Whether we particularly like it or not, physicians are accustomed to having our actions judged—by our patients and their loved ones, other members of the care team, and the organized medical staff of the hospital(s) where we have privileges. For many years, physician evaluation by the hospital and its medical staff came at periodic reappointment—every one or two years, was a somewhat basic, and was often a subjective validation of our perceived competence, technical skill and judgment.
More recently, The Joint Commission and other accrediting bodies and payers have established more stringent guidelines for the ongoing evaluation of the professional practice quality of each medical staff member, across all departments and services. Called Ongoing Professional Practice Evaluation (OPPE), the program features six core areas measuring a practitioner's clinical and behavioral competence. Evaluation is to be on a regular basis, such as every two, four or six months. This means more frequent scrutiny of physician practice patterns—and the outcomes of our practice of medicine—than ever before.
The Six Competencies in the Joint Commission Standards
Some physicians may not view this change as major or as a reason for concern. Hospitals have already been delivering a variety of performance management data to them for some time. But as regulations and medical practice in general have become more complex—and data have become more plentiful—having a positive dialogue regarding the specifics of a physician's practice as part of the organization's quality improvement program has become more challenging.
After all, by our very nature and the job we're challenged to perform, physicians want to be perfect and don't generally like hearing when we're not. None of us enjoys criticism. Also, being told that our method of practice is less than perfect means we have to experience change, which is typically a challenge for every human being. This is especially true for something as ingrained as an individual physician's (or a department's) daily practice of medicine.
Moving through the stages
Those hospital executives tasked with sitting down with a physician to discuss practice variations as part of OPPE or any other performance-improvement initiative will need to be prepared for the reactions they'll likely encounter. Thinking through the process ahead of time will help move the conversation toward a positive dialogue and acceptance for implementing change—change designed to lead to broader implementation of best practices and achievement of improved outcomes.
An incredibly useful model for coping with all types of change—or any news people don't want to accept, for that matter—has proven to be one adapted from the Elizabeth Kübler-Ross model on the stages of grief ("On Death and Dying"), developed in 1969. These stages are fluid; during the process, a person can go from a bargaining stage to denial and back again. So while predicting human behavior is not an exact science, the Kübler-Ross model is a useful foundation.
Stage 1: Denial. "This is not right! The data are incorrect!" In this initial stage, the data is in effect summarily dismissed. The most common summary dismissal is "this is just 'administrative' data." In my mind, the term 'administrative' is outmoded and relates to a former, less complex time—when five or so discharge codes were applied only for the purposes of reimbursement. Today, a discharge abstract contains 36, 64 or even more ICD-9 codes so that all co-morbidities and complications can be effectively captured. Coders have long since learned that this data is being used for public reporting, quality improvement and many other purposes.