HCPro.com - Credentialing Resource Center

Get your reappointments on the right cycle

Sun, 01 Jul 2012 04:00:00 GMT

Get your reappointments on the right cycle

If your reappointment process has become another exercise in paperwork, it's time to reassess it. Medical staff reappointment is another way for your organization to make sure only qualified, competent practitioners are providing expert care to your patients.

Without an efficient process in place-which includes a reasonable timeline-the importance of reappointment can become overshadowed by rushing to meet deadlines or processing unnecessary paperwork.

Whether you need to create a reappointment process or edit your existing one, the first thing you will need to do is consult your medical staff bylaws. If reappointment is addressed in your bylaws, the most important thing is to make sure your organization is following what is spelled out in those bylaws.

CHRISTUS St. Patrick Hospital in Lake Charles, La., learned this the hard way. The organization's bylaws are very prescriptive about the timeline to be followed for reappointment-from notifying the practitioner to getting the application to the board.

In the hospital's bylaws, it states the practitioner will receive a reapplication packet six months prior to his or her privilege expiration date. Because of that, there is no wiggle room for getting the packets out late.

During a recent survey by the Louisiana Department of Health and Human Services, the organization was dinged for mailing out one batch of reappointment letters late.

"We were two weeks late mailing them. Even though that was going to give [the practitioners] five and a half months, the surveyor dinged us for that. He said if we didn't have it in our bylaws, he wouldn't have counted it off," says Linda Van Winkle, CPMSM, CPCS, manager of medical staff services at St. Patrick. "So if you have it in your bylaws, you have to follow it."

It is up to your organization to decide whether you want to include deadlines for reappointment in your bylaws. The con is that you must meet those specific deadlines. However, being held to such standards can also be a good thing for you and the medical staff.

"There is so much going on in the medical staff office that it is good to have your rule that says, 'This is how it is going to be done.' It holds our feet to the fire," explains Van Winkle.

Including deadlines in the bylaws also gives MSPs a leg to stand on when practitioners do not meet them. "When we have an employee who is new in the department or a physician who wants to see what the process is, it is good to have it in the bylaws," continues Van Winkle.

To make the strict deadline for mailing out packets work, your organization must set up a notification system, either through your credentialing software or a manual spreadsheet. This should give you a way of tracking who is up for reappointment in what month. From that point, you must determine when the notification process begins.

The medical staff services department at Tuality Community Hospital in Hillsboro, Ore., sends out reapplication packets seven months in advance. "We do it seven months in advance just because there are those practitioners that take 60 days to reply," says Ann Klinger, CPCS, medical staff coordinator at Tuality.

Because the state of Oregon uses a standard medical staff application and Tuality uses a CVO, applicants receive the standard application from the CVO and a supplemental packet including the privileging form from Tuality. Klinger says the packet includes a letter that states, "This starts your re-credentialing process; you have 30 days to reply."

If practitioners have specific deadlines to meet for returning the application, make sure this is clearly spelled out in a cover letter sent with the application. This prevents practitioners from saying they did not know there was a deadline. Another helpful thing to do is to call or email the applicant to make sure he or she received the packet. Although it is the responsibility of the practitioner to keep his or her medical staff membership and privileges active, many practitioners rely on MSPs to keep them on track because they're so busy.

It is especially important to make sure the practitioner received the packet if you have not heard back from him or her by the first deadline. You can start by sending a friendly reminder, but after that, Klinger and Van Winkle advise sending a certified letter telling the practitioner that his or her membership is going to expire, and that he or she may be subject to an application fee and, eventually, voluntary termination of medical staff membership and privileges.

Klinger says she sends out her "nice" letter after 30 days and her "mean" letter after 60 days, thus giving the applicant 90 days to respond. On day 91, if there has been no communication from the applicant, he or she is resigned from the medical staff and has to go through the same process as a new applicant, including paying all of the relevant fees.

To keep track of reminder dates for each applicant, Van Winkle advises setting up alerts on your computer calendar/appointment program. "Otherwise, you aren't going to think about it," she says.

It is also important to notify any organizations or departments within your organization that are involved in the process. For example, Klinger has to communicate with her CVO regarding which applicants are due for reappointment. Because the CVO likes to re-credential on an alphabetical basis, if they are working on the letter "K" and someone with the letter "V" needs a packet soon, Klinger alerts the CVO.

