If patients had kidney dysfunction or kidney failure, they were not discharged on ACE inhibitors.
“But we as doctors didn’t do a great job of explaining why we weren’t doing that,” Dr. Kealey says. “We were not transparent in our reasoning, but the core measures caused us to become more transparent, to explain what we were thinking and what we were doing in a way that the public could see.”
At SHM’s annual meeting in May, the Benchmarks Committee released the white paper “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards” with the intent of assisting hospitals and hospital medicine programs develop or improve their performance monitoring and reporting.
“Hospitalists in general could do a better job of assessing themselves,” says Arpana Vidyarthi, MD, an assistant professor in the division of hospital medicine at the University of California, San Francisco (UCSF). “Self-assessment for those of us in cognitive specialties, like internists, is more complicated than in procedural specialties like surgery, partly because these procedural specialties have very specific outcomes that are linked to the procedure and that level of skill. With the new drivers of quality improvement and patient safety, and the dramatic increase of quality indicators for hospitals overall, this is now trickling down to thinking about how we truly assess the doctors themselves.”
The quality indicators that hospitalist groups are benchmarking may not be linked to the individual, she says. Dr. Vidyarthi, also director of quality for the Inpatient General Medicine Service at UCSF Medical Center, provides an example. “Pneumovax as a quality indicator is part of the Joint Commission core measures,” says Dr. Vidyarthi. “You can go online where it is publicly reported and choose this or other indicators to compare one hospital to another. That is the sort of benchmarking that some hospitalists groups are doing.”
But using that kind of evaluation for individual assessment misses the mark.
“Does the fact that the patient does not get Pneumovax reflect upon me and my abilities as a hospitalist? Not at all,” she says, “because my institution and those institutions who have done well with this specific indicator have taken it out of the hands of the doctors. It’s an automated sort of thing. At our hospital, the pharmacists do it.”
Although the American Board of Internal Medicine asks that the individual physician assess his or her own care as part of recredentialing, it’s more difficult for a hospitalist than for an outpatient internist. Hospitalists don’t have a panel of diabetic patients, for instance, for which the outcomes data can be easily analyzed.
Hospitalists as a group also haven’t had a tradition of self-assessment or peer assessment. Further, hospitalist groups differ as to how they handle assessments of individual physicians.
“In general if you ask our [UCSF] hospitalists, the way that we assess competency is generally through hospital privileging,” Dr. Vidyarthi says. Because the hospital as a whole reviews the competency of all the doctors that work there, the process known as “privileging” has consisted of asking a couple of colleagues to write letters of recommendation. “The division is changing this, but that is just on the cusp.
“We’ve built a new system for our quality committee in which one layer is peer assessment, looking at just the individual cases that bubble up from an incident report or a root-cause analysis or other sources. We’re looking at and identifying both systems issues and individual issues and trying to build a way to feed back those assessments.”
But that’s just half the equation, she says, the flip side being continual self-assessment for what a hospitalist is doing well.