performance measurement indicator report · performance measurement / indicator report table of...
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TABLE OF CONTENTS
I. Professional Qualifications 1
a. Physicians with Practice Deficits 2
b. Licensing Unqualified Physicians 6
II. Regulations and Enforcement 8
a. Quality of Care Cases 9
III. Consumer Education 13
a. Patients Informed 14
IV. Organizational Relationships 20
a. MBC Initiatives/Programs 21
V. Organizational Effectiveness 23
a. Use of MBC Resources 24
VI. Completion Status 28
a. Professional Qualifications 28
b. Regulations and Enforcement 30
c. Consumer Education 32
d. Organizational Relationships 33
e. Organizational Effectiveness 34
Medical Board of California March 2004
PERFORMANCE MEASUREMENT / INDICATOR REPORT
PROFESSIONAL QUALIFICATIONS GOAL: Ensure the professional qualifications of medical practitioners by setting
requirements for education, experience and examinations Desired Outcome Performance Indicator
Reduction in physicians with practice deficits REPORTING MEASURES that have or could lead to patient injuries Percentage of successful diversion
program cases Percentage of quality of care cases
resulting in removal of a physiciancausing or potentially causing patientinjury from practice
Number of physicians undergoingcompulsory physical and psychologicalcompetency exams under Section 820
TRACKING INDICATORS Number of currently active licensed
California physicians participating in thediversion program
Reduced risk of the Board licensing TRACKING INDICATORS unqualified physicians Number of applicants granted restricted
or probationary licenses Number of applicants denied licenses or
withdrawing from the licensure process
1
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: MEDICAL QUALITY/DIVERSION Responsible Program: : PHYSICIAN’S DIVERSION PROGRAM
Goal: Ensure the professional qualifications of medical practitioners by setting requirements for education, experience and examinations.
Desired Outcome: Reduction in physicians with practice deficits that have or could lead to patient injuries.
Performance Measurement/Indicator: The percentage of participants successfully terminated from the program annually.
Graph/Table Display:
ReThOuStabee
Perc
enta
ge
Participant Success
120% 100%
100% 87% 82% 79% 80% 65% 67% 63% 60%
40%
20%
0% 1998/99 1999/00 2000/01 2001/02 2002/03
Fiscal Year of Completion
In-State Success Rate Out-of-State Success Rate
sults Explanation and/or Variance Report: ere has been between 50 and 60 In-State participants exit the program annually. The t-of-State success rate has a broader range of fluctuations because the total Out-of-te completions have been between 3 and 6 individuals. Out of State data has only n presented in the Annual Report since 2000/2001.
2
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: MEDICAL QUALITY / ENFORCEMENT COMMITTEE Responsible Program: ENFORCEMENT PROGRAM
Goal: Ensure the professional qualifications of medical practitioners by setting requirements for education, experience and examinations.
Desired Outcome: Reduction in physicians with practice deficits that have or could lead to patient injuries.
Performance Measurement/Indicator: Percentage of cases resulting in removal of physician causing or potentially causing patient injury during the reporting period.
Graph/Table Display:
R
P e rc e n ta g e o f C a s e s R e s u ltin g in R e m o v a l o f P h ys ic ia n s P o te n tia lly C a u s in g In ju ry
2 3 %
P 2 3 % e 2 2 % r
2 2 % c e 2 1 % n 2 1 % t 2 0 % a
2 0 % g e 1 9 %
1 9 % J u ly - O c t - J a n - A p ril -S e p t D e c M a r J u n e 2 0 0 3 2 0 0 3 2 0 0 4 2 0 0 4
esults Explanation and/or Variance Report:
3
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: MEDICAL QUALITY/ENFORCEMENT COMMITTEE Responsible Program: ENFORCEMENT PROGRAM
Goal: Ensure the professional qualifications of medical practitioners by setting requirements for education, experience and examinations.
