Improving Performance Evaluation of Clinicians to Support National Standards of Practice

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Background: Clinician performance is a critical determinant of high-quality care delivery and patient outcomes. VA medical centers assess clinicians with Ongoing and Focused Professional Practice Evaluations (OPPE and FPPE), which require bi-annual chart abstraction by clinicians to assess for adherence to quality measures. This process is inefficient, lacks evidence of validity or impact, and has been the subject of multiple investigations by the Office of the Inspector General. VA has therefore committed to establishing national standards of practice for all clinicians for use in OPPE/FPPE. The Office of Specialty Care has selected a set of 154 performance indicators across 33 subspecialities. Of these, cardiology is best positioned to test novel methods for clinician assessment because of existing evidence-based quality measures and established mechanisms for quality measurement via the Clinical Assessment, Reporting and Tracking (CART) program. Significance: Two critical knowledge gaps prevent effective performance assessment of cardiology providers in VA: 1) existing quality measures for general cardiology practice have not been tested for validity and reliability; and 2) effective case-based peer review methods are unavailable for outpatient cardiology care. Since these two assessment methods are linked both conceptually and in current VA practice, we propose to test both in a novel, mixed methods study. Our overall goal is to provide practical tools to assess VA cardiology clinicians while demonstrating proof-of-concept of this novel paradigm. Innovation and Impact: These novel assessment methods would free VA clinicians from the burden of low- value chart abstraction, advance VA’s commitment to be a High Reliability Organization, and improve the overall quality and safety of Veteran healthcare. In addition, the research will provide generalizable knowledge to advance the field of clinician performance assessment and improvement. Specific aims: 1) To assess the reliability and validity of quality measures obtained from electronic health record data for cardiology clinician assessment; 2) To test the validity of case-based peer review of cardiology clinician performance; and 3) To identify barriers and facilitators to the use of these assessment methodologies for OPPE/FPPE in VA practice. Methodology: This mixed-methods study will build on the evidence-based Clinical Practice Feedback Intervention Theory and existing methods of quality assessment and peer review for cardiac procedures. In Aim 1, we will use electronic health record data to assess cardiology clinician performance on 4 indicators that are currently used for OPPE. Measures will be tested for reliability and validity. A composite measure will be developed to provide a summary assessment of clinician performance. In Aim 2, we will engage expert clinicians and other stakeholders to develop and test a web-based platform for blinded, case-based peer review. We will determine the reliability of peer review assessments and determine the optimal number of reviews. Finally, we will interview and survey clinicians to determine how these assessment methodologies may impact clinical care and can be most effectively implemented in practice. Next Steps/Implementation: This research will develop a trustworthy method for review of clinician performance that could replace the current inefficient and ineffective OPPE/FPPE process. We will work with our partners in the Program Offices of Cardiology and Specialty Care to implement in practice.