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Focusing Measures for Performance-Based Privileging of Physicians on Improvement

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Background: The Joint Commission requires ongoing professional practice evaluation—or what Cincinnati Children's Medical Center (CCHMC) has termed performance-based privileging (PBP)—for the medical staff reappointment and reprivileging process.

Building a System: CCHMC is a 475-bed academic medical center affiliated with the University of Cincinnati College of Medicine. Medical staff members are reappointed every two years, with divisions having staggered reappointment dates throughout the two-year cycle. In 2004, CCHMC devised a model in which the 38 divisions retained responsibility for development of measures; collection, maintenance, display, and monitoring of individual provider performance data; and sharing of data with providers, while medical staff services retained responsibility for ensuring compliance with timelines, technical assistance related to measure development, and the collection and display of data. Each clinical division developed a preliminary list of measures. The original PBP process was tested in 2005 and has been revised several times in response to division feedback.

Discussion: Members of all 38 clinical divisions have now been reappointed to the medical staff at least twice using measures that have become more robust, meaningful, and outcome oriented. Many measures support organizational or divisional quality imoprovement aims, are evidence based, or build on initiatives sponsored by external bodies and specialty societies. Examples of measures are shared via the PBP intranet, personal consultations, and an annual provider performance improvement conference. Yet, challenges remain, such as the absence of real-time, provider-specific, risk-adjusted data and the difficulty of attributing provider-specific outcomes when most complex and high-risk care is managed by a team.

Document Type: Research Article

Publication date: December 1, 2008

More about this publication?
  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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