Process, tools, and strategies for getting the performance data you need

Transcription

1 August 2010 Vol. 20, No. 8 OPPE for low-volume practitioners Process, tools, and strategies for getting the performance data you need When it comes to medical staff peer review, few areas are stickier than conducting ongoing professional practice evaluation (OPPE) for low- and no-volume practitioners. Medical staffs already struggle to collect data from numerous sources to assess the competence of highvolume practitioners, and the struggle becomes even more difficult when physicians visit the hospital only once or twice per year. Medical staffs must do their best to determine lowvolume practitioners competence, but many work with a less-than-ideal amount of data. Some data come from internal documentation, such as medical records. Other data may come from an outside facility where a practitioner is active. Regardless, the goal is to collect enough data to make an accurate judgment of a practitioner s competence. IN THIS ISSUE p. 5 Low-volume practitioner current competency attestation form Get the OPPE data you need from outside facilities with this easy-to-use form. p. 6 Spell it out Provide medical staff leaders with the information they need to perform their jobs well by using detailed position descriptions. p. 9 Better business writing MSPs can improve communication with medical staff members and colleagues with these tips and a handy checklist. p. 12 The self-governed medical staff William K. Cors, MD, MMM, FACPE, CMSL, discusses the ingredients that make up a successful self-governed medical staff. Determining internal data According to The Joint Commission (formerly JCAHO), medical staffs must conduct OPPE on all practitioners with active privileges. Each department chair should determine measures that provide a clear picture of competency for each privilege a practitioner holds. For practitioners who perform procedures, competency data will be The Joint Commission is trying to get doctors to understand that they based primarily on really shouldn t have outcomes. privileges if they aren t For example, the using them. chair of the gastroenterology depart- Christina Giles, CPMSM, MS ment may recommend that each gastroenterologist with colonoscopy privileges complete at least 15 colonoscopies during a one-year period as part of their eligibility criteria. If a physician does not perform the minimum number of procedures at a facility, the medical staff has several options. It can supplement its internal findings with data from other facilities or, if applicable, offer the physician refer-and-follow or dependent privileges. The performance of practitioners who do not perform procedures, such as primary care physicians (PCP), is trickier to track. Department chairs often must rely on retrospective chart review to determine competency. Two key measures are correct diagnosis and appropriate use of ancillary services. Start your OPPE process by collecting data that are relevant to all medical staff members, regardless of their specialty, says Marla Smith, MSHA, a consultant with The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. Compliance-based indicators to collect include: Documentation compliance (e.g., legible handwriting, appropriate abbreviations) > continued on p. 2

2 Page 2 Medical Staff Briefing August 2010 OPPE < continued from p. 1 Suspensions for delinquent medical records Validated incidents of inappropriate behavior Many medical staffs likely won t be able to collect enough information internally to determine a practitioner s competence. If this is the case, it is time to turn to outside sources. Gathering data from outside facilities The Joint Commission s March FAQ Using Data from Outside Organizations to Accomplish the Ongoing Professional Practice Evaluation/Low-Volume Practitioners, states: Every organization must collect its own data on each practitioner s performance, even if there are few or no data to collect Information received from another facility regarding a practitioner s performance can supplement the OPPE report a medical staff has created, but the outside information cannot stand in lieu of the facility s own OPPE Editorial Advisory Board William K. Cors, MD, MMM, FACPE, CMSL Senior consultant The Greeley Company Marblehead, MA Michael Callahan, Esq. Katten Muchin Rosenman, LLP Chicago, IL Sandra Di Varco McDermott Will & Emery, LLP Chicago, IL William H. Roach Jr., JD McDermott Will & Emery Chicago, IL Medical Staff Briefing Associate Publisher: Erin E. Callahan Associate Editor: Elizabeth Jones, ejones@hcpro.com Jodi A. Schirling, CPMSM Alfred I. dupont Institute Wilmington, DE Richard A. Sheff, MD, CMSL Chair and executive director The Greeley Company Marblehead, MA Raymond E. Sullivan, MD, FACS Waterbury Hospital Health Center Waterbury, CT Medical Staff Briefing (ISSN: [print]; [online]) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA Subscription rate: $389/year or $700/two years; back issues are available at $25 each. MSB, P.O. Box 1168, Marblehead, MA Copyright 2010 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/ Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/ or fax 781/ For renewal or subscription information, call customer service at 800/ , fax 800/ , or customerservice@hcpro.com. Visit our website at Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of MSB. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. The medical staff and governing body use these data, however limited, to determine whether each physician is competent enough to maintain his or her current privileges When sharing information with another facility, both the facility requesting OPPE data and the facility sharing the data should check with their legal experts to ensure that peer review protections are maintained The Joint Commission is trying to get doctors to understand that they really shouldn t have privileges if they aren t using them, says Christina Giles, CPMSM, MS, president of Medical Staff Solutions, a consulting firm in Nashua, NH. To read The Joint Commission s FAQ, visit Keeping the Commission s FAQ in mind, if Dr. Jones primarily practices at Hospital A but occasionally visits Hospital B, and Hospital B doesn t have enough performance data to assess Dr. Jones competence, it should ask Hospital A to provide specific data. However, Hospital B should not simply plug Hospital A s data into its OPPE report. The data, in whatever format Hospital A provides, may be included as a part of the evaluation, but Hospital B must also have continuously collected its own OPPE (even zeros) and created routine reports, says Sally Pelletier, CPMSM, CPCS, president of Best Practice Consulting Group in Intervale, NH, and consultant with The Greeley Company. The information obtained from Hospital A is a part of the picture but cannot be the whole picture. For example, if your medical staff needs additional performance data on a PCP, it might ask the physician for the names of two specialists he or she refers patients to and then send those specialists a letter asking for specific information about the PCP. Let s say you contact an ear-nose-throat specialist and he says, Dr. Smith, a PCP, sends everything over to

