• Jesse M Ehrenfeld, Justin P Henneman, Robert A Peterfreund, Tyler D Sheehan, Feng Xue, Stephen Spring, and Warren S Sandberg.
• Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA. jesse.ehrenfeld@vanderbilt.edu
• Jt Comm J Qual Patient Saf. 2012 Feb 1;38(2):73-80.

BackgroundThe Massachusetts General Hospital (Boston), a large academic center providing anesthesia services for more than 49,000 procedures each year, created an Ongoing Professional Practice Evaluation (OPPE) process that could use readily available, automatically captured electronic information from its vendor-provided anesthesia information management system.MethodsThe OPPE credentialing committee selected the following initial metrics: Blood pressure (BP) monitoring, end tidal CO2 monitoring, and timely documentation of compliance statements. Baseline data on the metrics were collected in an eight-month period (January 1, 2008-August 31, 2008). In February 2009 information on the metrics was provided to the department's staff members, and the ongoing evaluation process began. On the basis of three months of data, final reports for physicians being credentialed were distributed. Each report included a listing for each metric of the total number of compliant cases and noncompliant cases and a comparison by percentage to the baseline departmental evaluation. A summary statement indicated whether a physician's performance was within the group representing 95% of all department physicians. Noncompliant cases were listed by medical record number and case date so providers and reviewers could examine individual cases.ConclusionA novel, automated, and continuous reporting system for physician credentialing that uses the existing clinical information system infrastructure can serve as a key element of a comprehensive clinical performance evaluation that measures both technical and generalizable clinical skill sets. It is not intended to provide a complete system for measuring competence but rather to serve as a first-round warning mechanism and metric scoring tool to identify problems and potential performance noncompliance issues.

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