Desired Outcome: Performance Measurement/Indicator: Reduction in physicians with practice The number of physicians undergoing a deficits that have or could lead to patient physical, mental or competency injuries. examination during the reporting period.
Graph/Table Display:
R
0
1
2
3
4
5
6
7
8
J u ly -S e p t 2 0 0 3
O c t -D e c
2 0 0 3
J a n -M a r
2 0 0 4
A p r il -J u n e 2 0 0 4
N u m b e r o f P h y s ic ia n s T a k in g a n E x a m in a t io n
esults Explanation and/or Variance Report:
4
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: MEDICAL QUALITY/DIVERSION Responsible Program: : PHYSICIAN’S DIVERSION PROGRAM
Goal: Enhance the professional qualifications of medical practitioners by setting requirements for education, experience and examinations
Desired Outcome: Reduction in physicians with practice deficits that have or could lead to patient injuries.
Graph/Table Display:
Performance Measurement/Indicator: The number of licensed physicians currently participating in the Diversion Program at the end of the fiscal year.
R
Diversion Program Participation
Num
ber o
f Par
ticip
ants
350
340
330
320
310
300
290
280
270
294
321 326 327
348
1998/99 1999/00 2000/01 2001/02 2002/03
Fiscal Year
Total Monitored at the End of the Fiscal Year
esults Explanation and/or Variance Report:
5
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: DIVISION OF LICENSING Responsible Program: LICENSING PROGRAM
Goal: Ensure the professional qualifications of medical practitioners by setting requirements for education, experience and examinations.
Desired Outcomes: Reduce the risk of the Board licensing unqualified physicians.
Performance Measurement/Indicator: Number of applicants granted a restricted and/or probationary license during the reporting period.
Graph/Table Display:
ResulThe L1% of
Lice
nse
Issu
ed
Restricted/Probationary Licenses
10 8 6 4 2 0
Oct-Dec Jan-Mar April- July- Oct-Dec Jan-Mar 02 03 Jun 03 Sept 03 03 04
Quarter
ts Explanation and/or Variance Report: icensing Program processes an average of 385 applications per month. Less than the applicants are granted restricted or probationary licenses.
6
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: DIVISION OF LICENSING Responsible Program: LICENSING PROGRAM
Goal: Ensure the professional qualifications of medical practitioners by setting requirements for education, experience and examinations.
Desired Outcome: Performance Measurement/IndicatorReduce the risk of the Board licensing unqualified physicians.
: Number of applicants denied licenses or withdrawing from the licensure process during the reporting period.
Graph/Table Display:
RT1
012345
July-Sept 02
Jan-Mar 03
July-Sept 03
Jan-March
04
Quarter
Applicants Denied/Withdrawn
Denied Withdrawn
esults Explanation and/or Variance Report: he Licensing Program processes an average of 385 applications per month. Less than % of the applicants are eliminated from the licensing process.
7
REGULATIONS AND ENFORCEMENT GOAL: Protect the public by (1) preventing violations and (2) effectively enforcing laws
and standards when violations occur Desired Outcome Performance Indicator1 Quality of care cases resolved quickly and REPORTING MEASURES accurately Percent of quality of care accusations that
are upheld Average time to complete a Quality of Care
investigation during the reporting period Average resolution time for cases
resulting in removal of a physician causing or potentially causing patient injury from practice
TRACKING INDICATORS Percent of complaints that result in
accusations or disciplinary actions
1 Note: these measures are pending refinement by the Enforcement Committee. The SB 1950 definition (“resulting in serious injury or death”) is operative
8
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: MEDICAL QUALITY/ENFORCEMENT COMMITTEE Responsible Program: ENFORCEMENT PROGRAM
Goal: Protect the public by (1) preventing violations and (2) effectively enforcing laws and standards when violations occur.
Desired Outcome: To quickly and accurately resolve quality of care cases.
Performance Measurement/Indicator: Average time to complete a Quality of Care investigation during the reporting period.