3 August 2010 Medical Staff Briefing Page 3 me, even simple earaches, then you should question how good a diagnostician the PCP is, says Giles. Mindy Hays, CPMSM, medical staff coordinator at Lindner Center of HOPE in Mason, OH, puts to work the Low-/no-volume practitioner current competency attestation form: FPPE/OPPE on p. 5. I look to see if there is any data at our facility, and if there isn t or it s minimal, I send this form to the practitioner, Hays explains. By signing the form, the physician grants Lindner permission to retrieve information from the facility at which he or she primarily practices. That facility fills out the bottom half of the form and sends it back to Lindner. Obviously, you want to review what [practitioners] are doing at your facility, but the reality is that not all of the practitioners you credential and privilege are going to be active at your hospital, says Hays. Lindner has not yet had a Joint Commission survey since adopting the attestation form, but Hays doesn t expect any problems. We are doing our best to meet the intent of the standard. Surveyors are aware of the problems with no- and low-volume practitioners. If you have a reasonable process and you are following it per your policies or bylaws, I think you ll do just fine during a survey. If the physician is not active at another hospital but is active in an office practice, your medical staff may want to ask the physician s office practice to provide five random medical records, suggests Giles. Not all outpatient measures will coincide with inpatient criteria, but you ll get valuable information nonetheless. An individual from the quality department or a case manager should review the files and determine whether the physician: Diagnosed the patients appropriately Performed a history and physical examination for each patient Used appropriate abbreviations and wrote legibly Adequately documented the treatment plan Alternatives to OPPE for low-volume providers Low- and no-volume physicians may have limited their activity in the hospital because the adoption of a hospitalist program has negated their need to see patients in the hospital, except on rare occasions. Lowvolume physicians may also make more money in private practice and want to limit the time they spend away from their offices. Regardless of their reasons for not being active at the hospital, many low-volume practitioners want to maintain medical staff membership because their managed care plans require them to be affiliated with a hospital. Although the National Committee for Quality Assurance no longer requires this, many managed care plans still do, says Giles. If someone is low-volume or no-volume, the first thing the medical staff should do is have a leader talk to the practitioner in person and ask What is your need for the hospital? she says. The goal is to work with the physician to whittle down the number and types of privileges that he or she has. In the best-case scenario, the physician understands that the hospital must assess practitioner competency to meet accreditation standards and voluntarily relinquishes some privileges. The worst-case scenario is that the physician refuses to give up some privileges, and the medical staff is forced to revoke those privileges because the physician does not meet the medical staff s competency criteria. Revoking a practitioner s privileges based on his or her inability to meet the medical staff s criteria will not trigger a fair hearing and is not reportable to the National Practitioner Data Bank because it is the physician s failure to comply with requirements rather than an adverse action. > continued on p. 4 Questions? Comments? Ideas? Contact Associate Editor Elizabeth Jones Telephone 781/ , Ext ejones@hcpro.com

