Physician performance reporting evolves with greater transparency
St. Luke’s Hospital & Health Network, Bethlehem, PA, is a nationally recognized, regional, integrated network of nonprofit hospitals, physicians and other health-related organizations providing care primarily in Lehigh, Northampton, Carbon, Schuylkill, Bucks, Montgomery, Berks and Monroe counties in Pennsylvania. St. Luke’s strives to provide compassionate, excellent quality and cost-effective healthcare to the residents of the communities we serve. The network includes four hospitals encompassing 734 licensed beds, more than 44,800 annual admissions, 1,200 physicians, 6,800 employees and 1,000 volunteers
Situation:
St Luke’s began its physician performance reporting in the late 1990s as a result of The Joint Commission’s then-new requirement to develop a mechanism to demonstrate physician competency. Department chiefs received the information and were responsible for reviewing it with individual physicians. Physician performance reporting has evolved as an integral part of the organization – a top priority for physicians and other members of the St. Luke’s interdisciplinary team. It’s not just about physician profiles. It’s about a quality process that is completely transparent and focused on what the organization is most proud of – delivery of the highest level of healthcare possible.
Solution:
- Physician performance reporting and credentialing is an integrated process. Gathering the information at St. Luke’s is a joint effort by the Quality, Decision Support System and IT staffs. It includes physician activity around procedures, medical records, utilization, continuing medical education, meeting attendance, quality assurance review and outcomes, specifically severity-adjusted length of stay and mortality.
- Physician performance information is longitudinal and updated quarterly. St Luke’s scorecard uses information from Premier ClinicalAdvisor® for benchmark data and individual project data.
- At reappointment, data are sent to department chiefs for review and follow-up. A Web site enables physicians to access credentialing and performance information.
Results:
- The paradigm shifted about two years ago – from the medical staff being very protective of performance information to its becoming another area like any other in our organization whose data is transparent. Department chiefs’ engagement and leadership have been critical success factors.
- An integral part of St. Luke’s overall performance reporting, physician performance is measured routinely using a network scorecard, the basis of the organization’s quality agenda. When a variance from a benchmark is noted in the scorecard, data are analyzed to determine contributing factors and identify areas for improvement.
- Quality is one of St. Luke’s five corporate focuses. The IDN uses national benchmarks to focus on clinical process improvements and is committed to appropriately sharing its outcomes. The goal is to perform in the top decile in national pay-for-performance programs
"We use ClinicalAdvisor for benchmark data and individual project data. If we
want to look at how our physicians are ordering telemetry monitoring as compared
to other hospitals, we will look at that. We use ClinicalAdvisor to see how our
clinical practice compares to other hospitals."
Donna Sabol
Vice President of Quality/Chief Quality Officer
St. Luke’s Hospital & Health Network
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