How would you like to have your own patient mortality, morbidity, and complications made public for any potential patient to see? And then how would you feel about adding potential disclosure, any disciplinary actions, CME compliance, infection rates, compliance with rules and regulations, and outcome.

Well, we are slowly going in that direction and recent Joint Commission (JC — no longer called the JCAHO) directives are rapidly moving us there. Don’t forget that anyone can currently look you up on the Medical Board of California site and see if you have had any investigations or actions by the Medical Board. Look yourself up if you have not already done so at www.mbc.ca.gov/Choose_Doctor.htm. Also remember that many states have already published on the Internet physician specific mortality and complication rates for various procedures, for example, cardiac surgery in New York State. Can the rest of us be far behind?

Here are the new rules: Starting in January 2008, every medical staff in the United States will have to collect physician specific data regarding the six core competencies as defined by the JC, the American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education (ACGME). These are the same six core competencies that we are already using to rate every resident. Detailed descriptions of how to use these core competencies and the data elements that can be used are currently on the ACGME and ABMS websites.

The six core competencies and a brief description are:

Patient Care:
Practitioners are expected to provide patient care that is compassionate, appropriate, and effective for the promotion of health, prevention of illness, treatment of disease, and care at the end of life.

Medical/Clinical Knowledge:
Practitioners are expected to demonstrate knowledge of established and evolving biomedical, clinical, and social sciences, and the application of their knowledge to patient care and the education of others.

Practice-Based Learning & Improvement:
Practitioners are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices.

Interpersonal & Communication Skills:
Practitioners are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of health care teams.

Professionalism:
Practitioners are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession, and society. (The Joint Commission considers diversity to include race, culture, gender, religion, ethnic background, sexual preference, mental capacity, and physical disability.)

System-Based Practice:
Practitioners are expected to demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care.

We have recently purchased an expensive software program called MIDAS that will integrate data elements from various sources and produce various physician-specific reports. The information includes reports used for re-credentialing by your service chief and personal “report cards” (probably sent to you twice a year). This program is scheduled to be running at Stanford by this summer.

Each clinical service at Stanford will be asked to generate data metrics that can be used for quality improvement and physician-specific peer review. These data elements will be of two different types:

1. Rate-Based Indicators: These are defined as occurrence rates for specific indicators (for example, infection rates or length of stay for each physician). Thresholds for excellent and acceptable rates will be determined. Your rate will be plotted on a graph with your peers’ rate and benchmark values for comparison purposes. If your rate falls below the defined acceptable range, some action or investigation will be taken to help you improve this performance.

2. Rule-Based indicators: These are defined as compliance with specific rules of the medical staff, safety indicators, or quality indicators (for example, avoiding unapproved abbreviations). In the case of these Indicators, you will either be in compliance or not in compliance (Yes or No). Actions would be taken to correct your compliance with these rules or indicators.

Each of these indicators will be tied to one or more of the six core competencies listed above.

The term “Ongoing Professional Practice Evaluation” (OPPE) has been defined to encompass the entire process described above. Every physician will be subjected to the OPPE process on a continuous basis with periodic reports being generated.

Information for the OPPE can be acquired through:

1. Monitoring clinical practice patterns through process and outcome monitoring

2. Periodic chart review

3. Direct observation of procedures and patient care

4. Simulation exercises

5. Proctoring

6. Discussion with others involved in the care of the patient including consulting physicians, assistants at surgery, nursing, and administrative personnel

Some examples of the type of data that can be collected are:

1. Morbidity and mortality data

2. Operative and other clinical procedures and their outcomes

3. Requests for tests and procedures

4. Practitioner’s use of consultants

5. Length of stay patterns

6. Transfusion practices

7. Infection rates

8. Other relevant criteria as determined by the Medical Staff

A second evaluation process has been defined by the JC. This is the “Focused Professional Practice Evaluation” (FPPE), which is indicated if any question arises regarding a new or currently privileged practitioner’s ability to provide safe, high quality care. The Medical Staff would do the following, using the FPPE:

1. Evaluate practitioners without current performance documentation at the organization (new applicants, for example)

2. Evaluate practitioners in response to concerns regarding the provision of safe, high quality patient care (concerns that arose during the OPPE)

3. Develop criteria for extending the evaluation period

4. Communicate to the appropriate parties the evaluation results and recommendations based on results

5. Implement changes to improve the practitioner’s performance

Now, you might ask whether you will be able to see all the data that is being collected on a continuous basis that impacts your personal report card. At this point the data is not being published, but personally I see that possibility in the wind. Respective of whether the data will be made public, you might also feel a bit nervous about the process, since the data collection might not really accurately describe your practice patterns. Another good question is whether you will have the right to eliminate or veto certain data if you feel they are not correctly attributed. And even another good question that I have heard is “If we have to do this, why don’t the nurses and lawyers have to do it also.”

The answers to these questions are yet to be determined since we are not currently using these processes. One thing that certainly can be said, however, is that the practice of medicine will never be the same after this process starts. Whether the process will actually improve patient care and patient safety over the long run is still questionable, but anything that we can do which might improve care — not just make us look good — is surely worth doing. Let’s see.