Graph/Table Display:
R
A ve ra g e T im e to C o m p le te a Q u a lity o f C a re In ve s tig a tio n
3 4 0 3 3 5 3 3 0 3 2 5 3 2 0D
a 3 1 5 y 3 1 0 s 3 0 5
3 0 0 2 9 5 2 9 0 2 8 5
Ju ly - S e p t O c t - D e c Ja n - M a r A p ril -2 0 0 3 2 0 0 3 2 0 0 4 Ju n e 2 0 0 4
esults Explanation and/or Variance Report:
9
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: MEDICAL QUALITY/ENFORCEMENT COMMITTEE Responsible Program: ENFORCEMENT PROGRAM
Goal: Protect the public by (1) preventing violations and (2) effectively enforcing laws and standards when violations occur.
Desired Outcome: To quickly and accurately resolve quality of care cases.
Performance Measurement/Indicator: Average resolution time for cases resulting in removal of physician causing or potentially causing patient injury during the reporting period.
Graph/Table Display:
R
A ve ra g e T im e fo r R e m o va l fro m P ra c tice o f P h ys ic ia n s P o te n tia lly C a u s in g In ju ry
6 2 0
6 0 0
5 8 0 D
5 6 0a y 5 4 0 s
5 2 0
5 0 0
4 8 0 Ju ly - S e p t O c t - D e c Ja n - M a r A p ril -
2 0 0 3 2 0 0 3 2 0 0 4 Ju n e 2 0 0 4
esults Explanation and/or Variance Report:
10
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: MEDICAL QUALITY/ENFORCEMENT COMMITTEE Responsible Program: ENFORCEMENT PROGRAM
Goal: Protect the public by (1) preventing violations and (2) effectively enforcing laws and standard when violations occur.
Desired Outcome: To quickly and accurately resolve quality of care case.
Performance Measurement/Indicator: Percentage of complaints resulting in an accusation during the reporting period.
Graph/Table Display:
R
P e rc e n ta g e o f Q u a lity o f C a re C o m p la in ts R e s u lt in g in a n A c c u s a t io n
6
P 5e
r 4 c
e 3 n t 2 a g 1 e
0 J u ly - O c t - J a n - A p r il -S e p t D e c M a r J u n e 2 0 0 3 2 0 0 3 2 0 0 4 2 0 0 4
esults Explanation and/or Variance Report:
11
P e rc e n ta g e o f Q u a lity o f C a re C o m p la in ts R e s u lt in g in a n D is c ip lin a ry A c tio n
5 % 5 %P
e 4 % r 4 % c 3 % e 3 % n
2 %t a 2 % g 1 % e 1 %
0 % J u ly - O c t - J a n - A p r il -S e p t D e c M a r J u n e 2 0 0 3 2 0 0 3 2 0 0 4 2 0 0 4
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: MEDICAL QUALITY/ENFORCEMENT COMMITTEE Responsible Program: ENFORCEMENT PROGRAM
Goal: Protect the public by (1) preventing violations and (2) effectively enforcing laws and standard when violations occur.
Desired Outcome: To quickly and accurately resolve quality of care case.
Performance Measurement/Indicator: Percentage of complaints resulting in disciplinary action during the reporting period.
Graph/Table Display:
Results Explanation and/or Variance Report:
12
CONSUMER EDUCATION GOAL: Increase public awareness of MBC’s mission, activities and services Desired Outcome Performance Indicator Patients are able to make informed decisions REPORTING MEASURES about medical practitioners and unlicensed Number of media and consumer outreach practitioners and know how to seek remedies activities through accessible information provided by Number of hits to the MBC website the Medical Board Number of calls to the Complaint Unit
Number of calls to the Consumer Information Unit
Number of non-jurisdictional complaints received
Level of complainant satisfaction with MBC response
13
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: PUBLIC EDUCATION COMMITTEE Responsible Program: PUBLIC INFORMATION OFFICE
Goal: Increase public awareness of MBC’s mission, activities and services.