If your quality department stores practitioners' OPPE reports, this department must also be notified in advance of when these files will be needed.

Stalling the process

The same red flags on a credentials file that arise during initial appointment can also be a problem during reappointment. Although you don't need to reverify a practitioner's education or malpractice coverage history at reappointment, you do need to get an updated claims history verification from the insurance carrier or verify any new educational endeavors. An example of a recredentialing application process is included on page 5.

Obtaining these verifications at reappointment is no quicker than at initial appointment. And the onus is still on the applicant to provide this information and turn in a completed application.

Instead of pulling the bylaw caveat that the burden is on the physician, Klinger prefers to remind applicants that organizations usually respond quicker if the applicant calls requesting the information. Healthcare facilities where the practitioner previously practiced will be more likely to bump the practitioner's request for information to the top of their to-do list if the practitioner picks up the phone and says, "You are holding up my application." Additionally, some malpractice insurance companies prefer to send information directly to the practitioner.

Although it is not the MSP's responsibility to get the information, most MSPs are willing to help because they have personal relationships with their medical staff members and know they are busy. Klinger discovered a trick that has served her well over the years. When she attends state or national medical staff services conferences, she tries to make as many connections with people from other facilities as possible.

"If I have met someone from Wisconsin and we exchange cards, and I have a physician that comes on board either from the same facility or Wisconsin, I call my contact and say, 'Hey, do you have any good resources at this facility? They might have a tip for how to get a hold of someone at that hospital," she says.

These holdups are why it is important to start the reappointment process early. Another reason is what can happen once medical staff leaders start reviewing the file.

Taking it to the board

Before taking reappointment files for approval, you need to know who will need to review the file and when those committees meet. For example, St. Patrick's governing board meets once a quarter, so Van Winkle has to prepare and bring to the board all reappointments that will expire during that three-month time period without a meeting.

The file will also be viewed by the credentials committee and a division chief or department chair, so allow enough time for these reviews to happen as well.

If your credentials committee and board meet once a month, you still want to give yourself some leeway with reappointments.

Klinger takes reappointments to the board 30 days prior to expiration. "In case my executive committee or board wants additional information, it gives me an extra 30 days to get it before that physician's privileges expire," she explains. "You never know what may come up or get questioned. It is always better to have that [time]."

However, she cautions against taking files to committee too far in advance of expiration. "I would say if you are taking it to committee 90 days prior, I think that opens up too much of a window for something to change on a physician's status," Klinger says.

To deal with this, Van Winkle's department will review the information collected to make sure it is up to date. She says because the medical staff at her facility is small, they know most of the practitioners and know if anything has happened. She gets an email notifying her when a change has been made to the status of one of her practitioners on the NPDB, so she does not have to rerun that report.

There are also pieces she will wait to verify until the file is about to go to committee, such as license verification. Van Winkle says this is easy to do because these items can be verified online.

In fact, because so much is done online now, CHRISTUS Health (which St. Patrick Hospital is part of) is developing an online application for initial and re-appointment. This will standardize the process among the hospitals in the health system, and it will make the process easier for practitioners.

"That way the doctor can get in [at any time] and it is not just paper floating around his office," says Van Winkle. "I am sure online applications are the wave of the future as we go paperless."

How should we address reappointment in our bylaws?

At CHRISTUS St. Patrick Hospital in Lake Charles, La., the medical staff wrote a very prescriptive bylaw about the reappointment process. Linda Van Winkle, CPMSM, CPCS, manager of medical staff services, says this helps the medical staff services department keep reappointments on track and helps them enforce the process when questioned by practitioners. Below is the language of the hospital's bylaw:

The reapplication form is mailed to each practitioner scheduled for reappointment six months prior to expiration of the appointment period. The member completes and signs the reapplication form and returns it to the Medical Staff Services Office. The deadline for receipt of the reapplication form by the Manager of Medical Staff & Credentialing Services is six (6) weeks after the date the application form was mailed. A reapplication form received after that date is delinquent. A member whose reapplication form is delinquent will be notified by certified mail that the application is delinquent and that, if the completed reapplication form has not been received by eight (8) weeks after the date the application form was mailed, he is subject to an automatic reapplication fee, in an amount specified by the Medical Staff executive committee, if a completed reapplication form has not been received by the 8-week deadline. If the form has not been completed and processed by the date of expiration of the appointment period, the member is considered to have voluntarily resigned from the Medical Staff.

