March 13, 20081 Medical Staff Standards New … Challenging Presentation by Linda Van Winkle, CPMSM,...

March 13, 2008 1

Medical Staff Standards

New … Challenging

Presentation by Linda Van Winkle, CPMSM, CPCS,Manager, Medical Staff Services

March 13, 2008 2

Medical Staff StandardsNew/Challenging

“Determining the competency of practitioners to provide

high quality, safe patient care is one of the most important

and difficult decisions an organization must make.”

(The Joint Commission)

http://www.jointcommission.org/

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… Determining competency is

accomplished through the processes of

Credentialing and Privileging.


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It’s not just about

paperwork!


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The Credentialing & Privileging processesinvolve a series of activities designed to

COLLECT

VERIFY

and EVALUATE

datarelevant to a practitioner’sprofessional performance.

This is the foundationfor objective, evidence-based decisions

regarding(a) membership and (b) privileges.


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The Credentialing process …

Involves (a) collecting, (b) verifying, & (c) assessing information regarding 3 critical parameters:

1)Current licensureVerification informs the organization that applicant is appropriately licensed to practice as required by state &/or federal law. The license verification process is conducted at ALL of the following times: (a) prior to granting initial privileges, (b) prior to re-privileging, & (c) at time of license expiration.

2)Education and relevant trainingVerification informs the organization of applicant’s clinical knowledge and skill set. Whenever feasible, verification should be obtained from original source of specific credential. When not possible, reliable secondary sources* may be used.

• A reliable secondary source can be another hospital that has documented primary source verification.

3)Experience, ability, & current competence to perform the requested privileges.

–Verified by peers knowledgeable of applicant’s professional performance. This process may include an assessment for proficiency in the 6 areas of “General Competencies”.

Why Verify?To minimize possibility of granting privileges) based on fraudulent

documents.


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The Credentialing process …For those of you in Medical Staff Services … we’ve come a long way,

haven’t we?

In 1988 the Joint Commission began to require Primary Source Verification (PSV) … which changed the credentials file from a skinny folder to a very fat folder. The reappointment application packet was one page, front and back. Now the reappointment packet is ½” to 1” thick depending on the practitioner.

HOWEVER … the good news in the last few years is the impact of the Internet, email, faxing, credentialing software, and scanners!!!!

The PSV process in some aspects takes seconds as opposed to the days and even weeks it used to take. SCANNING technology saves filing time and space. And with TJC now permitting us to share PSV with other TJC-accredit4ed hospitals … this has also been a major time-saver.

While the credentialing process is becoming more and more streamlined, the same cannot be said of the privileging process … YET!!!


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The Privileging process …

Typically entails …

1) Developing and approving a procedures list 2) Processing the application3) Evaluating applicant-specific information4) Submitting recommendations to governing body for

applicant-specific delineated privileges5) Notifying applicant, relevant personnel, and, as required by

law, external entities re privileging decision6) Monitoring the use of privileges and quality of care issues

Add to the above three (3) new TJC Medical Standards


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Let’s FOCUS …… on these 3 newest concepts related to the Credentialing &

Privileging processes

6 General Competencies FPPE OPPE


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1st NEW CONCEPT: 6 General Competencies*NEW STANDARD (2007): The integration of the

6 General Competencies* into the Credentialing & Privileging processes.

The 6 areas:

*Developed by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) joint initiative.

Why? To allow the organized medical staff to expand

to a more comprehensive evaluation of a practitioner’s professional practice.

Patient Care

Medical/Clinical Knowledge

Practice-based Learning & Improvement

Interpersonal & Communication Skills

Professionalism

Systems Based Practice


http://www.acgme.org/outcome/

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6 General Competencies as defined by TJC - “Practitioners are expected to …”

… but how to measure?

Patient Care

… provide patient care that is compassionate, appropriate & effective for promotion of health, prevention of illness, treatment of disease, & care at end of life.

Medical/Clinical Knowledge

… demonstrate knowledge of established & evolving biomedical, clinical &social sciences, and the application of their knowledge to patient care and the education of others.

Practice-based Learning & Improvement

… be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices.

Interpersonal & Communication Skills

… demonstrate interpersonal & communication skills that enable them to establish & maintain professional relationships w/patients, families, & other members of health care teams.

