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Inside: Quality physicians

Credentialing Resource Center Connection, June 7, 2007

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Sally J. Pelletier, CPMSM, CPCS, is a consultant with The Greeley Company, a division of HCPro, Inc., specializing in the areas of credentialing and privileging.

Dear credentialing colleague:

As I was browsing one of the numerous retail catalogs I receive in the mail each day, the front cover of one catalog caught my eye with this statement: "Inside: Quality Furniture." Inside the catalog, the furniture descriptions went on at length to define what characteristics constitute quality furniture. Such descriptions included "wide and comfortable seating," and "finest mortise and tenon joinery for lifelong durability."

That got me thinking about how a hospital might describe its "products" if its "cover" said, "Inside: Quality Physicians." Having well-designed and meaningful credentialing, privileging, and ongoing monitoring systems would certainly be part of that description. Your particular hospital might also define a quality physician as someone who does the following:

-          Treats all patients and fellow members of the healthcare team with dignity and respect

-          Participates in relevant continuing medical education (CME) as evidenced by practicing the current standard of care

-          Completes medical records in a timely fashion, and ensures that they are legible and contain pertinent information

-          Maintains and respects patient confidentiality at all times

-          Holds board certification in his or her primary area of practice

There are, of course, many policies, processes, and practices that your institution must have in place before it can make the statement, "Inside: Quality Physicians." 

Regulators like The Joint Commission also play a role in defining quality physicians. The Joint Commission has incorporated three new concepts into the 2007 Medical Staff Standards that are designed to measure what constitutes a quality physician. The first such concept is the Accreditation Council for Graduate Medical Education/American Board of Medical Specialties' six general competencies:

-          Patient care

-          Medical/clinical knowledge

-          Practice-based learning and improvement

-          Interpersonal and communication skills

-          Professionalism

-          Systems-based practice

The Joint Commission also requires your organization to have mechanisms in place to measure those competences, known as focused professional practice evaluation (FPPE) and ongoing professional practice evaluation (OPPE).

For a number of years, The Greeley Company has been promoting, as best practice, the need for hospitals to define how they expect physicians on their medical staff to function within their organization, and then communicate those expectations to physicians. This approach includes setting and communicating clear expectations to all staff members, and then measuring performance against these expectations and providing periodic feedback (both positive and negative) through an evaluation process.

As the focus increases on using evidence-based data to determine physician competency both for the initial applicant and during the renewal of privileges, the importance of collaboration between the quality department and the medical staff office also increases.

You should design your privileging systems to ensure that the hospital has quality physicians who have been fully vetted by an evaluation of their licensure, training, experience, and competence to perform the procedures and/or privileges requested and granted. Privileges should be criteria based and establish minimal qualifications for all applicants. Healthcare organizations must also assess each candidate regarding character, competence, training, experience, and judgment. 

Any hospital should want its clinical reputation to be based on the high quality of its practitioners and its commitment to patient safety. From a risk-management perspective, the organization wants a credentialing and privileging process that is as risk adverse as possible and provides a strong defense from negligent credentialing lawsuits. The governing body is ultimately responsible for the quality of the care provided by the institution and needs to be able to trust that there are well-designed systems in place upon which they ultimately grant approval for privileges.

Remember, credentialing has no other master than the patient.

That's all for this week.

All the best,

Sally J. Pelletier, CPMSM, CPCS

http://www.greeley.com/consulting.cfm

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