Focusing Measures for Performance-Based Privileging of Physicians on Improvement

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.