4 Page 4 Medical Staff Briefing August 2010 OPPE < continued from p. 3 In many cases, granting the practitioner refer-andfollow privileges is appropriate. Refer-and-follow privileges are the perfect solution, says Giles. They give practitioners the minimal amount of privilege to come in and see their patients but not order or write anything in the medical record, and it is still called a privilege. If a managed care plan asks whether a physician has privileges at your hospital, and the physician has referand-follow privileges, the answer would be yes. Another option is to grant the practitioner medical staff membership but not privileges. Medical staffs have come up with various names for such medical staff categories, such as associate, affiliate, or consulting. Members can still participate in meetings and, in some cases, vote on medical staff decisions, but they are not granted privileges. Although many hospitals find both of these approaches helpful, medical staffs must consider political implications. What about physicians who feel angry, insulted, or otherwise injured by the hospital reducing their privileges, making them feel the hospital is not physician friendly? writes Richard Sheff, MD, CMSL, chair and executive director of The Greeley Company, in the June 17 Medical Staff Leader Connection available at This is not the outcome CEOs want for the primary care physicians who are an important referral source for the hospital, especially if their unhappiness makes them vulnerable to competitors recruiting away their referrals, Sheff writes. Credentialing Resource Center Symposium The 2011 Credentialing Resource Center Symposium is scheduled for May at Caesar s Palace in Las Vegas. Registration is $995 per person. Order before March 11, 2011, and get a discounted rate of $885 per person. Call our customer service line at 877/ for more information or to register. If politics don t allow for refer-and-follow privileges at a facility, the medical staff may allow low-volume practitioners to maintain dependent privileges. Dependent privileges require another practitioner to participate in the care of a low-volume provider s patients. For example, an active provider may comanage patients with a low-volume provider, serve as a mandatory consulting physician for all cases, or assist the lowvolume provider during surgical procedures. If your facility chooses to grant dependent privileges, it will need to figure out how to pay the physicians who assist low-volume providers. Sheff suggests that the medical staff bill for consultations so the consulting physician can be reimbursed. During surgical procedures, the consulting physician may receive the primary surgeon s fee, while the low-volume physician receives the first assistant s fee. Whichever of these approaches your organization uses, it should place the burden on the applicant to obtain the necessary supervision or comanagement services, writes Sheff. Before modifying or dissolving any practitioner s privileges, first be sure that all practitioners receive a copy of the bylaws and related policies at initial appointment, and remind them about your medical staff s focused professional practice evaluation (FPPE) and OPPE criteria regularly at medical staff meetings and through medical staff newsletters. I ve found that regularly including information in newsletters is especially helpful. It can be overwhelming to practitioners when trying to grasp all at once by reading through policies, Hays says. If the medical staff must revoke a practitioner s privileges, it should provide the practitioner with a summary of how the medical staff came to that decision. Every medical staff must decide for itself whether it wants to obtain performance data from other facilities or discontinue a practitioner s privileges. But the alternative making competency determinations without enough data isn t a risk the medical staff can afford to take. n

5 August 2010 Medical Staff Briefing Page 5 Low-/no-volume practitioner current competency attestation form: FPPE/OPPE I,, understand that to qualify for continued appointment and privileges on the medical staff of Lindner Center of HOPE (LCOH), I must provide evidence of current clinical competence. I understand it is my responsibility to ensure that this information is provided to the LCOH medical staff. Acceptable verification is the completion of this form by an appropriate representative from another area hospital who is able to verify the needed information. ************ Section below to be completed by applicant I release all individuals and institutions from liability for statements and data (including my clinical activity and a copy of my delineation of privileges) provided in good faith with respect to their responses. I authorize the information below to be provided to LCOH. Signature: Date: ************ Section below to be completed by hospital representative I,, verify that the above-named physician has had the following patient activity at this facility during the past 12-month period, without any identified problems necessitating disciplinary action or focused review. The practitioner s privileges are in good standing, and he or she has been deemed currently competent to perform the privileges granted (attached current delineation of privileges). Current staff category: Initial appointment date: Specialty: Reappointed through: # Anesthesia cases # Procedures # Consultations Delineation of privileges form attached Signature: Title: Hospital: Date: Source: Mindy Hays, CPMSM, medical staff coordinator, Lindner Center of HOPE, Mason OH. Reprinted with permission.

6 Page 6 Medical Staff Briefing August 2010 Spell it out Detailed leadership position descriptions open the door to better performance and greater transparency Often, medical staff bylaws describe the processes for nominating, electing, and removing medical staff officers. However, bylaws often lack details new leaders need to know to hit the ground running or experienced leaders need to maintain optimal performance. Most medical staff officers don t have a clue what the job is before they take it. They consider it an honorary position, but no one considers that it is a job with performance expectations and requirements, says Jonathan H. Burroughs, MD, MBA, FACPE, CMSL, senior consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. To get the best performance from medical staff leaders, medical staffs should enumerate each leader s responsibilities in a written position description. Such positions include: Medical staff officers, including the medical staff president/chief of staff, immediate past president/chief of staff, treasurer, secretary, and members at large Department chairs Committee chairs Position descriptions can live as policies that are separate from the medical staff bylaws. Best practice is for the leadership and succession planning committee to sit down with potential candidates to review the position descriptions and assess whether each candidate is competent and interested in fulfilling the obligations of the job, says Burroughs. If` your medical staff does not have a leadership and succession planning committee, the nominating committee can fulfill this role. Decide which positions need descriptions Medical staff leaders and MSPs should work together to decide which positions require a formal description. Some organizations create position descriptions only for medical staff officers (e.g., president, president-elect, treasurer, secretary) and department chairs, whereas others create position descriptions for committee chairs as well. For example, Good Samaritan Hospital in Los Angeles created leadership position descriptions for all medical staff officers, as well as each department and committee chair, explains Guenther Baerje, BSIT, CPMSM, HACP, director of medical staff management at Good Samaritan. However, Flagler Hospital in St. Augustine, FL, creates position descriptions only for medical staff officers (i.e., president, chief of staff, secretary, treasurer, and members at large) and department chairs but not for committee chairs. Although committee chairs do not receive a distinct position description, the medical staff bylaws describe clearly the functions of each committee, which the chairs use as a guiding light, says Terry Wilson, CPMSM, CPCS, director of medical staff services at Flagler. Because each medical staff is different, your organization will need to decide for itself whether committee chairs will receive specific position descriptions or simply rely on the written goals and objectives of the committee as a whole. Define leadership qualifications According to The Medical Staff Leaders Practical Guide, Sixth Edition, published by HCPro, each position description should: Identify who the medical staff leader is accountable to Enumerate the medical staff leader s responsibilities in that position Define the expectations of the medical staff leader for each responsibility