Due diligence: Handling imposters and questionable physician history

Sun, 01 Jul 2012 04:00:00 GMT

Due diligence: Handling imposters and questionable physician history

One of the primary roles of an MSP at any healthcare facility is ensuring that a physician actually possesses the credentials that he or she claims to have. An MSP must closely examine a physician's background and history for evidence of qualifications or instances of poor performance. Failure to do so could have devastating consequences, particularly with regard to patient safety.

Nothing left unturned

"The medical staff offices are really the first line of patient safety, and we take that very seriously as credentialing staff and medical staff professionals," says Kay Brown, CPMSM, CPCS, director of medical staff services at St. Vincent Healthcare in Billings, Mont. "The patients never see us, but we're working on their behalf to make sure that the providers that are caring for them are competent."

Yet occasionally an imposter is able to slip through the cracks and come into contact with patients. Just last year, a Florida teenager obtained a hospital badge and impersonated a physician's assistant for nearly a week-conducting exams, providing patient care, and accessing confidential patient information-before hospital staff became suspicious and alerted authorities. According to Brown, however, cases of nonphysicians gaining privileges or access to patients at hospitals are rare because of "stopgaps" built into credentialing processes.

Brown notes that her facility prescreens all interested parties before they go through the formal application process. During this prescreen, Brown looks for an AMA profile to verify a physician's information; she recommends checking the imposter list maintained by the Federation of State Medical Boards (www.fsmb.org/pdf/imposters.pdf) as well as searching for any other publically available information.

"Google is a wonderful tool for us," Brown says. "We try to do as many searches as we can to make sure that the provider is bona fide."

Following a prescreen, Brown and her staff go through the typical process of verifying credentials, checking the applicant's work history, confirming board certification, examining procedure logs, and looking into affiliations with other facilities.

"We try to get validation of all those items so that we fill every gap within their medical history life, and so that there's nothing left unturned," Brown explains.

Oftentimes, the applicants that cause the most concern are not those who impersonate physicians without possessing any of the appropriate credentials-instead, they are credentialed physicians with questionable histories.

"Most of the [applicants] that we have concerns about are the one that have had malpractice cases and sanctions for whatever reasons," notes Kathy Mosley, BSN, CPMSM, CPCS, medical staff performance improvement coordinator at Northern Navajo Medical Center in Shiprock, N.M. "Once they've been scrutinized and credentialed and verified, judgments have to be made on their backgrounds and their pasts."

Mosley works at a federal facility, which means that department chairs are only allowed to recruit from certain agencies that are on a government-approved list. That does not mean, however, that her facility can be any less vigilant in checking data bank reports and credentials. One of Mosley's major concerns lies in appointing locum tenens. Because locums move around more than ordinary physicians and have an extensive work history that medical staffs must go through, high locum use increases the likelihood of someone getting through the system that should not. It also increases the use of temporary privileges, which could lead to legal liability if a facility does not properly monitor the expiration of those privileges, according to Mosley. She notes that locum use falls into the high-risk, problem-prone quality categories as defined by The Joint Commission.

Getting everyone involved

Whether the applicant in question is an imposter or a credentialed physician with a history of poor performance, notifying all relevant parties is essential. This includes not only people within your organization but also the appropriate outside authorities. In the case of imposters, you should contact local law enforcement, state medical boards, and accrediting agencies.

"It's really important to report it to law enforcement," say Brown, whose facility recently dealt with a man claiming to have the proper credentials. "Particularly in Montana, before the state medical board can act upon it, there has to be an official legal complaint made. And until such time, they can't file a complaint with the Federation of Medical Boards to put the physician on an imposter list that is published nationally."

Brown notes that law enforcement sometimes hesitates to act because they are not certain what role they play in preventing imposters. Before an issue arises, check with your local law enforcement agency to see how they would handle an imposter situation. Also, make sure to have documentation of all interactions with the imposter. Medical boards and accreditation agencies are more receptive to these reports but will ask for documentation and other information. Brown also advises reaching out to other MSPs to warn them of potential issues with individuals posing as physicians.

Within your facility, the entire medical staff should be attuned to who belongs and who does not, and should not be afraid to ask for identification.