Desired Outcome: Patients are able to make informed decisions about medical practitioners and unlicensed practitioners and know how to seek remedies through accessible information provided by the Medical Board.
Performance Measurement/Indicator: Number of significant media and consumer outreach activities conducted during the fiscal year.
Graph/Table Display:
R
Num
ber o
f Eve
nts
Public Information Outreach
12108 C ons um er E v ent s6 4 P r of es s i onal2 0 N e w s R e l eas es
Oct-Dec
03
Jan-M
ar 04
Jan-M
ar 03
Oct-Dec
02
y-Sep
t 03
April-J
un 03
Jul
Reporting Period
esults Explanation and/or Variance Report:
14
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: PUBLIC EDUCATION COMMITTEE Responsible Program: INFORMATION SYSTEMS BRANCH
Goal: Increase public awareness of MBC’s mission, activities and services.
Desired Outcome: Patients are able to make informed decisions about medical practitioners and unlicensed practitioners and know how to seek remedies through accessible information provided by the Medical Board.
Performance Measurement/Indicator: Number of unique hits to the MBC Web Site during the reporting period.
Graph/Table Display:
R
Uni
que
Visi
tors
Unique Visitors Per Month
60,000 55,593
49,294 50,000 48,266 48,506 48,910 46,420
45,261 43,522
41,232
40,000
30,000
20,000
10,000
0 Jul-03 Aug-03 Sep-03 Oct-03 Nov-03 Dec-03 Jan-04 Feb-04 Mar-04
Month
esults Explanation and/or Variance Report:
15
Num
ber o
f Cal
ls
Consumer Complaint Calls
5000 4000 3000 2000 1000
0
May-03
Nov-03
Dec-03
Jul-0
3
Feb-04
Mar-03
Apr-03
Jun-0
3
Oct-03
Aug-03
Sep-03
Jan-0
4
Month C a lls R e c e iv e d
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: PUBLIC EDUCATION COMMITTEE Responsible Program: ENFORCEMENT PROGRAM Goal: Increase public awareness of MBC’s mission, activities and services. Desired Outcome: Performance Measurement/Indicator: Patients are able to make informed decision Number of public calls received on the about medical practitioners and unlicensed Consumer Complaint Unit toll-free lines practitioners and know how to seek during a reporting period. remedies through accessible information provided by the Medical Board.
Graph/Table Display:
Results Explanation and/or Variance Report:
16
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: PUBLIC EDUCATION COMMITTEE Responsible Program: LICENSING PROGRAM
Goal: Increase public awareness of MBC’s mission, activities and services.
Desired Outcome: Patients are able to make informed decisions about medical practitioners and unlicensed practitioners and know how to seek remedies through accessible information provided by the Medical Board.
Performance Measurement/Indicator: Number of calls received in the Consumer Information Unit during the reporting period.
Graph/Table Display:
R
Num
ber o
f Cal
ls
Consumer Information Calls
9000 8000 7000 6000 5000 4000 3000 2000 1000
0 May June July Aug Sept Oct Nov Dec Jan Feb Mar
6162 6724 7017 6878 6684 6904 5151 5703 6351 6619 8301
Month Calls i d
esults Explanation and/or Variance Report:
17
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: PUBLIC EDUCATION COMMITTEE Responsible Program: ENFORCEMENT PROGRAM
Goal: Increase public awareness of MBC’s mission, activities and services.
Desired Outcome: Patients are able to make informed decisions about medical practitioners and unlicensed practitioners and know how to seek remedies through accessible information provided by the Medical Board.
Performance Measurement/Indicator: Number of non-jurisdictional complaints filed with the Central Complaint during the reporting period.