Professionalism

… demonstrate behaviors that reflect commitment to continuous professional development, ethical practice, understanding and sensitivity to diversity, & responsible attitude toward their patients, their profession, & society.

Systems Based Practice

… demonstrate both an understanding of contexts & systems in which health care is provided, & ability to apply this knowledge to improve and optimize health care.


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Getting started …

Make an inventory of what you are already

measuring.

Decide which of the 6 general competency(ies)

the data satisfies.

Can you pull that data into a profile format that

can be generated periodically?

Etc.

Risk Mgmnt(variances,

sentinelevents Pt.

Satisfaction Survey

Comments

VolumeReport

Elements

PICommitteeActivities

PeerReview

CommitteeActivities

WhichCompetency

???


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General Competency #1 - Patient Care

For Measures, consider …

Core Measures (CHF, P, MI data) SCIP Data Results of cases referred to Peer Review

Committee Report of diagnoses treated & procedures

performed Mortality Rates


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General Competency #2 – Medical/Clinical Knowledge

For measures, consider …

Continuing Medical Education (CME) activities attended

Board certification

Appropriateness of antibiobic usage


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General Competency #3 – Practice-based Learning & Improvement


Continuing Medical Education (CME) hours related to specialty

Post-graduate training, preceptorships Board certification Education regarding pathways, protocols,

best practices … as a result of cases identified thru peer review cases.


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General Competency #4 – Interpersonal & Communication Skills

For Measures, consider … Patient/Family Satisfaction Survey comments (complaints + compliments) Written complaints from peers and associates (e.g., case managers; ED staff) Inappropriate comments in medical records about other physicians Monitoring of handwriting legibility. Use of unacceptable abbreviations. Timeliness of H&Ps and operative notes.


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General Competency #5 - Professionalism


Written complaints from peers and associates Inappropriate comments in medical records

about other physicians Timeliness of H&Ps and Operative Reports Medical record suspensions/delinquency MS meeting attendance Responsiveness to ER Call obligations Compliance with MS Bylaws & Rules & Regs Participation on MS committees


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General Competency #6 – Systems Based Practice


Avoidable Days Average LOS Utilization of Resources Clinical Pathways


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Why do we need to measure physician competence?

Patient SafetyQuality of Care

To report to the physician for his/her own use …(If a hospital provides a physician with reliable

performance data, performance WILL CONTINUOUSLY IMPROVE!)


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Once you have the 6 General Competency

measurements defined …

you can incorporate them into the

remaining 2 new processes:

OPPE and FPPE.

Let’s look at them now.

6 GeneralCompetencies

OPPE(Ongoing

ProfessionalPractice

Evaluation)

FPPE(Focused


Evaluation)


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2nd NEW CONCEPT:Ongoing Professional Practice Evaluation

(OPPE)STANDARD MS.4.40: “OPPE information is factored into each

decision to maintain existing privilege(s), revise existing privilege(s), or revoke existing privilege(s) prior to or at time of

renewal.”TRADITIONAL Credentialing & PrivilegingProcedural and cyclical processes … practitioners

evaluated (1)when privileges are initially granted and

(2)every 24 months thereafter [i.e., reappointment].

NEW! OPPEContinuous evaluation of practitioner’s performance. Requires medical staff to conduct ongoing evaluation

of each practitioner’s performance. Allows ID of professional practice trends that impact quality of

care & patient safety.


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TJC: “OPPE CRITERIA may include:

_ Review of operative & other clinical procedure(s)* performed and their outcomes

*Includes operative and other invasive & noninvasive procedures that place patient at risk. Focus is

on procedures & is not meant to include medications that place patient at risk.

_ Patterns of blood and pharmaceutical usage_ Requests for tests & procedures_ Length of stay patterns_ Morbidity & mortality data_ Practitioner’s use of consultants_ Other relevant criteria as determined by

Medical Staff”The type of data to be collected is determined by individual departments and approved by the

organized medical staff.


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Information used in OPPE may be acquired thru:

_ Periodic chart review

_ Direct observation (proctoring)

_ Monitoring of diagnostic and treatment techniques

_ Discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, nursing, and administrative personnel.


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There must be a CLEARLY DEFINED OPPE PROCESS!

