QualityAdvisor™ helps TX hospital meet Joint Commission requisites

Challenge:

Medical staff credentialing and reappointment is an important responsibility of the medical staff office at all hospitals. In 2007 The Joint Commission revised its requirements to include physician performance review in the form of ongoing physician performance revaluation (OPPE) and focused physician performance evaluation (FPPE) for new medical staff appointments and physicians with practice concerns. 

Solution:

Valley Baptist Medical Center-Harlingen, TX, joined the Premier-CMS Hospital Quality Incentive Demonstration™ (HQID) in 2003 and began using Premier’s QualityAdvisor™ – and specifically the Practitioner Profile – as part of its medical staff reappointment process and as the foundation of its physician performance evaluation process.

The Current Competency and Feedback Committee – made up of the administrative director of medical staff services, four physicians and all department chiefs – developed and oversees the OPPE/FPPE process for 595 physicians. 

The Practitioner Profile is sent to each member of the medical staff quarterly. From a medical staff office standpoint it is an asset. Rather than having to reach out to many different sources for information, it comes in one report.

Results:

The entire process received high marks from the surveyors in December 2008. In a more recent survey of the hospital’s disease-specific certified Stroke Program, the survey team reviewed credentialing, OPPE and related matters and found no problems.

“Physicians have generally accepted the profiles, and within the past year have embraced them,” said Pamela Warner, administrative director, medical staff services. “At first, physician response varied. Some paid little attention. There has been a steady increase of physicians requesting updates and more information. Within the last two years, medical staff leaders have been using practitioner profiles for quality review, and within the last year, they’ve become interested in the utilization function.”

Some still question the information, but their questions are a sign that they are “paying attention,” Warner says.

The medical center is shifting to using the profiles to examine utilization, and savings are expected. “We are looking more closely at length of stay and cost per case,” Warner said. “That information has always been in the practitioner profile, but we do not do economic credentialing. However, as a part of our ongoing performance improvement, we are now comparing and addressing outliers. We are detailing down and that’s where QualityAdvisor™ is so helpful. It has a great deal of information about conditions – extended length of stay for hospital-acquired infections and excessive readmissions, for example – which hospitals and doctors won’t be reimbursed for in the near future. You can trend all of those things, physician specific, in QualityAdvisor™.”

Valley Baptist also is using QualityAdvisor™ as it attacks its readmission rate. The medical center is in one of 14 communities around the nation that CMS has chosen for its Care Transitions Project, seeking to eliminate unnecessary hospital readmissions. The goal is to improve healthcare processes so that patients, caregivers and the entire provider team have what they need to help keep patients from returning to the hospital within 30 days of discharge.

 

"In our most recent Joint Commission survey, our physician practice evaluations received high marks. The surveyor was fully aware that we use Premier and what it can do. The wonderful thing is, you can run physician-specific core measures and the Joint Commission really likes that. QualityAdvisor™ helped make our survey extremely easy and successful”

Pamela Warner
Administrative Director
Medical Staff Services
Valley Baptist Health System Harlingen, Texas

 

 

 

 

 

 

 

 

 

 

 

 

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