By Dr. Dan Ezekiel (biography and disclosure)
What I did before
If you have spent any time in the past year reading the BC College of Physicians and Surgeons’ quarterly newsletter, you are well aware that our governing body has significantly ramped up its Peer-Review Assessment Program. This means more funding and training of assessors. You would be well-advised then, particularly if you have been in practice for twenty years or more, to prepare for a visit from one of them sooner rather than later.
Oh, and one more thing. When you do get the call, do not expect much sympathy from your family and friends that are not physicians. I found that Joe Public LOVES the fact that doctors get a review of their practices once in a while!
What changed my practice
I underwent the assessment in the spring of 2011 and, like most practices, I discovered that there were some things I was doing well and some other things that could do with some improvement. All in all though, I found the process neither punitive nor disciplinary in any way. On the contrary, I was relieved that it was much more educational than I had expected. My assessor was warm and helpful, and provided me with plenty of useful advice that I have since incorporated into my practice.
The assessment itself lasts about 4-5 hours and is broadly divided into three sections: the physical aspects and inner workings of the office, medical record-keeping, and the quality of care.
- Physical Aspects and Inner Workings: In this part of the assessment, the assessor reviewed my waiting room, examining rooms, emergency equipment, sterilizer, refrigerator, sample cupboard, chart storage area, sharps containers, opioid pads, and so on. Of particular importance was maintaining patient privacy and confidentiality so fax reports, printers, telephone conversations, office charts, and other items of a potential delicate nature are inaccessible to snooping eyes and ears.The assessor also spent considerable time with my receptionist understanding how the flow of messages within the office functioned. In other words, if my receptionist has a message for me, how does that message reach me? And if I have a message for my receptionist, such as needing a chart pulled or wanting a patient to come in, how does that message reach her? Several improvements in these inner workings were suggested in order to minimize the possibility of an action getting missed or something not being properly followed-up.
- Medical Record Keeping: The bulk of the peer-review assessment involved the examination of 15 patient charts. First, the quality of the medical records was examined. The gold standard here is a comprehensive SOAP-style note for each patient encounter. In addition, however, the assessor also looked at my referral letters, pediatric growth charts, immunization records, pre-natal forms, and appropriate charting for all those GPSC initiatives (14050, 14051, 14033, etc.). Of particular importance was having a proper at-a-glance summary sheet at the front of every chart, displaying chronic illnesses, previous surgeries, medications, allergies, family history, personal/social history, and so on.
- Quality of Care: Finally, the actual clinical management of the 15 selected patients was examined. For patients with a chronic illness, was I following the recommended treatment guidelines? And conversely, for healthy patients, was I doing the appropriate disease screening tests such as pap smears, mammograms, stools for occult blood, etc. The assessor gave me many useful suggestions here, again to minimize the possibility of a patient falling through the cracks.
What I do now
Since having my assessment, I now pay very close attention to two very important questions whenever I write a note in a chart. First, is it possible to determine why the patient presented, what was found out, and what was done about it? And second, is the treatment adequate, including follow-up care for both acute and chronic conditions? If you can answer in the affirmative to both these questions, then you can be fairly sure you are doing a good job.
The College has a mandate to protect the public, and as such, we must expect to have a review of our practices just like other professionals. But an assessment is not necessarily a bad thing. In fact, it may save you from an even worse fate one day! Most civil actions initiated by patients, or patient complaints to the College, are due to either: a) poor communication, b) poor medical management, c) poor office organization such that something was missed, or d) misdiagnosis or a delay in diagnosis. Making improvements in your office may preclude these things from happening or, if they do, will certainly put you in a much better position to defend yourself. The peer-review assessment, as I look back on it now, mitigates risk.
This is borne out in the latest College newsletter:
- “When a physician is the subject of a patient complaint, civil action, practice review, or billing audit, conclusions as to whether the care provided was acceptable inevitably turn to what has been documented in the clinical record… A physician’s note is regarded as his/her intellectual footprint.”
- “This College’s revalidation program regards the quality of recorded care as being a reasonable surrogate marker of competent medical care.”
So when the College does come calling, and they surely will, do not fear the worst. Instead, think of the process as part of your life-long commitment to serving your patients as best you can.
MPAC (Medical Practice Assessment Committee) https://www.cpsbc.ca/about-college/mpac and https://www.cpsbc.ca/about-college/practice-assessment.
September College Quarterly https://www.cpsbc.ca/files/u6/CQ_September_2012_Web.pdf page 8.
Participating physicians are eligible for MainPro C credits.