Tip of the week: Set a threshold for the medical staff to approach a physician regarding a poor outcome on a performance feedback report

Should follow up occur if a single indicator is below the acceptable level, or should it occur after the physician has not improved two reporting cycles in a row? Many medical staffs feel that to give a physician the opportunity for self improvement, it is appropriate to follow up after two sequential periods of unacceptable performance, unless the physician requests assistance understanding the data. Another option is to have a “gentler” follow up after a single reporting period and a more aggressive approach after two periods of unacceptable performance. Some medical staffs have also created a rule that states that if any competency category has more than one or two indicators below acceptable levels in a single period, the medical staff will follow up. The key is to define your approach in a policy so that each department handles the data consistently.

This week’s question and answer are from Measuring Physician Competency: How to Collect, Assess, and Provide Performance Data by Robert Marder, MD, CMSL; Mark Smith, MD, MBA, FACS; Marla Smith, MHSA; and Vicky Searcy, CPMSM, now available at a reduced price.