Dear Dr. Hospitalist:
We have several physicians in our large academic group whom I hate to follow when picking up teams. There have only been a few situations when I thought there was a clear knowledge deficit, but the most irritating problem is that they don’t discharge patients. I’ve only been in the group for several years, so I don’t want to come across as a complainer. However, I am concerned about poor patient care and the work left to me to discharge patients. How can I help these physicians improve without damaging my relationship with them?
Dr. Hospitalist responds:
You bring up a problem that I’m certain many of us in hospital medicine have experienced at some point in our career. Since the “practice” of medicine can often be done with much variability, there are many gray areas that occur during the care of patients. However, we all know it is the transitioning of patients into and out of the hospital that is the most labor-intensive period of their care. If at all possible, the discharge process is best performed by the person with the most longitudinal knowledge of the patient’s hospital course.
Your leadership team has the responsibility to assess the quality and quantity of work of all team members. The periodic assessment of a clinician’s skill and aptitude, as well as the safety of care delivered to patients, can be done in several ways. Typically, the initial assessment is done by focused professional practice evaluations (FPPEs) and later by ongoing professional practice evaluations (OPPEs). The Joint Commission created these tools in 2007 to help determine if the quality of care by clinicians fell below an acceptable level.
FPPEs, as defined by the commission, are “the time limited evaluation of practitioner competence in performing a specific privilege.” They are usually done three to six months after the initial credentialing period, when a new or additional privilege is requested after the initial appointment, or when a condition or issue affecting the delivery of safe and high-quality care is identified.
OPPEs, as the name suggests, are typically done on an ongoing basis (usually annually). These practitioner-specific reports are best utilized as screening tools, and when unusual or aberrant tendencies are observed, a more detailed analysis typically is required.
Although these formal evaluations are carried out by chart review and analysis of data collected by the hospital, they should always be supported by discreet and candid conversations with other frontline team members. It is during these sessions that individuals should take the opportunity to express their opinions regarding the care delivered by their colleagues. From my experience, because of the shared care of patients in hospital medicine, if there is a problem with an individual’s professionalism or clinical abilities, it is usually well-known by others in the group.
If for some reason group leaders are not performing these mandated evaluations (and thus risking regulatory sanctions) or don’t have a formal mechanism in place, I would encourage them to establish one. In the interim, I would discreetly address the individuals and share your concerns. Many times, the problems you mention can be resolved with awareness, mentoring, and/or proctoring, but like any needed corrective actions, they must first be acknowledged.
Good luck! TH