Graph/Table Display:
Re
Non-Jursidictional Complaints
0 500
1000 1500
FY98/99
FY99/00
FY00/01
FY01/02
FY 02/03
Fiscal Year
Num
ber o
fC
ompl
aint
s
Com p laints
sults Explanation and/or Variance Report:
18
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: PUBLIC EDUCATION COMMITTEE Responsible Program: ENFORCEMENT PROGRAM
Goal: Increase public awareness of MBC’s mission, activities and services.
Desired Outcome: Patients are able to make informed decisions about medical practitioners and unlicensed practitioners and know how to seek remedies through accessible information provided by the Medical Board.
Performance Measurement/Indicator: Level of complainant satisfaction with MBC response during the reporting period.
Graph/Table Display:
R
% o
f Ove
rall
Satis
fact
ion
Consumer Satisfaction
60
40 Overall Satisfaction 20
0 1997 1998 1999 2000
Fiscal Year
esults Explanation and/or Variance Report:
19
ORGANIZATIONAL RELATIONSHIPS GOAL: Improve effectiveness of relationships with related organizations to further MBC
mission and goals Desired Outcome Performance Indicator MBC initiatives and programs promoted REPORTING MEASURES through effective relationships and alliances Number of legislative initiatives approved with partner organizations and agencies. by the Board with the assistance of
partner agencies TRACKING INDICATORS Number of organizational relationships
resulting in collaborative activities andventures
20
Reporting Division/Committee: EXECUTIVE COMMITTEE/FULL BOARD Responsible Program: LEGISLATION/REGULATION OFFICE
Goal: Improve effectiveness with related organizations to further MBC’s mission and goals.
Desired Outcome: Performance Measurement/Indicator: To increase the percentage of MBC Percentage of Board initiated legislation legislative initiatives implemented through introduced during the legislative year. partnerships and relationships.
Graph/Table Display:
R
QUARTERLY MEASUREMENT/INDICATOR REPORT
Board Initiated Legislation
100%
90%
80%
70%
60% Introduced
50% Not Sponsored
40%
30%
20%
10%
0% FY 02/03 FY 03/04 FY 03/04 FY 03/04 FY 03/04
4th qtr 1st qtr 2nd qtr 3rd qtr 4th qtr
Legislative Proposals
esults Explanation and/or Variance Report:
21
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: EXECUTIVE COMMITTEE Responsible Program: LEGISLATION/REGULATION OFFICE
Goal: Improve effectiveness with related organizations to further MBC’s mission and goals.
Desired Outcome: Performance Measurement/Indicator: To increase the number of partnerships Number of collaborative or partnership with organizations supportive of MBC activities conducted with various initiatives, programs and improvements. organizations throughout the fiscal year.
Graph/Table Display:
No data is available at this time for this measure. Discussions are currently underway to determine if measures can be developed for this goal/objective. The final determination will be reported at the May 2004 Quarterly Board meeting.
Results Explanation and/or Variance Report:
22
ORGANIZATIONAL EFFECTIVENESS Goal: Enhance organizational effectiveness and systems to improve service to constituents Desired Outcome Performance Indicator Ability of MBC to achieve its mission R
T
EPORTING MEASURES through effective and efficient use of revenue Percentage of staff indicating job satisfaction and staff resources to support priority through the annual survey initiatives and programs Percentage of staff remaining employed with
the MBC – retention rate RACKING INDICATORS Percentage of time data and systems areavailable to staff when neededAverage ticket resolution completed on time
23
Reporting Division/Committee: FULL BOARD / EXECUTIVE COMMITTEE Responsible Program: ADMINISTRATIVE SUPPORT SERVICES
Goal: Enhance organizational effectiveness and systems to improve service to constituents.
Desired Outcome: Performance Measurement/Indicator: Ability of MBC to achieve its mission Percentage of employees satisfied with through effective and efficient use of their employment at MBC during the fiscalrevenue and staff resources to support year. priority initiatives and programs.