7 August 2010 Medical Staff Briefing Page 7 Identify the mandatory prerequisites of the position, including all necessary education, skills, tenure on the medical staff, experience, and other criteria List the financial and nonfinancial rewards and recognition associated with the position Outline the burdens, challenges, time commitment, and risks of the position Note: The Joint Commission s standard MS , EP 8, requires medical staffs that are organized into departments to include 15 department chair responsibilities in their bylaws. When creating a list of qualifications for committee chairs, start with the description of the committee in your medical staff bylaws. If the bylaws list five functions of the credentials committee, decide what the chair needs to do to accomplish those five functions. Your medical staff may decide that certain committee chairs receive additional training, and these requirements should be spelled out in the position description. For example, Good Samaritan requires the chair of the infection prevention committee to take a Centers for Disease Control and Prevention course on disease prevention and bioethics. It also requires the chair of the well-being committee to attend an annual conference on practitioner well-being. Although it may be necessary to require some committee chairs to obtain additional education that is specific to their position, it may be difficult to require all medical staff leaders to do so. Baerje had advocated for all department chairs to attend annual conferences to hone their leadership skills, but many physicians were reluctant to leave their practices for several days. The compromise to that is instead of requiring it, it is highly recommended, says Baerje. Members of the medical staff may take a department chair s leadership training into consideration during the next elections. A department chair who doesn t attend leadership training courses may eventually be voted out of office in favor of someone who does. To decide what standards leadership candidates must meet to qualify for medical staff leadership positions, talk to existing committee members and hospital administrators about what personal and professional qualities they would like to see in leaders. For the pharmacy and therapeutics [P&T] committee, I talked with the director of the pharmacy and said, These are the things I m looking at. What else would you expect from the chair of the P&T committee? says Baerje. It is helpful to include all options for progression, says Wilson. At Flagler, for example, at the end of the medical staff president s term, he or she steps down and simultaneously becomes chief of staff and chair of the credentials and quality review committees. At minimum, you have a four-year commitment because you are leaving one office and rolling into another, Wilson says. > continued on p. 8 MSB Subscriber Services Coupon Start my subscription to MSB immediately. Options No. of issues Cost Shipping Total Electronic 12 issues $389 (MSBE) N/A Print & Electronic 12 issues of each $389 (MSBPE) $24.00 Order online at Be sure to enter source code Sales tax (see tax information below)* Grand total N0001 at checkout! For discount bulk rates, call toll-free at 888/ *Tax Information Please include applicable sales tax. Electronic subscriptions are exempt. States that tax products and shipping and handling: CA, CO, CT, FL, GA, IL, IN, KY, LA, MA, MD, ME, MI, MN, MO, NC, NJ, NM, NV, NY, OH, OK, PA, RI, SC, TN, TX, VA, VT, WA, WI, WV. State that taxes products only: AZ. Please include $27.00 for shipping to AK, HI, or PR. Your source code: N0001 Name Title Organization Address City State ZIP Phone Fax address (Required for electronic subscriptions) Payment enclosed. Please bill me. Please bill my organization using PO # Charge my: AmEx MasterCard VISA Discover Signature (Required for authorization) Card # Expires (Your credit card bill will reflect a charge to HCPro, the publisher of MSB.) Mail to: HCPro, P.O. Box 1168, Marblehead, MA Tel: 800/ Fax: 800/ customerservice@hcpro.com Web:

