Professional Practice Evaluation

Clinical Performance Concerns

By Bill O'Neill, MBA; and Elizabeth J. Korinek, MPH

Dr. X was a surgeon with a long and distinguished career. Recently, his complication rate went up as the quality and timeliness of his documentation went down. In addition, there were questions about case
selection — did all of those patients actually require surgery?

Does this scenario sound familiar? What are the warning signs of declines in clinical competence? What processes can be put in place to make them easier to recognize and, once identified, what actions can MSPs and other hospital leaders take?

Not at My Hospital

According to studies done in both the United States and Canada, up to 12% of practicing physicians are “dyscompetent,” meaning they exhibit crucial deficiencies in the quality of care they provide.¹ Does your medical staff have 1,000 members or more? If the research is correct, your institution could have up to 120 dyscompetent physicians caring for patients.

Warning Signs and Detection

There are a number of potential red flags that can help identify poor physician performance. These may include complaints from patients, peers, and staff. In addition, “alarm bells” may be triggered by chronically deficient or delinquent record keeping, an unusual pattern of negative patient outcomes, and, of course, a history of paid malpractice claims.

Record Keeping and Care

Is deficient record keeping a symptom of more significant quality of care issues? Researchers in the Netherlands sought an answer to that question and examined records for 7,926 hospital admissions to 21 Dutch institutions. They found that poor quality of the information present in patient records was associated with higher rates of adverse events, implying that the quality of the present medical record keeping may be a predictor of the quality of care delivered.²

Malpractice as a Marker

If one assumes that paid malpractice claims are a potential marker for poor clinical performance, then research indicates that a history of paid claims may be a predictor of future poor clinical performance. In a 2016 study published in The New England Journal of Medicine, researchers found that physicians with a history of two paid claims had almost twice the risk of having another paid claim compared with physicians with only one paid claim. Physicians with a history of three paid claims had just over three times as much risk for another claim, and physicians with a history of six or more claims had over 12 times the risk of another claim compared with physicians with a history of one claim.

Interestingly, male physicians had a 38% higher risk of recurring paid claims than female physicians, and physicians over 35 years old had three times the risk of recurring paid claims compared to physicians younger than 35 years old.³

The Ongoing Professional Practice Evaluation (OPPE) and Focused Ongoing Professional Practice Evaluation (FPPE) processes introduced by The Joint Commission (TJC) in 2007 and external peer review are important parts of a comprehensive “early warning system.” These programs can guide MSPs and
clinical leadership and provide insight regarding the need for intervention.

Importance of Early Intervention

If quality of care issues are addressed early and effectively, the end result can be a win-win situation for patients, physicians, and institutions. If not addressed, performance and performance-related problems
can spiral downward. Medical team dynamics can suffer, patient care may deteriorate further, and significant liability concerns for the institution can multiply. In addition, if these situations lead
to termination of a physician’s contract, the cost of replacing that physician can be excessive, with estimates ranging from $500,000 to over $1,000,000, depending on specialty.

Early intervention through assessment and education can often turn these difficult situations around. At the Center for Personalized Education for Professionals (CPEP), we have found that the vast majority
of physicians referred by hospitals for clinical skills assessments are capable of remediation while they continue to work.

If hospital leadership chooses not to intervene, patterns of poor care may become more acute. These cases may then come to the attention of medical licensing boards, by which time “bad habits” have become hard to break. An informal look at CPEP data shows that physicians referred by licensing boards are 3 1/2 times more likely to demonstrate pervasive performance deficiencies than their hospital-referred peers.⁴

Intervention: Diagnosis and Treatment

In medicine, a patient’s illness must be properly diagnosed before devising an effective treatment strategy. When a clinical performance intervention is deemed necessary, the same logic applies. The clinician’s practice must be looked at from a variety of angles to determine the root cause of any performance deficiencies. Once that root cause is identified, an appropriate intervention can be designed, often in the form of a learning plan that focuses on identified educational gaps.