Graph/Table Display:
RRcto
QUARTERLY MEASUREMENT/INDICATOR REPORT
Affirm
ativ
e Fe
edba
ck
Employee Survey Results 100.0% 90.0% 81.7% 73.6% 74.4% 80.0%
63.0% 62.5% 68.6% 70.8% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
nt b n s or rkion
es s oat me rc ssio
n rviSt eni My Jo
Mip m W
u rovi aSu eTEnom
mC
esults Explanation and/or Variance Report: esults were based on surveys sent to MBC employees (permanent, part-time), medical onsultants, retired annuitants and students. Response rate was 71%. Next year’s goal is increase the response rate to 80%.
24
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: EXECUTIVE COMMITTEE Responsible Program: ADMINISTRATIVE SUPPORT SERVICES
Goal: Enhance organizational effectiveness and systems to improve service to constituents.
Desired Outcome: Ability of MBC to achieve its mission through effective and efficient use of revenue and staff resources to support priority initiatives and programs.
Performance Measurement/Indicator: Employee vacancy rate for the major programs within the MBC during the reporting period.
Graph/Table Display:
Res
As Julfirs
MBC Vacancy Rate
30%
25%
20% Support
Licensing 15% Enf/Prob
Diversion 10%
5%
0% FY FY FY FY FY FY FY FY FY FY FY
01/02 01/02 01/02 01/02 02/03 02/03 02/03 02/03 03/04 03/04 03/04 1st qtr 2nd 3rd qtr 4th qtr 1st qtr 2nd 3rd qtr 4th qtr 1st qtr 2nd 3rd qtr
qtr qtr qtr
ults Explanation and/or Variance Report:
a result of the vacancy sweep and 12% reduction in personal services, imposed on y 1, 2003, by the Department of Finance the MBC had no vacant positions during the t and second quarter of this fiscal year.
25
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: EXECUTIVE COMMITTEE Responsible Program: INFORMATION SYSTEMS BRANCH
Goal: Enhance organizational effectiveness and systems to improve service to constituents.
Desired Outcome: Ability of MBC to achieve its mission through effective and efficient use of revenue and staff resources to support priority initiatives and programs.
Graph/Table Display:
Performance Measurement/Indicator: Percentage of time data systems is available to staff during critical working hours.
% o
f Wor
k H
ours
System Availability
100
99.5
99
98.5
98
97.5
97 July Aug Sep Oct Nov Dec Jan Feb March
Month
Results Explanation and/or Variance Report:
Hours of operation include 06:00 to 18:00, Monday thru Friday.
26
QUARTERLY MEASUREMENT/INDICATOR REPORT
Reporting Division/Committee: EXECUTIVE COMMITTEE Responsible Program: INFORMATION SYSTEMS BRANCH
Goal: Enhance organizational effectiveness and systems to improve service to constituents.
Desired Outcome: Ability of MBC to achieve its mission through effective and efficient use of revenue and staff resources to support priority initiatives and programs.
Performance Measurement/Indicator: Average number of minutes required for ticket resolution.
Graph/Table Display:
R
esults Explanation and/or Variance Report:0 5
10 15 20 25 30 35 40
Minutes
July Sept Nov Jan March
Month
Average Time to Close a Call Track Ticket
27
COMPLETION MEASUREMENTS
Professional Qualifications GOAL: Ensure the professional qualifications of medical practitioners by setting requirements for education, experience and
examinations
Ongoing Responsibilities Status Update Lead Responsibility Improve and expedite the review process
Completed: Many improvements made to the process, resulting in shortened time frames for licensing.
Division of Licensing
Determine future Board handling of alternative medicine: appropriate use, balance, licensing and Board responsibilities (such as new boards)
Two major factors identified for action; Committee will meet on November 31 for discussion and to formulate recommendation to the Board.
Non-Conventional Medicine Committee
Identify physicians who would benefit from rehabilitation and provide options. Develop a pilot program to implement
Pilot has been developed, Memo of Understanding signed by Cedars Sinai and legislation was passed to grant immunity for participation. As of yet, no candidate has been recommended or selected for participation.