8 Page 8 Medical Staff Briefing August 2010 Position descriptions < continued from p. 7 Wilson also includes in her medical staff leader position descriptions some subjective criteria, such as the personality traits that a good leader should possess. You want someone who is organized, personable, responsible, and interested in the position. The person should also be a good communicator, a good analyzer, and not afraid of confrontations, she says. Listing these traits in the position description serves as a reminder to voting members of the medical staff what qualities they should look for in future elected leaders. Use position descriptions to assess performance Position descriptions provide the president of the medical staff/chief of staff with a way to ensure that the individuals in leadership positions fulfill their obligations. For example, at Good Samaritan, the chief of staff conducts annual evaluations for every department chair. If a department chair isn t performing up to expectations set forth by the position description, the chief of staff can refer to the position description when suggesting ways for the department chair to improve, Baerje explains. If a department chair is removed from his or her position for not meeting obligations, the objective position description eliminates the appearance that politics motivated the decision. Update descriptions regularly Burroughs recommends updating position descriptions annually or whenever federal or regulatory standards affect a leader s responsibilities. For example, when The Joint Commission (formerly JCAHO) added the ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE) standards in 2007, no one had any idea that the department chairs would oversee the process with medical executive committee, credentials committee, and quality committee oversight, says Burroughs. In that case, medical staffs should have added these new responsibilities to the department chairs position description as soon as they established an FPPE and OPPE process. Wilson updates position descriptions when medical staff leadership terms end and the medical staff starts preparing to recruit new leaders. Before every election, update the job descriptions accordingly so you can hand them out to prospective candidates, she advises. Distribute position descriptions to the entire medical staff Before recruiting new leaders, medical staffs should review, update, and publish the position descriptions on the organization s intranet. Medical staffs should also distribute position descriptions in the physicians lounge and during medical staff meetings. I m not talking about the day of the election do it a month or two in advance. Job descriptions should not be secretive, says Wilson. By publishing and distributing the position descriptions prior to elections, the medical staff ensures that candidates have a full understanding of the positions they have been nominated for, and medical staff leaders can instead concentrate on who they want in the open leadership positions. Publishing the position descriptions is like a reminder to the medical staff that this is what you are asking someone else to do for you, says Wilson. Second, when you publish them, people stop and think about their current leaders and say, I just thought he got a stipend for going to a few meetings a month. I had no idea he had these other responsibilities. It reemphasizes the importance of your current leaders. n For a sample credentials committee chair position description, visit CredCommDesc. To view Good Samaritan s new medical staff leader orientation booklet, visit

9 August 2010 Medical Staff Briefing Page 9 MSP perspective Experts offer better business writing tips One of MSPs most important functions is to communicate effectively. Whether you re writing an to the chief of staff, sending a letter to a physician, or documenting meeting minutes, you must get your point across clearly and concisely. The good news is you don t need to be on the New York Times bestseller list to write well. MSB spoke with Lynn Gaertner-Johnston, founder of Syntax Training, a Seattle-based consulting and education firm, and Sherry Roberts, founder of The Roberts Group, an editorial and design services firm, to discuss the five biggest problems people experience with written business communication and how you can overcome them. Problem #1: The writer doesn t think about what the reader needs. A big mistake is to focus on what one has to say rather than what the reader needs, says Gaertner-Johnston. We end up writing a lot of information that the reader may not need and that may not be useful to us in achieving the goal of the communication. Solution: Put yourself in the reader s shoes. Imagine that you are having a conversation with your intended audience, whether the chief of staff or the entire peer review committee. Think about what questions they might ask you. Often, I hear journalists ask who, what, when, where, and why, but it is much more subtle than that for this kind of communication, says Gaertner-Johnston. For example, if you re writing an to the members of the peer review committee regarding the next scheduled meeting, they might ask: What time does the meeting start and end? Where is the meeting taking place? Do you expect the meeting to run long? Are there any documents I need to review beforehand? If so, what are they and where can I find them? Will we be ordering lunch, and if so, how do I submit my lunch order? After answering all anticipated questions, be sure to include any attachments (if ) or directions to help the reader follow through with the task you are asking of him or her. Gaertner-Johnston says that one of the most typical messages is the oops message. The sender realizes he or she forgot to include a vital piece of information or attach an important document, so it s worth double-checking every piece of correspondence to ensure that the reader gets what he or she needs. For clarity, close your message with an action point, such as Please me by Monday with this data, or I will call you Friday to follow up. Problem #2: clutter downplays professionalism. People often include unprofessional clutter in their communication to save time, draw attention to a particular point, or add a personal touch to their correspondence. Such clutter includes: Emoticons (facial expressions, such as smiley faces, created using punctuation marks) Abbreviations for common phrases (such as FWIW, which stands for for what it s worth ) Font overload (using bold, italic, and underline to draw attention to particular words or phrases or using multiple font types) wallpaper or stationery (often an attachment) All capital letters (to emphasize a point) Philosophical or inspirational quotes Solution: Strip your down to the essential elements. Emoticons are not professional. We can use them with our friends, but they rarely come across as professional with anyone else, says Gaertner- Johnston. People need to break the habit of using them because it is something annoying that people notice and think, There is her smiley face again. Although in this age of texting and Facebook when abbreviations are the norm, they can cause confusion > continued on p. 10

