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March 2, 2014

Performance Evaluations for Docs

"We found Government is not ensuring that physician services are achieving value for money. Government is unable to demonstrate that physician services are high-quality and cannot demonstrate that compensation for physician services is offering the best value. Furthermore, there are systemic barriers that are hampering Government's ability to achieve value for money with physician services."
Office of the Auditor General (OAG), Oversight of Physician Services, February 2014

When doctors went on strike in Saskatchewan in 1962, some complained that Medicare would turn them into civil servants. Fifty-two years later, the mild reaction from Dr. William Cunningham, president of the Doctors of B.C., (formerly the BCMA), to the Auditor's report shows how attitudes have changed. The Globe and Mail quoted Cunningham as saying: "We agree that many of these things not measured should be measured." Not very long ago the official reaction from organized medicine probably would have been that the government has no business telling doctors, a self-regulating profession, what to do. Doubtless there are physicians who still harbour those attitudes. Perhaps that is why the Auditor reported:
"The proposed Physician Performance Enhancement Framework: The Province's Physician Quality Assurance (PQA) Steering Committee has been working to implement a Physician Performance Enhancement Framework and a common credentialing and privileging system for the province. However, progress in achieving this has been slow for several reasons, including the challenge of obtaining consensus with the many different entities involved, the significant cultural shift that is required to implement the initiatives, and the lack of clarity about roles and responsibilities."
The PQA was established to develop province-wide processes and standards in response to the findings and recommendations of Dr. Doug Cochrane, chair of the BC Patient Safety & Quality Council, in his two phased 2011 reports Investigation into Medical Imaging, Credentialing and Quality Assurance. Phase 1, released March 9, 2011, reviewed whether all 287 "radiologists practicing in British Columbia have the appropriate credentials and experience to interpret medical images". Cochrane was mandated by then health minister Colin Hansen to do the review because three cases came to the attention of health authorities where radiologists were practicing beyond the scope of their qualifications and were producing imaging interpretations and reports of questionable quality. During the course of his review, Cochrane identified two other radiologists whose reports warranted intensive review.

Phase 2 of Cochrane's report reviewed "the existing structure for the licensing and credentialing of physicians in BC's health authorities including the processes for quality assurance and peer-review". It produced 35 recommendations to produce a quality assurance system for physicians in British Columbia.

The Auditor General's 2014 report is based on Cochrane's work; he is essentially saying get on with implementing his recommendations. Cochrane and the Auditor General have called for regular performance measurements on each of BC's more than 10,000 physicians. Cochrane's 26th recommendation was that "the health authorities, affiliates and the College develop a performance assessment and review process for all physicians." The Auditor recommended that all physicians be required to participate in the Physician Performance Enhancement Framework, one of the programs of the PQA. The cautious language used on the PQA's website demonstrates how challenging their task may be. It says:
"The key guiding principles for the Physician Performance Enhancement Framework (PPEF) are that the framework should be:
It will be a significant challenge to implement a performance system in BC for individual physicians; however, the PQA website says:
"International efforts related to physician performance enhancement have been in development over the last decade, most notably in the United Kingdom, Australia, New Zealand and the United States. While there are a number of concepts and tools available, British Columbia needs to develop a framework for the unique British Columbia and larger Canadian health-care context - there is no "plug and play" benchmark available."
The Auditor General's first recommendation was for the Ministry of Health to work with the College of Physicians and Surgeons of British Columbia and health authorities to "document and address barriers that are preventing timely action to ensure that a performance review process is implemented by December 2014 (target completion date of the current Physician Performance Enhancement Framework)". The Auditor said he'll follow up on his recommendations in spring 2015. It may take public pressure for anything to happen by then. The Ministry's response to his recommendations includes the statement: "We appreciate the OAG's efforts, but also recognize the limitations inherent in any attempt to gain a comprehensive understanding of such a complex and nuanced topic within a relative short timeframe." There's little subtlety in that brushoff!