Physician Competency Report (PCR) Sample Policy
I. Principles for PCR use
Why is the report being distributed?
The medical staff’s goals for creating and distributing the PCR are:
To set clear expectations of physician performance for all competency categories
To create a medical staff culture that accepts performance data feedback in the spirit
of continuous improvement
To make physicians aware of areas of excellent performance, as well as areas of
To allow physicians the opportunity to self-improve based on the data provided
To meet the Joint Commission standards for ongoing professional practice evaluation
What aspects of competency will the report cover?
The PCR will eventually provide data for each of the six general competencies:
Interpersonal and communication skills
The specific measures selected reflect the medical staff’s expectations for these
How will the indicators and targets be selected?
Indicators and targets are selected by the medical staff quality committee with input from
the appropriate departments and approved by the medical executive committee (MEC).
Only indicators relevant to physician performance will be used for the PCR.
Which indicators will be linked to credentialing?
The PCR may contain indicators for feedback purposes only and that will not be used in
reappointment decisions. These indicators will be determined by the MEC and clearly
labeled in the PCR as “not for use in reappointment.”
Who will receive the data?
PCRs will be sent to all attending physicians with sufficient volume of activity as defined
by the MEC. Providers with low volumes of activity will be evaluated by alternative
means. The PCR will be kept confidential and only distributed to the individual physician
and the appropriate department chair and medical staff leader or committee.
How often will it be distributed?
The PCR will be distributed every six months. To ensure there is insufficient volume of
data for a six month report, PCR indicators may contain a rolling two-year time period
for the data.
How should the report be interpreted?
Prospective targets for both acceptable and excellent performance will be set by the
medical staff for each indicator to ensure consistent interpretation by the physician
receiving the data and the medical leaders responsible for reviewing it.
The indicators in the PCR only provide broad comparisons and are not precise measures
of physician competence. The PCR data should be viewed as a starting point for
identifying improvement opportunities. Variations should not be considered definitive
without further evaluation and discussion with the involved physician. Physicians are
encouraged to express any concerns or questions they have about data.
When will the physicians be held accountable for performance?
Following the distribution of the initial PCR, there will be a one-year grace period, during
which reports are distributed but no follow-up will occur unless the data has been
distributed to physicians in the past. This grace period will also apply to any new
indicators added to the PCR over time. Once the grace period has passed, medical staff
leaders will follow-up with individual physicians based on the PCR as described below.
How will the report follow-up be performed?
Follow-up by the department chair with the provider will occur if there is performance
below the acceptable target in any one of following patterns:
More than one time period in a row for an individual indicator
Two out of three time periods for an individual indicator
More than one indicator in the same general competency in a single time period
The department chair will follow-up with the physician to discuss the potential reasons
for the variance. The department chair will document the findings for each indicator that
is below the acceptable level including efforts to understand why the physician is
different and whether the difference actually is related to physician performance.
How will the report be improved?
When individual or systematic data problems are identified, the medical staff quality
committee will address the issues and work with the hospital to either resolve the
problem or recommend deletion of the indicator from the PCR.
II. PCR format and support
How will the data be organized?
Indicators will be organized by the physician competence category being measured
Physician activity data (i.e., volume data) will be separated from performance data.
How will the data be reported?
For each indicator the following information will be provided:
Indicator type (i.e., review , rule, rate)
Actual data for the provider for the indicator (number of events or volume and
“Excellence” and “Acceptable” targets
Symbolic interpretation (e.g., green, yellow, or red)
What support materials are available?
The following support materials are available to assist the provider:
1) A report cover letter: This is typically from the medical staff president or peer
review committee chair (or co-signed by both). It should be brief and explain
the medical staff’s ownership of the report, the reason the report is being sent,
and the philosophy behind the use of the data.
2) An explanation of the report format: This is usually a brief document that
accompanies each report that should describe the purpose of each column and
how to interpret the colors or symbols that are used.
3) A glossary of terms and indicators: This is a more substantial document that
provides the physician greater detail regarding the indicators and the terms
used in the report. For each indicator, the glossary defines the following:
Reason for selection
How it is calculated for rate measures
Typical factors that could contribute to below acceptable results
Who will support the PCR?
The support of the PCR will be a combined effort of the following departments:
Medical staff office
Hospital quality department
Information systems department
The medical staff quality committee will provide general oversight to ensure that the
PCR is assembled and distributed appropriately.
What information systems will be used to support the PCR?
The following software or systems will be used to create and produce the PCR:
[Insert software or systems applicable to your hospital.]