these as the “organization.”
The presumption in the ambulatory care setting is that fewer issues would rise to the level of severity requiring detailed case review like those in the acute care setting. However, if the organization is concerned about the total care provided by its practitioners, it needs to review the acute care events as well to identify improvement opportunities. In addition, there are some issues detected in the ambulatory care that would warrant the case review approach, such as an office-based procedure significant complication or a missed diagnosis or misdiagnosis resulting in patient harm, like an unplanned emergency department visit or hospital admission. Thus, the organization’s peer review committee needs to define a set of review indicators with inclusion and exclusion criteria to ensure fairness in case selection that address both the acute and ambulatory care settings and then apply a similar approach to the case review process.
In addition to the hospital identifying events for review, once the peer review committee selects its ambulatory case review indicators, it needs to establish a mechanism to identify these cases. Typically, this will come from referrals from clinic staff and patient complaints. However, if the ambulatory care EMR can be mined to identify such events, it will increase the effectiveness of the case identification.