When does marginal performance become incompetence?

It’s time to take stock. Most hospitals accredited by The Joint Commission are making progress at implementing ongoing professional practice evaluations (OPPE) and focused professional practice evaluations (FPPE), though considerable challenges remain. Hospitals not accredited by The Joint Commission still need to meet the CMS requirement for an effective quality monitoring and improvement process, so they, too, should be making progress achieving more effective peer review. The progress being made is creating a new set of challenges. For example, how should medical staffs use the data now being collected through peer review during the reappointment process? Specifically, when does marginal performance become incompetence that warrants the medical staff restricting a physician’s privileges?

Let’s clear up one potential misunderstanding at the outset. If you have identified that a provider’s performance is putting patients or the hospital at risk, is it appropriate to wait until that provider’s next reappointment date to take action? Of course not.  But does this mean that every time a physician’s performance is subpar, the medical staff should restrict or rescind their privileges? That doesn’t make sense either. So how should medical staffs approach the challenge of marginally performing physicians?

Many of you are familiar with the Physician Performance Pyramid utilized by The Greeley Company. The bottom layer of the pyramid is labeled "Appoint excellent physicians." The next level is "Set, communicate, and achieve buy-in to expectations," while the next is "Measure performance against expectations." The next layer is "Provide periodic feedback," and the layer above that is "Manage poor performance." Finally, at the top of the pyramid, is "Take corrective action." The idea is that if you do the things at the bottom of the pyramid well, you will rarely have to engage in the activities at the top of the pyramid.

When data generated by peer review reveals a problem with a provider’s performance, the first step is to provide feedback to the provider so he or she has a chance to self correct. If he or she does not self correct, then it is appropriate to move into the “manage poor performance” layer of the pyramid. This layer of the pyramid is a series of escalating interventions. The first intervention is generally collegial, the next a little less collegial, and the process ends with a final warning. The final warning should make clear that either a single episode (such as with disruptive behavior) or persistent poor performance will result in the medical staff restricting or terminating his or her privileges. This is a logical, collegial, and effective process for enhancing physician performance and achieving higher levels of physician accountability.

Despite using this methodology, a thorny problem remains. How will the medical staff determine when a provider crosses the line from marginal performance to incompetence? This is one of those choices that is not black or white. (Please see the May 20  and July 15 articles about this topics for a discussion of what to do when credentialing decisions aren’t clear.)

At The Greeley Company, we have long recommended that medical staff leaders establish targets for performance for each peer review indicator that is being measured. In fact, we have found that establishing two targets, a good enough target and an excellent target, is a best practice. As long as the physician is above the good enough target, there is no need to move to the “manage poor performance” layer of the Pyramid. Having an excellent target causes many physicians, who are already wired to be overachievers, to aim for exceeding the excellent level target, which is what continuous performance improvement is all about. This approach has proven very helpful in shifting a medical staff culture away from a punitive, “gotcha” approach to peer review to one of continuous performance improvement. 

Sometimes, medical staffs must take this process one step further. What if a physician’s performance continues to not meet the good enough target? How long will your leaders work with this physician through the process of managing poor performance before the medical staff concludes a physician is not meeting the minimal level of competency required to maintain his or her privileges? In most circumstances, this question falls into a gray area. Rather, it requires significant dialogue and development of consensus among medical staff leaders before they decide to take corrective action to take away some or all of a provider’s privileges.

Are there situations that call for a different approach? Is there some level of performance below the good enough target at which the medical staff would have to conclude a physician is not competent? Let’s consider a fairly straightforward medical staff indicator, such as perforation rate on colonoscopies. A competent practitioner performing colonoscopies is likely to have a perforation rate in the range of 0.01% to 0.05%. If a provider has a perforation rate of 0.1%, is this good enough? What if their rate was 1%? What if their rate was 10%? At what point would a medical staff conclude that this is no longer marginal performance but has moved to the level of incompetence and the provider should not be doing these procedures?

Answering such questions is challenging at best. Yet these questions go to the heart of the effort to raise the bar in privileging to make it a truly “objective, evidence-based process,” as Joint Commission standard MS.06.01.01 requires. This is a worthy goal, but it will require physicians to struggle to establish a basis for differentiating between marginal performance and incompetence.

Richard A. Sheff, MD, CMSL, is executive director and chair at The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.