Questions Program Directors Need to Answer Before Using Resident Clinical Performance Data

Sarah Gebauer; Elizabeth Steele

摘要

Twice a year, training programs must report milestones for every resident to the Accreditation Council for Graduate Medical Education (ACGME). The ACGME lists possible resident progress assessment methods to inform the milestones, but many are subjective. In addition, the ACGME surveys residents to verify that programs give trainees feedback on their performance, as well as their personal clinical effectiveness. In an effort to make feedback in the latter dimension reliable and meaningful, program directors are searching for and devising systems to give objective, unbiased clinical performance data. The ability to gather and report process and outcome data via automated systems (eg, electronic health records, registries, and billing data) in medical practice is relatively new, and educators should be aware of the complexities. Obtaining structured, objective clinical performance feedback data can be a challenge. Some groups provide automatic feedback of clinical performance data on measures like proper antibiotic administration and incidence of complications. Unfortunately, the authors of 1 study were unable to find a correlation between the level of training and the performance on these metrics, or any longitudinal improvement in the metrics for a given resident over time.1 As departments collect data for quality and milestone reporting, this should allow them to parse the data to the level of individual residents. The temptation to use these data to “get some numbers,” to meaningfully fulfill the feedback requirement, may become significant. This secondary use of patient data from electronic health records, billing, and other sources to understand individual provider performance is still in its infancy, and data can easily be misinterpreted and misused. Accuracy and transparency must be considered before providing residents with data gathered for other purposes, and particularly before using it for competency determinations. When devising policies to use data gathered for other purposes to evaluate resident clinical performance, program directors should be prepared to answer the following questions.;1.?How can we be sure that these data reflect a specific resident's patients? Understanding the process of attribution, or the way a patient is assigned to a provider, is crucial. Many patients are seen by multiple providers in both inpatient and outpatient settings; thus, deciding which patients are attributed to a resident can be challenging. One study of primary care residents used data from patients, with a minimum number of visits over a defined time frame, for tracking the use of preventative measures.2,3 Other methods may be more appropriate for physicians with a largely inpatient practice, such as inpatient consultants and proceduralists. For example, in anesthesiology, residents could be attributed (table) to any patient they cared for, or only to patients for whom their care constituted the majority of anesthesia time. For some metrics, such as postoperative pain score, it may make sense to credit only the last resident (ie, the anesthesiology resident who took the patient to the recovery room). In inpatient clinical services, many resident metrics will track closely with attending physicians' performance. This issue has been addressed by some authors pointing out the team- or system-related differences in any physician's practice, and suggesting that resident performance metrics should reflect the team nature of contemporary medical practice.4 View larger version (15K) tableDefinitions of Key Words Related to Data and Quality;2.?Were the patients of the given resident just sicker than the other residents' patients? Risk adjustment is an attempt to avoid unfairly penalizing residents caring for higher-risk patients. Adequate and transparent risk adjustment is often a difficult hurdle for departments and even for institutions. To the extent available, omnibus comorbidity indices such as EuroSCORE5 may offer convenient an

机译：培训计划必须每年两次，向每位居民向里程碑式研究生医学教育认证委员会（ACGME）报告里程碑。 ACGME列出了可能的居民进度评估方法以告知里程碑，但许多方法都是主观的。此外，ACGME还对居民进行了调查，以验证该计划是否向受训人员提供了有关其绩效以及其个人临床效果的反馈。为了使在后一个维度上的反馈可靠且有意义，程序主管正在寻找并设计出能够提供客观，无偏见的临床表现数据的系统。在医学实践中，通过自动化系统（例如，电子健康记录，登记表和账单数据）收集和报告过程和结果数据的能力是相对较新的，教育工作者应意识到其复杂性。获得结构化，客观的临床表现反馈数据可能是一个挑战。一些小组会就适当的抗生素管理和并发症发生率等措施提供临床表现数据的自动反馈。不幸的是，一项研究的作者无法找到培训水平与这些指标的绩效之间的关联，或者找不到特定居民随时间推移指标的纵向改善。1随着部门收集质量和里程碑报告的数据，这应该使他们能够将数据解析到各个居民的水平。使用这些数据“获取一些数字”以有意义地满足反馈要求的诱惑可能变得很重要。电子病历，账单和其他来源对患者数据的这种二次使用，以了解各个提供者的表现仍处于起步阶段，并且数据很容易被误解和滥用。在为居民提供其他目的收集的数据之前，尤其是在将其用于能力确定之前，必须考虑准确性和透明度。在制定政策以将收集到的数据用于其他目的以评估住院医生的临床表现时，计划主管应准备回答以下问题：1.我们如何确保这些数据能反映出特定住院病人的病情？了解归因过程或将患者分配给提供者的方式至关重要。多个提供者在住院和门诊都可以看到许多患者。因此，确定哪些患者归因于居民可能具有挑战性。一项对基层医疗居民的研究使用了患者的数据（在限定的时间范围内进行最少的就诊）来跟踪预防措施的使用[2,3]。其他方法可能更适合在很大程度上住院的医生使用，例如住院顾问和程序师。例如，在麻醉学中，住院医师可归因于（表）他们所照顾的任何患者，或仅归因于其护理占麻醉时间大部分的患者。对于某些指标（如术后疼痛评分），仅考虑最后一位住院医师（即将患者带到康复室的麻醉科住院医师）可能是有意义的。在住院临床服务中，许多居民指标将与主治医生的表现密切配合。一些作者已经解决了这个问题，指出了任何医师执业中与团队或系统相关的差异，并建议居民绩效指标应反映当代医学实践的团队性质。4查看大图（15K）表关键词的定义与数据和质量有关; 2。特定居民的病人是否比其他居民的病人病得更重？风险调整旨在避免对照顾高风险患者的居民造成不公平的惩罚。对于部门乃至机构而言，充分而透明的风险调整通常是一个困难的障碍。在可能的范围内，综合性合并症指数（例如EuroSCORE5）可为

Questions Program Directors Need to Answer Before Using Resident Clinical Performance Data

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