Relevant information obtained from OPPE is integrated into PI activities.

PI activities adhere to policies/procedures intended to preserve confidentiality or legal privilege of information established by applicable law.

If there is uncertainty regarding a practitioner’s professional performance, the Medical Staff should follow course of action defined in the MS Bylaws for further evaluation of a practitioner.

NOTE: Privileged practitioners have access to the medical staff fair hearing and appeal process should the

intervention result in corrective action.


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STANDARD MS.4.45

“The organized medical staff evaluates and acts upon

reported concerns regarding a privileged practitioner’s clinical

practice and/or competence.”


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RATIONALE: A well-structured internal reporting process supports OPPE and enhances the quality of

care & patient safety.

Effective OPPE =

Systematic Measurement +

Systematic Evaluation +

Systematic Follow-throughBased on this equation … creating a systematic and timely physician competency report* will be the key to successful

OPPE. *See 26.1 for Sample Physician Competency Report. SOURCE: The Greeley Company.

How often will reports be generated?

Can we modify the CURE report to follow the 6 General Competencies format and be our OPPE tool?


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6 GeneralCompetencies

OPPE(Ongoing


Evaluation)

FPPE(Focused


Evaluation)

What happens when OPPE identifies a problem?


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This bring us to the 3rd New Concept:Focused Professional Practice Evaluation

(FPPE)Standard MS.4.30 – effective 1/1/08 FPPE is a process used by the

organization in 2 circumstances.

1. Evaluation of privilege-specific competence of a practitioner who does not have documented evidence of competently performing the requested privilege(s) at the organization.

AND2. May be used when a question arises regarding a

currently privileged practitioner’s ability to provide safe, high quality patient care.


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Focused Professional Practice Evaluation (FPPE)

Standard MS.4.30 – effective 1/1/08In FPPE the organized Medical Staff

does the following: Evaluates practitioners without current performance

documentation at the organization Evaluates practitioners in response to concerns

regarding the provision of safe, high quality patient care

Develops criteria for extending the evaluation period

Communicates to the appropriate parties the evaluation results and recommendations based on results

Implements changes to improve performance


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Focused Professional Practice Evaluation (FPPE)

Standard MS.4.30 – effective 1/1/08 The FPPE process is defined by the

organized Medical Staff.

The time period of the evaluation can be extended … and/or a different type of evaluation

process assigned.


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Although this standard went into effect 1/1/08,

approximately 75% of hospitals do not have a defined FPPE process in place yet.

Why?What is required?


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It’s a BIG process!!!

TJC requires use of an FPPE process to confirm competency for ALL initially granted

privileges.AND

When questions arise in the OPPE process related to competency.

“Triggers” that indicate the need for performance monitoring must be defined.

TJC is looking for CONSISTENT implementation.


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Information for FPPE may include: Chart Review

Monitoring clinical practice patterns

Simulation

Proctoring - Prospective, Concurrent, and/or Retrospective**Excellent Resource: “Proctoring & FPPE” - The Greeley Company. Recently used by our new MS President to design a proctoring process when questions arose about a practitioner’s competency..

External Peer Review

Discussion with other individuals involved in the care of each patient (e.g., consulting physicians, assistants at surgery, nursing, or administrative personnel).

COLLABORATIONamong hospital depts (including hospitalists)

and the Medical Staff is KEY.


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Elements of Performance:EP-1 - A period of focused professional

practice evaluation is implemented for all initially requested privileges.

EP-2 – The organized medical staff develops criteria to be used for evaluating the performance of practitioners when issues affecting the provision of safe, high quality patient care are identified.


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Elements of Performance:

EP-3 – The performance monitoring process is clearly defined and includes each of the following elements: Criteria for conducting performance

monitoring Method for establishing a monitoring

plan specific to the requested privilege Method for determining the duration of

performance monitoring Circumstances under which monitoring by

an external source is required.


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EP-4 – FPPE is consistently implemented in accordance with the criteria and requirements defined by the organized medical staff.

EP-5 – The triggers* that indicate the need for performance monitoring are clearly defined.

“Triggers” can be single incidents or evidence of a clinical practice trend.


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EP-6 – The decision to assign a period of performance monitoring to further assess current competence is based on the evaluation of a practitioner’s current clinical competence, practice behavior, and ability to perform the requested privilege.*

*Other existing privileges in good standing should not be affected by this decision.