Diversion Committee/Division of Medical Quality
28
Objectives Lead Target Date Completion Status Research and bring back a recommendation on accreditation of off-shore medical schools that provides for periodic review and revisiting of certification and ensures continuing quality of offshore-educated physicians practicing in California
Re-certification Committee
January 2003 Regulatory Hearing held on May 9, 2003, and regulations were adopted relating to standards and methodologies of review of international medical schools. The regulations are moving forward to DCA and OAL for approval.
Review eligibility requirements and uniformity of licensing between U.S. and foreign schools to match requirements with quality control
Division of Licensing April 2003 As schools are identified as needing further review because of changes in administration, etc., reviews will be conducted in compliance with adopted regulations.
Explore ways to achieve continued competency and report on options, including augmenting or replacing continuing education requirements with peer reviews or competency recertification
Re-certification Committee
July 2004 Dr. Kohatsu was researching this matter and no action will be taken until a new Medical Director is appointed.
Outline a course of action for dealing with standards of practice for expert witnesses, including: Identification of issues and problems Optional solutions Potential course of action
Division of Medical Quality
January 2004
Design and implement a physician recognition program focused on both individual and group recognition of those who improve access and fill gaps in the
medical system
Physician Recognition
Committee
March 2003 The Committee reviewed applications and made two selections, one individual and one medical
group. Award for the one individual was given at the January meeting; the group will receive
its award during the May 2004 meeting.
COMPLETION MEASUREMENTS
29
COMPLETION MEASUREMENTS
Regulations and Enforcement GOAL: Protect the public by (1) preventing violations and (2) effectively enforcing laws and standards when violations occur
Ongoing Responsibilities Completion Status Lead Responsibility Monitor and implement SB 1950 Project to develop regulations are in process. New Web Profiles Public Education Committee/ (Complaint Disclosure) were operational on April 24, 2003. Staff is working on Division of Licensing/
regulations. Enforcement Committee Assess status of allied professional certification and explore capacity and options
• Under discussion as it relates to resource management and Board priorities.
Enforcement Committee/ Division of Licensing
Objectives Lead Target Date Completion Status Appoint an Enforcement Monitor Enforcement
Committee March 2003 Enforcement and Diversion Program staff has
been working closely with the Enforcement Monitor to ensure the appropriate information is provided to assist with the evaluation.
Assemble data for Board discussion to determine validity of issues, correct any differential practices and communicate results to the public and licensees
Enforcement Committee (data collection) Public Education Committee (communication)
November 2002
Data will be available after physician surveys are gathered and are entered into the data systems. Appropriate data will be included in physician profiles, and overall statistical data will be published.
Reform the enforcement program to expedite reviews and investigation and to improve the quality and consistency of expert reviews and legal rulings.
Enforcement Committee
November 2003 Enforcement Committee continues to meet.
30
COMPLETION MEASUREMENTS Complete and implement revision of the Disciplinary Guidelines to improve timeliness, quality and uniformity of discipline
Division of Medical Quality
November 2003 Scheduled for discussion and vote at May 9, 2003 DMQ meeting.
Explore establishing an early warning system to provide for early identification of problem physicians through monitoring, technology and partnerships for inspection
Enforcement Committee
November 2003
Examine, assess and monitor the Diversion Program and determine potential new options including location of program administration to ensure confidentiality and confidence in the system
Diversion Committee January 2004 The Enforcement Monitor has begun the appropriate data gathering required to perform an assessment of the Diversion Program.
Consider new potential legislation on complaint disclosure to augment SB 1950 and fill gaps
Executive Committee January 2004
31
COMPLETION MEASUREMENTS
Consumer Education GOAL: Increase public awareness MBC mission, activities and services
Ongoing Responsibilities Completion Status Lead Expand the use of the Web site to communicate with consumers and licensees
Continuously being improved New Profiles are now in Use. Staff “User Group” meets regularly to reassess user issues and problems.