10 Page 10 Medical Staff Briefing August 2010 Writing tips < continued from p. 9 for readers who might not know what they mean. Whether it is in or a letter, your readers should never have to look something up in the dictionary, says Roberts. etiquette refresher checklist Scan this checklist before you hit the send button to ensure that your exudes professionalism and achieves its intended goal: Write a specific, informative subject line (e.g., Medical staff meeting moved to 3 p.m. instead of Update ) Appropriately address the receiver (e.g., Hi Sue, Hello John, Dear Dr. Smith) Summarize the purpose of your in the first sentence Use the active voice Double-check that all relevant documents are attached Proofread numbers (e.g., dates, times, phone numbers) Include time zones when appropriate (e.g., ET, PT) Spell out the receiver s assignment (e.g., Please review the attached documents before Monday s meeting.) as well as your own assignment (e.g., I will call you Friday to follow up) Avoid emoticons (e.g., :) or :P) Avoid using acronyms for common phrases (e.g., BTW for by the way ) Choose black type, white background, and an easy-toread font such as Times New Roman or Arial Spell out acronyms on the first reference Close salutations appropriately (e.g., Sincerely, Thank you, Best regards) Include a signature with your contact information Avoid including inspirational quotes Sources: Lynn Gaertner-Johnston, founder of Syntax Training in Seattle; Sherry Roberts, founder of The Roberts Group in Minneapolis; and HCPro, Inc. Roberts also warns about using abbreviations as business jargon. For example, it is appropriate to use MEC throughout your correspondence, as long as you spell out medical executive committee on the first reference. If you don t spell it out, readers may not know what it stands for or confuse it with another abbreviation. For example, MEC also stands for Medical Education Collaborative, Medical Examiners Commission, and month-end closing. To make your correspondence easier to read, choose black or dark blue font, a white background (no wallpaper), and limit the number of fonts you use. Too many colors or fonts can be distracting and cause readers to miss important information. Also, using all caps to emphasize a point can turn readers off, as they feel that they are being screamed at. As for inspirational quotes that many people include at the end of their s, They are distracting, and no one who is focused on business is focusing on the quote, says Gaertner-Johnston. Problem #3: Writers don t cut to the chase. Writers sometimes hesitate to come right out and say, I need you to gather this data for me. But in today s fastpaced working environment, writers do their readers a disservice by making them weed through text to find the information they need. Solution: Start with the most important information first. When readers open correspondence, their first two questions are, What is this about? and What do you need me to do? says Gaertner-Johnston. If you put your key information at the end, people will put aside the information for another time because it is not as simple as they hoped it would be, and they may not return to it. Once you ve squared away the purpose of your correspondence, then provide background, but not too much. For example, if you are ing the chair of the credentials committee asking him or her to review five new

11 August 2010 Medical Staff Briefing Page 11 applicant files, don t summarize each applicant s history in the . Rather, state that all the information he or she needs can be found in the practitioners files, which are located in the medical staff services department. This rule applies to subject lines as well. Too often, writers use vague subject lines, such as Update or Meeting. Boil down your message into one specific, informational phrase, such as Please review five cases by Monday, or Peer review meeting time has been moved to 3 p.m. Thursday. Explaining your position or asking for information in a direct way is not being rude or blunt; it is being professional, says Roberts. Problem #4: Typos degrade professionalism. We ve all written so instead of to or spelled onomatopoeia incorrectly from time to time, but typos in business correspondence can significantly affect the way others perceive your work. Common errors include: Dates not matching the day of the week Times (particularly if you are corresponding with someone in a different time zone) Prices Punctuation Solution: Take a break before you proofread. We re all in a hurry, but the five minutes we spend proofreading can save us so much time following up and making amends, says Gaertner-Johnston. Before hitting the send button or sealing the envelope, take a short break. Do something else to clear your head, then come back to it with fresh eyes. This will help you catch mistakes that you didn t see previously. Problem #5: Writers use lofty language. Some writers believe that professional language is lofty language filled with passive, indirect phrases. The result: confused readers. Solution: Use clean, active, friendly language. The first step in writing clear language is to use the active voice. Many writers fall into the trap of believing that the passive voice serves as a buffer. If you don t use an active phrase, you can t take responsibility for the action. Therefore, you can t get in trouble with your boss if something goes wrong with the action, says Roberts. In reality, using the passive voice only muddles your message. Although there are exceptions, the active voice puts the subject before the verb. Take these examples: Passive voice: The report was read by the chief of staff. Active voice: The chief of staff read the report. Also, reconsider traditional business phrases such as I am in receipt of your letter. It s more direct and friendly to simply say, Thank you for your letter. To ensure that your writing is understandable, keep tabs on sentence length. Gaertner-Johnston suggests limiting sentence length to between 15 and 20 words. When we have sentences of words, we need to break them up so that people can easily understand what could be complex information. Roberts offers an alternative way of thinking about sentence length: Every sentence needs a subject, a verb, and an object, if necessary. If your sentence has several subjects and several verbs, you need to break it into two or three sentences. Roberts also recommends that each sentence contains only one thought. Take the following example: Run-on sentence: The meeting has been moved to 3:00 to accommodate everyone s schedule, and it will be held in conference room 4. Clean sentence: Dr. Smith moved the meeting to 3:00. It will be in conference room 4. Whether you are new to the job or just want to brush up on your business writing skills and etiquette, these tips should help you hone your writing to create strong, effective business communications and keep your career moving in the right direction. n For more business writing tips, visit Syntax Training s website at com and The Roberts Group website www. editorialservice.com.

