Peer review tip: Select strong rule and rate indicators

Today’s Q&A-based quick tip comes from the webinar “Benchmarking Your Peer Review Program: Applying Best Practices and Removing Barriers to Success.” During this program, expert speaker Robert J. Marder, MD, provides best practices for moving to a multispecialty peer review model and improving the overall culture surrounding clinical performance evaluation.

Q: Can you provide some selection strategies regarding rule and rate indicators?

A: The most common rule indicators are going to be your core measures where the physician is responsible for something. Rule indicators are an event, and we are looking at how well they were complied with, and when they are not, you want to respond quickly to the practitioner to let them know they didn’t comply. You don’t want to wait six months for an OPPE report or two years for a credentialing process to let them know they could have done something better. So you send them a quick letter and say, “You missed this measure,” and you set targets around how many is too many.

Core measures have been very likely rule indicators because people are looking at them individually for the physicians. They are abstracting that information, and often sending out communications about them in some form already. There are all kinds of other rule measures. They could be related to policy compliance like handwashing, surgical timeouts, or critical processes, or H&P not present within 24 hours on the chart.

There are a range of things that can be rule measures, and the only criteria is it is something that the medical staff feels is important and is in the bylaws or is a generally accepted practice, or a national required evidence practice. It is also something in general you have reasonable compliance with and you are just trying to pick out the people who occasionally miss. If you have 30% of the medical staff not complying with something, you are going to be sending out zillions of letters, and you should probably start with a rate and some education first. It is for those people who miss one or two or three or five a year, and you are trying to get them down to zero or one or two a year.

Rate indicators are basically numerators and denominators, such as percentages and indexes. A lot of people are using risk-adjusted mortality indexes, and they are using complication rates or rates of compliance with protocols. Those are what you use for rates. The issue is not whether or not something happened, but how frequent. You have to set targets for rates as you do for rules, and I would always recommend a target for acceptable performance and a target for excellent performance.

Some of your rules and rates will be general for the medical staff. For example, you might use mortality rates for the whole medical staff in every specialty, but they have their own cases in their rate. Some may be very specific, like the use of a prophylaxis in orthopedics; that might be a rule indicator or a rate indicator for orthopedic surgeons if they have approved a certain protocol.    

Source: “Benchmarking Your Peer Review Program: Applying Best Practices and Removing Barriers to Success”