The Coalition for Physician Enhancement (CPE) comprises of eight organizations across the United States and Canada whose mission is to support and develop expertise in assessment and educational enhancement for physicians and healthcare providers who seek a higher level of performance.

Although all CPE members have unique methods for conducting assessments and evaluations, they all share some common features. They are multifactorial — examining clinical knowledge, skills, and judgment — and they are all designed and managed by professionals with years of experience in clinical competence assessments. This experience provides CPE members with unique context and insight into assessment techniques and results that can be beneficial to individual participants and the organizations that refer them.

At CPEP, although each assessment is tailored to the clinician’s specific needs, a typical clinical competence assessment may include some or all of the following testing modalities.

» Structured Clinical Interviews: In-depth conversations with specialty-matched peers that focus on clinical judgment and reasoning as well as knowledge

· Prior to the assessment, CPEP will request a series of patient charts that represent the clinician’s scope of practice. These charts are reviewed for quality of documentation and quality of care, and some of the cases will be discussed during the interviews.

» Simulated Patient Encounters: Live encounters with standardized patients to evaluate a participant’s communication and documentation skills

» Procedure Simulations: High-fidelity simulations testing technical skills in areas such as surgery, obstetrics and gynecology, anesthesiology, and emergency medicine
» EKG or Fetal Monitoring Strip Exam: Interpretations of test results when appropriate

» Multiple Choice Exams: Tests of knowledge in various areas, including ambulatory and hospital-based care, pharmacotherapeutics, and others
» Neuro-cognitive Screen: Computerized activity that screens for signs of cognitive slippage

Once a CPEP assessment is complete, a highly detailed report is issued that describes what was included in the evaluation, how the participant performed each step of the way, and an executive summary of conclusions and recommendations for the path forward.

In addition to standard competence assessments, CPEP and other CPE members offer specialized assessment services such as fitness for duty evaluations, late career screens, and reentry to clinical practice evaluations.

Closing the Gap

Once an assessment is complete, most CPE organizations can design a learning plan to help the clinician address any educational deficiencies revealed through the evaluation process. These plans may include study of evidence-based literature, accredited CME activities, and work with a preceptor to guide them through the process.

At the 2018 Annual Meeting of the Federation of State Medical Boards, CPEP staff presented data demonstrating the positive impact of this process. Staff examined over 2,000 patient charts submitted by participants in CPEP’s Practice Monitoring Program. Of those, 1,275 were submitted by physicians who had completed the CPEP Assessment and Educational Intervention program, and 788 were submitted by physicians who were in monitoring but had not gone through the process.

When compared to the monitoring-only group, charts from the assessment/education group were far less likely to reveal care that did not meet pre-determined standards. That difference was statistically significant.

Investments in Quality and Careers

The assessment and educational interventions conducted by CPE organizations require significant investments in time and money, and referrals are never made lightly. However, when measured against the costs of negative patient outcomes and the financial burdens of malpractice settlements and physician replacement, those investments may provide a positive return.

For more information on the CPE, please visit http://cpe.memberlodge.org/

Footnotes

1 J Contin Educ Health Prof. 2006 Summer; 26(3):173-91.
2 BMJ Qual Saf. 2011 Apr; 20(4):314-8
3 N Engl J Med 2016; 374:354-362
4 Internal CPEP data

This feature appeared in the September/October 2019 issue of Synergy. 

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Bill O'Neill, MBA, is the director of outreach and communications for CPEP. Bill has 20 years of experience in healthcare, focusing on medical education as well as new product and service development. He has an MBA in marketing and finance from the Wharton School of Business and is based in Raleigh, North Carolina.

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Elizabeth J. Korinek, MPH, is the chief executive officer for CPEP. She has been a speaker at the NAMSS educational conference annually since 2015 and has also spoken at NAMSS state chapter meetings. She received an MPH from University of California Los Angeles. Ms. Korinek is an expert on physician competence, physician reentry, and interprofessional communication.