Public Education Committee
Use existing communication channels to improve legally mandated reporting and outreach on MBC programs and improvements
Committee has proactively sought the involvement of Coroners, court reporters, malpractice insurers, hospitals & the media in their quarterly meetings.
Public Education Committee
Utilize the Board as a speakers’ bureau to communicate MBC initiatives to constituencies
Speaker's Bureau is in planning stages. Public Education Committee
Use medical consultants as a communications tool for MBC initiatives and programs
Will be incorporated into the Speaker's Bureau. Public Education Committee
Objectives Lead Target Date Completion Status CE1 Develop a strategic communications plan to
increase public awareness of MBC, how to use information and services and initiatives for improvement.
Implement plan with key measures and annual review and evaluation system.
Public Education Committee
May 2003 Plan is completed and was adopted by the Board on May 10, 2003, keeping in mind the present budgetary restraints.
32
COMPLETION MEASUREMENTS
Organizational Relationships GOAL: Improve effectiveness of relationships with related organizations to further MBC mission and goals
Ongoing Responsibilities Completion Status Lead Responsibility Work with collateral organizations to advocate improved access to quality care for all Californians
Working with a variety of organizations on legislation.
Executive Committee
Pursue open communications with related organizations such as the California Medical Association (CMA) and the Center for Public Interest Law (CPIL), including a common language, common understanding of issues and joint legislative strategies
Working with a variety of organizations on legislation.
Executive Committee/ Public Education Committee
Align relationship-building activities with communication plan priorities
Communication Plan completed, and was adopted on May 10, 2003 by the full Board.
Public Education Committee
Objectives Lead Target Date Completion Status OR1 Identify collateral organizations and strengthen
relationships, including the following: CMA, CPIL, the Healthcare Association (HCA), the Office of Administrative Hearings and Hearing Officers (OAH) and the Department of Consumer Affairs (DCA)
Executive Committee
June 2003 Board President and Executive Director have met with CMA and various media to improve communications with the various organizations.
OR2 Develop a position paper on the crisis in access to medical care, outlining issues and potential courses of action
Executive Committee
June 2003 The Indigent Care Committee was established and they will be exploring the issues.
OR3 Identify creative approaches to access to care, and will develop a recommendation for action and follow-up by the Board.
Executive Committee
January 2005 Indigent Care Committee has been established to Explore and identify issues and develop recommendations for remedies.
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COMPLETION MEASUREMENTS
Organizational Effectiveness GOAL: Enhance organizational effectiveness and systems to improve service to constituents
Ongoing Responsibilities Completion Status Lead Responsibility Provide the Board with a financial overview of Staff working With Board officers, Department of Staff source and use of funds and methods for Consumer Affairs, and Dept. of Finance. leveraging resources Work with other organizations to accomplish The PEC is continuously working with others to Staff the MBC agenda Provide outreach & cooperation. Staff is working with
Numerous organizations on legislation.
Objectives Lead Target Date Completion Status OE1 Set priorities based on MBC’s core mission to
emphasize protection of the public Executive Committee
June 2003/ Ongoing
The Board’s priorities have been outlined in the 2002 Strategic Plan. Annual review of those priorities and quarterly performance will ensure the core mission is the Board’s primary focus.
OE2 Work with DCA and its departments to upgrade information technology systems to provide the level of sophistication needed to meet public information needs and manage licensing, enforcement and discipline
Staff 2007 DCA is currently working on an integrated system, Professional Licensing and Enforcement Monitoring System (PLEMS), which will involve all boards and create a uniform approach to regulating the various professions.
OE3 Address potential business system improvements to meet consumer information and system management needs in the interim
Staff April 2003 The State’s current budgetary crisis prevents further movement on this objective.
OE4 Review investigative staff compensation and align with market conditions
Executive Committee
June 2003 The State’s current budgetary crisis prevents further movement on this objective.
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