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EP-7 – Criteria are developed that determine the type of monitoring to be conducted.

EP-8 – The measures employed to resolve performance issues are clearly defined.

EP-9 – The measures employed to resolve performance issues are consistently implemented.


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The FPPE clock starts tickingwhen an applicant is approved for privileges by the

Board.

There must be a mechanism for tracking physicians and AHPs undergoing FPPE and ensuring that there is an evaluation and action taken at the end of the FPPE

period.


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FPPE - Where to Begin?

Assign an ad hoc task force of medical staff members and hospital associates.

Build on the strengths of existing processes. Use your OPPE Physician Competency Reporting process, your Peer Review Committee …

Establish accountabilities.

Assure all participants understand their roles & accountabilities.

Document the process in a policy & procedure.Sample FPPE Policy. Source: The Greeley Company.

Implement.


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Remember who owns FPPE …… the Organized Medical Staff!

Who are the Key Individuals/Groups?

for Design of FPPE:Medical Staff Organization leaders

Dept Chairs/Section ChiefsCredentials Committee

PI Committee/Peer Review CommitteeMEC

for Support of FPPE:Medical Staff Services DepartmentQuality Management Department


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FPPE – What are Typical Roles of Key Individuals/Groups?

Medical Staff Services DepartmentCommunicating requirements to involved practitioners and staff

TrackingReporting (status reports)

Notifying (practitioners, dept chairs, etc.)Summarizing and presenting results

Documentation of the review process, ensuring follow-through.

Quality Management DepartmentSupporting the peer review-like processes

Screening casesFacility of review processes (participation in committees and with individuals)

Collecting any required aggregate dataForwarding results of review to MSSD


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FPPE – What are Typical Roles of Key Individuals/Groups?

Each Clinical SpecialtyExamines current methods & systems for confirming competency for new

applicants/new privileges.Evaluates current privilege forms to determine scope of services for which

competencyneeds to be confirmed.

Identifies what new methods for confirmation of competency need to be developed.Develops specialty-specific written plan/guidelines.

Submits guidelines to Credentials Committee.

Department ChairsTailor guidelines to new applicants

(depending on privileges requested, knowledge of applicant’s current competency, etc.).

Make written recommendation related to FPPE(along with recommendation related to granting of privileges)


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FPPE – … more typical Roles of Key Individuals/Groups …

Credentials CommitteeDevelops overall policy/procedure for FPPE

Evaluates recommendations/plans made by department chairs.

Medical Executive CommitteeFinal recommending authority for FPPE.

Board of DirectorsFinal approval/denial authority for FPPE.


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Medical Staff StandardsNew/Challenging -

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FPPE Process - What will it take?

Education of Elected Medical Staff Leaders and hospital associates who

support the FPPE process. Selection of MS leaders willing to take on

the challenge & spend the time it will take.


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Developing & maintaining

credible processesto determine competency

requires diligent

data collection …&

data evaluation.


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… And Collaboration!!!!

COLLABORATION among hospital depts (including hospitalists) and the Medical Staff is KEY.

Don’t work in a vacuum.

Access to a shared tool (i.e., software) to maintain information about status/tracking of FPPE – this provides the “glue” to assist in

communication.


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Collaboration!!!!

(cont’d)

Understand each department/area’s

specific accountabilities.

Identify required outputs/inputs.

Flow diagram.

Imbed utilization of IT.

Linda Van Winkle

lkdf


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Get the right information to the right people at the right time!

Peer Review CommitteeDepartment Chairs

Credentials Committee

Linda Van Winkle

lkdf


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Ensure Analysis and Evaluation …

… And Follow-Through,

to Competent Practitioners

providing Quality, Safe Patient

Care!!!


March 13, 2008 52


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Some last-minute FPPE Lessons Learned

Develop overall policy before developing individual FPPE criteria.

Make guidelines reasonable & attainable.Do not overuse labor-intensive FPPE methods

such as concurrent proctoring.Build in ability to shorten or lengthenFPPE process as situation requires.


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Let’s work together to get the processes in place!


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March 13, 20081 Medical Staff Standards New … Challenging Presentation by Linda Van Winkle, CPMSM,...

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