"When in doubt, you should always check the credentials of a provider," says Brown. She adds it is always best to be proactive about the situation, even if you end up querying an authorized individual or a resident who just misplaced his or her identification badge.

A similar level of staff involvement and communication is required if red flags come up while checking credentials. As mentioned, a physician may have all the necessary credentialing documents, but might also have malpractice cases or license sanctions. In these instances, it is important to bring concerns to the attention of department chairs and other decision-makers. Some physician leaders may not be as concerned with red flags, in which case you may need to take the issues to other leaders in the organization.

One way to keep executive leadership involved in credentialing concerns is to scan data bank reports and note concerns, and then attach those to email communications with the executive leadership, says Mosley.

Communication across departments ensures that nothing is overlooked and that all parties involved in the hiring process are well informed of any potential issues. MSPs should not be afraid of the reactions that questioning a provider's past may cause. Physicians may become defensive when they feel they are being scrutinized, but the medical staff must perform its due diligence regardless, according to Mosley.

"You need a credentialer who really has a backbone," she says. "If you have really passive people doing credentialing, it doesn't work and someone could slip through the system."

Everyone should be aware of the processes in place when hiring new individuals. The medical staff should make credentialing policies as clearly defined as possible, which may be difficult because there are many parameters that may seem simple and basic but cannot be followed if they are not written into policies or bylaws, says Mosley.

"If the medical staff defines everything and has it written down, it's really easy for someone doing the credentialing to follow, whether it's someone who's been doing the job for 10 years or someone who is filling in," she says. "It's right there in black and white, and you don't have any second guessing."

By keeping communications open, reporting suspicious activities or concerns, and creating comprehensive policies, MSPs can fulfill their role as the first line of defense in patient safety.

New policy lays the term 'board eligibility' to rest

Sun, 01 Jul 2012 04:00:00 GMT

New policy lays the term 'board eligibility' to rest

ABMS establishes time limits between residency and certification

Gone are the days when physicians could claim they were board eligible, even if they finished residency training 30 years ago. Effective January 1, the American Board of Medical Specialties (ABMS) has put limits on the time between when a physician finishes residency training and when he or she passes the board certification examination. MSPs are welcoming the policy change with open arms because it defines a once-hazy term that made it difficult to determine a physician's eligibility to join a medical staff.

"We made the change because, despite our efforts, physicians can claim to be board eligible for decades, and we think that link between residency training and when you get certified is important. It shouldn't go on for decades because it is a system-training and certification are linked," says Sheldon D. Horowitz, MD, senior advisor of professional and scientific affairs at the ABMS.

As a result of the policy change, physicians must achieve initial board certification between three and seven years after completing Accreditation Council for Graduate Medical Education-accredited residency training. Horowitz notes that the three-year minimum is simply an estimate given that some boards require physicians to get hands-on practice experience before completing the certification exam, while other boards allow physicians to take the exam immediately after completing residency training. After seven years, a physician can no longer claim to be board eligible; to do so would breach medical ethics.

Each of the 24 ABMS member boards has established a specific time period for physicians to pass their certifying exam depending on the exam requirements and schedules. For example, some boards require written and oral examinations spaced apart, while others only require a written examination. Thus, the ABMS could not apply a single timeline across all member boards.

Member boards may choose to waive time restrictions for physicians under extenuating circumstances, such as acute illness or military deployment.

Physicians who have completed residency training but have not yet achieved board certification must pass their certifying examinations in accordance with the time limits of their member board. Each member board will specify its time limits going forward and will choose a year by which physicians currently in process must achieve certification. The year chosen must occur between 2015 and 2019.

Each member board is in the process of developing a reentry process for physicians who fall outside of the time limit. Physicians may be required to participate in additional education, training, testing, self-evaluation, or performance evaluation before becoming eligible to recertify.

"They can't just be board eligible for seven years, miss the end date, and then just start again. There will have to be a reentry plan if they want to get back in," says Horowitz.

Policy change makes credentialing clear-cut

So what does all of this mean for the credentialing process? "It's good news," says Kathy Matzka, CPCS, CPMSM, a medical staff consultant in Lebanon, Ill. "If everyone has to be certified in seven years, we can write that language into the bylaws. Historically, it has been a moving target because people can remain board eligible for a pretty long time, and some boards have limits but others do not, so now we have a clear line in the sand."

