Focusing measures for performance-based privileging of physicians on improvement

Jt Comm J Qual Patient Saf. 2008 Dec;34(12):724-33. doi: 10.1016/s1553-7250(08)34095-1.


Background: The Joint Commission requires ongoing professional practice evaluation--or what Cincinnati Children's Medical Center (CCHMC) has termed performance-based privileging (PBP)--for the medical staff reappointment and reprivileging process.

Building a system: CCHMC is a 475-bed academic medical center affiliated with the University of Cincinnati College of Medicine. Medical staff members are reappointed every two years, with divisions having staggered reappointment dates throughout the two-year cycle. In 2004, CCHMC devised a model in which the 38 divisions retained responsibility for development of measures; collection, maintenance, display, and monitoring of individual provider performance data; and sharing of data with providers, while medical staff services retained responsibility for ensuring compliance with timelines, technical assistance related to measure development, and the collection and display of data. Each clinical division developed a preliminary list of measures. The original PBP process was tested in 2005 and has been revised several times in response to division feedback.

Discussion: Members of all 38 clinical divisions have now been reappointed to the medical staff at least twice using measures that have become more robust, meaningful, and outcome oriented. Many measures support organizational or divisional quality imoprovement aims, are evidence based, or build on initiatives sponsored by external bodies and specialty societies. Examples of measures are shared via the PBP intranet, personal consultations, and an annual provider performance improvement conference. Yet, challenges remain, such as the absence of real-time, provider-specific, risk-adjusted data and the difficulty of attributing provider-specific outcomes when most complex and high-risk care is managed by a team.

MeSH terms

  • Academic Medical Centers / organization & administration*
  • Clinical Competence
  • Communication
  • Employee Performance Appraisal / organization & administration*
  • Guideline Adherence
  • Humans
  • Medical Staff, Hospital / organization & administration*
  • Practice Guidelines as Topic
  • Practice Patterns, Physicians'
  • Quality Assurance, Health Care / organization & administration*
  • Quality Indicators, Health Care / organization & administration