12 Page 12 Medical Staff Briefing August 2010 Choosing the right medical staff model Structure, process, and leadership make or break the self-governed medical staff by William K. Cors, MD, MMM, FACPE, CMSL, vice president The Greeley Company, a division of HCPro, Inc., in Marblehead, MA There are five components of a truly effective medical staff. Last month s column explored three of the five: culture, collaboration, and communication. This month, we conclude with the remaining two: medical staff structure and processes and leadership. Structure and processes. Effective medical staffs need excellent structure and processes. Start with succinct governance documents that medical staff leaders can readily understand. These documents should serve as a guide when leaders face a conflict or challenge. Best practice is for medical staffs to first design their form of self-governance and then codify that form in bylaws, policies, and procedures. Streamlined structures are built on high functioning, well-run committees. Many medical staffs function extremely well with two or three committees, including a medical executive committee, credentials committee, and medical staff peer review body. Proactively develop policies to address the common challenges facing most medical staffs, including: Low-/no-volume providers Cross-specialty privileges disputes Conflict of interest Aging physicians Focused professional practice evaluation Ongoing professional practice evaluation Unbiased peer review Leadership. All five components of an effective medical staff are important, but none are possible without strong medical staff leadership. Although a practitioner is clinically competent, he or she isn t necessarily a competent leader. Leadership requires an investment in development, education, and training. This investment is an ongoing commitment to engage in best practices, such as replacing the nominating committee with a leadership and succession committee. The leadership and succession planning committee is responsible for developing job descriptions, selection criteria, and performance evaluation processes for key medical staff leadership positions. The committee should institute a mechanism on- or off-site to ensure that medical staff leaders obtain the tools and skills they need to become competent leaders. All medical staff leaders need the skills to lead change and manage conflict. Some require specific subject matter expertise in areas such as: Credentialing and privileging Assessment of physician performance Regulatory and legal requirements Medical staff bylaws, rules and policies Note: See an example of an ongoing leadership curriculum at Because it is required and embedded in the culture of U.S. hospitals, the self-governed medical staff will persist despite the many others that have emerged in recent years. In next month s column, I will conclude this 12-part series with an overview of key takeaway points for successful implementation of effective models in your organization. Until next time, be the best that you can be. n

13 August 2010 Vol. 3, No. 8 Special report Expert tips for implementing hospitalist program dashboards Hospitalists have long been touted as the drivers of quality improvement initiatives, and one of their key tools for tracking the effectiveness of their initiatives is a dashboard. Dashboards are short reports containing data, often depicted in graphs, charts, and tables, that summarize the hospitalist program s performance. With dashboards, hospitalist program leaders focus their data collection efforts on a few key areas and provide hospitalists with regular feedback, which is key to encouraging improvement. Despite the benefits that dashboards provide to hospitalist programs, 30% 50% of hospitalist programs don t use them, says John Nelson, MD, FACP, partner at Nelson Flores, LLC, a hospitalist consulting firm based in Bellevue, WA. With the wave of healthcare reform building speed, all hospitalist programs will need to create and squeeze the most out of dashboards, says Martin Buser, MPH, FACHE, founding partner at Hospitalist Management Resources, LLC, a hospitalist consulting firm in Del Mar, CA. IN THIS ISSUE p. 3 Suggested dashboard measures Not sure what to include on your hospitalist program performance dashboard? Try this list. p. 4 Sample dashboard Adapt this sample dashboard to fit your own program s needs. For more news and tips from the experts, visit Hospital CEOs have woken up to the fact that quality indicators and patient satisfaction are crucial to their hospitals future, and hospitalists are the most significant driver of these improvement goals, Buser says. As a result, many hospitals are basing a portion of hospitalists compensation on meeting quality Having a dashboard is like saving for retirement. and patient safety It doesn t really matter targets. Because what funds you invest in, hospitalists function as a group, but you better be saving something. programs must be John Nelson, MD, FACP able to demonstrate to hospital administration the value they bring to the organization. To get you started on creating a dashboard or improving the one your program already uses, follow these tips. Gather existing data There is no need to reinvent the wheel when creating a useful hospitalist program dashboard. For example, the ED already collects information about ED admissions, and the pharmacy has data on medications ordered by hospitalists. Figure out what your hospital is already collecting and use those data as the foundation for your dashboard. You ll probably need to go to your decision support department (otherwise known as the information services or information technology department) to request specific information, such as hospitalist admission rates. Keep in mind, though, that gathering data shouldn t consume all of your time. Don t create a dashboard that requires you to spend hours every month collecting and abstracting the data, says Nelson. Hospitalist program leaders may need to invest significant time up front but then turn the majority of the data collection over to others. Nelson notes that a lot of data > continued on p. 2

