28/10/21 7:42 How Am I Doing?

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How Am I Doing?
The Hospitalist. 2007 December;2007(12)

Author(s):
Andrea Sattinger

How hospitalists assess their performance and hone their skills is critical to
patient care. Continuing medical education (CME), relicensure, specialty
recertification, and lifelong learning are all linked to hospitalists’ abilities to
assess and meet their learning needs.

But the preponderance of evidence suggests physicians have limited ability

to accurately assess their performance, according to a physician self-
assessment literature review published in September 2006 in JAMA.1

“Self-assessment should be guided by tools designed by experts, based on

standards, and aimed at filling gaps in knowledge, skills, and competencies
—not simply the internally based self-rating of individual practitioners,” says
C. Michael Fordis, MD, senior associate dean for con-

tinuing medical education at the Baylor College of Medicine in Houston, and

one of the authors of the study.

“Hospitalists and other physicians are not doing themselves a service to rely
on their own internal self-rated judgments of knowledge and performance,”
Dr. Fordis says. “There’s too much to know, too much that’s changing, and
too much that affects the implementation into practice of the knowledge
that you have for any one person to be able to take care of patients and at
the same time have some sense of whether there are gaps along that
implementation pathway.”

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“Guided” self-assessment represents the thinking of many experts who ask

questions, consider guidelines, and suggest tools that can help physicians
pursue the best ways of identifying those gaps that reflect differences in
what they think they are doing and their actual performance.

Regular, consistent self-assessment is imperative for a self-regulating

profession such as medicine. How well are hospitalists doing—and what
mechanisms or tools do they use?

HOW TO SELF-ASSESS

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Develop a more holistic continuing professional development process

(learning portfolios, documentation of practice-based learning and
improvement activities), creating less general and more detailed
learning and practice objectives;

Reduce the variation between self- and external assessments by

encouraging the internalization of objective measurements or
benchmarks of performance;

Use multisource feedback evaluations especially to address more

difficult improvement needs that may be difficult to assess
(communication, psychosocial);

Consider using objective measures of competence and performance;

Increase the role of specialty societies by providing current evidence-

based learning objectives on a regular basis to give members external
markers of competence;

Make self-assessment an iterative process that particularly focuses on

scope of practice; and

Use separate initiatives to identify physicians who require remediation.

Although those professionals can also benefit from guided self-
assessment, the process is designed primarily to support competent
physicians who want to continuously improve their practice
performance.—AS

Group Assessment
Hospital medicine groups are increasingly able to measure their clinical
competence against other hospitals’ and hospitalist groups. SHM’s
Benchmarks Committee has been working on performance assessment at a
program level.

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“When the JCAHO [Joint Comm­ission on Accreditation of Healthcare

Organizations] Core Measures were coming out a few years back, as a
whole most docs when reflecting on their practice would say they do a fine
job within these measures,” says Burke T. Kealey, MD, chairman of the
Benchmarks Committee from 2006-07. “For instance, [they might say] ‘I
always send people out on ACE inhibitors and beta-blockers,’ or, ‘We always
start people on aspirin when they come into the ER,’ but when you looked at
the data, you found that their self-assessment was not as accurate as we
hoped it would be.”

A lot of hard work went into discovering why their self-assessment was
inaccurate. “We found there were documentation problems that they didn’t
really incorporate a lot of the contraindications when giving their answer
about self-assessment,” says Dr. Kealey, who leads the hospital medicine
program at Regions Hospital and HealthPartners Medical Group in St. Paul,
Minn.

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
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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.

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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.

To Dr. Kealey, self-assessment plays a significant role in helping physicians

with their career goals and ensuring that their careers are on track and on
target.

At HealthPartners, physicians fill out a self-evaluation form on which they list

all activities they’ve been involved in over the previous year. Then they are
asked what they got out of these activities, what their career goals are, and
whether they are meeting them. They’re also asked how the group can help
them reach those goals.

“We ask them to pause and reflect on where they’re headed with their
career and their life, and put it down in writing so that in that moment they

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take the time to ask, ‘What is it that I’m ultimately after?’ ” says Dr. Kealey.

Day to day, they are immersed in patient care and focused on doing a good
job. “But in the trajectory of where they are headed—the committees,
projects, and educational activities they are involved in—are they all aligned
and pointing in the same direction and the right direction?” Dr Kealey asks.

The process, which HealthPartners hospitalists have been using for about 10
years, was modified from the American College of Physician Executives
course “Managing Physician Performance.”

“It is a tool to help hospitalists pause and reflect on their career and how to
move it forward,” Dr. Kealey says.

Marc B. Westle, DO, FACP, president and managing partner of the Asheville
Hospitalist Group, PA, in Asheville, N.C., relies on ongoing conversations.
This group also uses Crimson’s Physician Management Software to track
various group quality and cost indicators, looking at data from as many
angles as possible.

“It’s an excellent tool to look at a group, it is a poor tool to look at an

individual,” Dr. Westle says. “Although the insurance companies like to say
you can apply it to the individual, in reality there is no good way to attribute
that data down to the physician level.”

Within the group data, it may be possible to recognize underperformers, but

still it is anecdotal, based on experience and interaction.

“Under, ‘How am I doing?’ there is an objective category in the software

where there are hard end-points and measures you can look at,” says Dr.
Westle

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On the subjective side, Dr. Westle collects data on relative value units
(RVUs), non-monetary, numeric values Medicare uses to represent the
relative amount of physician time, resources, and expertise needed to
provide various services to patients. They review total RVUs as well as
individual-components that make up total RVUs.

“I’ll track how many simple, moderate, or complex follow-up visits were
made, how many simple or moderate histories and physicals or
consultations, how many procedures are they doing.” Dr. Westle says. “I’ll
track every statistic that way for every individual and give them that
feedback so they can see how they’re doing from a performance and a
work standard, compared to their peers within the group, and nationally as
published by Medicare.”

Dr. Westle uses charts and graphs to drive his points home.

“It just gives them an idea about where they are,’’ he says. “It doesn’t mean
they’re doing a bad job. Our patients may be sicker than some other
patients. And that is why we do it as a group, too, because their patients
should be similar to the group’s patients and the group’s patients may be
different than the average Medicare patient.”

They also look at hospitalists’ quality of life, their schedules, and the
quantity of work the average physician is doing compared with those
around the country. They discuss scheduling, income, disposable income,
and the kind of work they’re doing in the hospital. “All this comes into a
discussion of where they are in their lives and are they happy with what
they’re doing,” Dr. Westle says. TH

Andrea Sattinger is a medical writer based in North Carolina.

Reference
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1. Davis DA, Mazmanian PE, Fordis M, et al. Accuracy of physician self-

assessment compared with observed measures of competence: a
systematic review. JAMA. 2006;296(9):1094-1102.

Copyright by Society of Hospital Medicine or related companies. All rights reserved. ISSN 1553-085X

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