How and why to create practitioner performance reports
This week, CRC Daily dives into the world of medical staff and physician leadership. Today’s excerpt from The Medical Executive Committee Manual arms MEC members with an easy step-by-step process for developing effective practitioner performance reports.
10-Step Process for Creating Practitioner Performance Reports
Use the following 10-step process for creating effective practitioner performance feedback reports:
- Educate medical staff leadership to understand:
- The importance of quality improvement (QI)
- The basis for creating a nonpunitive approach to improving practitioner performance
- The need for medical staff leaders to own their role in improving care provided by the medical staff
- Appoint a task force (done by the MEC) to create a practitioner feedback report system that includes:
- The importance of QI
- Principles of report use
- Expectations of leaders and individual physicians for data interpretation
- Resource needs
- Ongoing responsibilities
- Inventory and evaluate all current indicators by performance dimension and type, ensuring that you:
- Create a comprehensive list
- Keep only those indicators that add value
- Create indicators for priority areas lacking measurement
- Determine benchmarks or targets that include:
- Internal data
- National best practices measures
- A risk-adjusted data strategy
- Design the process for effective distribution and input by ensuring that it includes:
- A user-friendly format
- Pilot-test versions for medical staff input
- Resource limitations
- A process for medical staff feedback input
- Identify the necessary resources for current and future versions, including:
- Data systems
- Personnel
- Obtain medical staff approval, making sure that:
- The MEC approves the recommended approach
- The board receives education about the process
- Educate practitioners about the initial report by explaining the:
- Principles of development
- Basis for selecting content
- Interpretation of format
- Data limitations
- Process for feedback and response (e.g., academic detailing)
- Summarize the policies and procedures in a medical staff quality manual and include the defined mechanism and responsibility for at least annual review and update
- Distribute the initial report and immediately:
- Coordinate the resources
- Listen to the feedback
- Plan the next version
In the practitioner performance feedback report, it makes sense to organize the data according to the expectations of your organization’s chosen competency framework.
Each data element should be identified as a rate, rule, or review indicator. The targets for acceptability and excellence should be with the practitioner’s personal data. The target for acceptability is that basic level that defines competence versus “needs improvement.” The target for excellence gives a goal that all practitioners can strive to reach. It’s easy to interpret the report when there are three categories of performance: excellent, acceptable, and needs improvement. You can enhance the report with the use of color coding: green for excellent, yellow for acceptable, and red for needs improvement.