14 Page 2 Hospitalist Leadership Advisor August 2010 Dashboards < continued from p. 1 collection can be automated. A person in our decision support department set up some queries or scripts that run automatically and keep everything up to date. Keep it simple Nelson and Buser suggest including less than 10 measures on the dashboard, and three to five of those measures should have quality incentives associated with them. Whatever the number, keep the dashboard focused on the handful of measures that are relevant and important to your program. You ll know you have too many measures on your dashboard if hospitalists can t Editorial Advisory Board Alpesh N. Amin, MD, MBA, FACP Executive Director Hospitalist Program Vice Chair for Clinical Affairs & Quality Dept. of Medicine University of California, Irvine Robert Bessler, MD CEO Sound Inpatient Physicians Tacoma, WA Kieran T. Bird Director of Bus. Development HRA Medical Management, Inc. San Diego, CA Jeffrey R. Dichter, MD, FACP Partner Medical Consultants, PC Muncie, IN Stacy Goldsholl, MD Founder Catalyst Inpatient Solutions, LLC Wilmington, NC Ron Greeno, MD Cofounder and Chief Medical Officer Cogent Healthcare Irvine, CA Senior Partner California Lung Associates Los Angeles, CA Hospitalist Leadership Advisor Associate Publisher: Erin Callahan, ecallahan@hcpro.com Associate Editor: Karen M. Cheung, kcheung@hcpro.com Associate Editor: Elizabeth Jones, ejones@hcpro.com Jeffrey A. Hay Chief Medical Officer Monarch HealthCare Irvine, CA Roger A. Heroux, MHA, PhD, CHE Founding Partner Hospitalist Management Resources, LLC HMR ED Call Panel Solutions Pensacola Beach, FL Jonathan Lovins, MD, SFHM Hospitalist and assistant clinical professor of medicine Duke University Health System Durham, NC Sylvia Cheney McKean, MD, FACP Medical Director BWF Hospitalist Service Boston, MA Associate Professor of Medicine Harvard Medical School Cambridge, MA Richard E. Rohr, MD, MMM, FACP, FHM Director of Hospitalist Programs Guthrie Healthcare System Sayre, PA Kenneth G. Simone, DO Founder and President Hospitalist and Practice Solutions Veazie, ME Hospitalist Leadership Advisor is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA HLA, P.O. Box 1168, Marblehead, MA Copyright 2010 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/ Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/ or fax 781/ For subscription information, call customer service at 800/ , fax 800/ , or customerservice@hcpro.com. Visit our website at Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of HLA. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. HLA is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. rattle them off without looking. If you can t, from memory, say every element that is on the dashboard, you probably have too many, says Nelson. Aside from financial metrics, Buser says four key metrics to include are: Patient satisfaction Readmission rates Implementation of clinical pathways Achievement of core measures Align with the CEO Many CEOs compensation is based, at least in part, on their hospitals performance. It is not unusual for a CEO to have a bonus program of 40% 50% of his or her income based on hitting certain objectives set by the board, says Buser, who is a former hospital executive. Hospitalist leaders should align their program dashboards with the dashboard the CEO presents to the board. For example, if the CEO is measuring readmission rates for the entire hospital, the hospitalist program should be measuring program-specific readmission rates. Buser says that CEOs most likely represent financial information, patient satisfaction rates, readmission rates, and cost per discharge on their dashboards. We would translate cost per discharge to hospitalists as implementation of clinical pathways, he explains. Stick with the same format Don t present patient satisfaction data using a pie chart one month and a bar graph the next month. Stick with the same format all the time so people s eyes can quickly fall on the numbers that matter, says Nelson. The report structure should also be consistent. Each month, for example, you might present a three-page report with the first page containing information on patient satisfaction. Issue reports regularly Nelson suggests issuing dashboards to all hospitalists on a monthly basis. Hospitalists should know when