For hospitals that do not require physicians to be board eligible, the ABMS policy change may spark a discussion as to whether it's time to add that requirement to the bylaws now that it is a more meaningful achievement. For hospitals that already require physicians to be board certified or board eligible, the ABMS policy change helps define the term "board eligible" and makes the task of determining a physician's eligibility to join the medical staff simpler.

"It will help simplify the credentialing process because it helps define the parameters of what board eligibility means," says Michael Coyne, director of business development at ABMS. "The limits give medical staff professionals the ability to find out if board eligibility is being reported inappropriately. If there are limits, it will be obvious when there has been a breach of ethical standards with physicians reporting board eligibility."

Medical staffs should look through their rosters of medical staff members to see who is board eligible under the policy. Matzka says that most medical staffs will elect to grandfather in physicians who joined the staff before the policy change took effect.

"I think if a physician has been working all this time without being board certified, I doubt the hospital is going to require them to be board certified. Usually, if they have the requirement in the bylaws, it is for when someone new comes on staff," Matzka says.

Medical staffs that require physicians to be board certified or eligible must also review their bylaws language to ensure that it complies with the policy change. According to Matzka, because each board has determined its own time frame, it's not wise to include a blanket seven-year provision for all physicians on staff because each board has its own time limit, which falls anywhere between three and seven years.

"I would make sure the language is generic enough to accommodate each board's requirements. It may say, 'Each physician must be board eligible or qualified within the appropriate number of years according to the specific board.' If you leave it open, you can simply refer back to that board for the time frame," says Matzka.

At Baystate Health in Springfield, Mass., the ABMS policy change will not likely change the medical staff bylaws, says Roxanne Chamberlain, MBA, CPMSM, CPCS, director of medical staff services and provider enrollment. The medical staff bylaws already require physicians to become board certified within five years of joining the staff, which falls nicely in the middle of the three- to seven-year period ABMS requires.

Matzka also notes that the ABMS policy change will be helpful when it comes to recruiting and contracting with physicians. "If the hospital requires board certification, they can put a finite number of years on each physician contract," she says. "People who are recruiting need to look at the contractual language."

The bigger picture

Horowitz explains that the policy change is part of a bigger initiative to make board certification a more meaningful endeavor for physicians that will ultimately result in better patient care and outcomes. The maintenance of certification (MOC) initiative that the ABMS rolled out in 2006 is part of the same initiative.

There has been much debate in recent years as to the value of board certification. Until recently, becoming certified usually required a physician to take an exam every 10 years, which did not speak to his or her current competence. Many medical staffs stopped requiring physicians to be board certified because they found that a larger percentage enjoyed successful practices without ever having taken a board certification exam.

Thanks to MOC, instead of merely taking a periodic examination, physicians are required to participate in ongoing education and assessment, which may include self-assessments, participation in practice performance evaluation, reading assignments, and other activities. The recent policy change putting time limits on board eligibility help assure medical staffs that when a physician claims to be board eligible, he or she will be taking the examination within a specified time frame, and after certification will be demonstrating current competence during the MOC process. For medical staffs tasked with verifying applicants' qualifications, the ABMS policy change is a gift.

The Complete Guide to FPPE

Sun, 01 Jul 2012 04:00:00 GMT

The Complete Guide to FPPE

The variability of peer review results across the nation has made it necessary for organizations to develop wider, more standardized systems for root cause analyses. Although the shortcomings of the peer review process cannot be solved overnight, many accreditation bodies are taking these systematic inadequacies seriously. In 2007, The Joint Commission introduced the concept of continuous evaluation and performance improvement (PI) through two concepts: OPPE and FPPE. The Joint Commission also stated that the term "focused professional practice evaluations" should be used instead of "peer review." (Source: The Joint Commission, Standards BoosterPak™ for Focused Professional Practice Evaluations (FPPE)/Ongoing Professional Practice Evaluations (OPPE), 2011.)

OPPE and FPPE increased the scope and reach of credentialing and peer review. Traditional credentialing centered on the verification of practitioners' credentials, including medical degree or professional education, board certification, professional history, continuing education requirements, recommendations and references, and legalities such as active state medical license, federal and state drug and controlled substance program participation, and malpractice and liability insurance. In addition to educational, professional, and legal validation, The Joint Commission now requires the credentialing process to include quantitative clinical and nonclinical performance indicators to ensure a comprehensive evaluation process.

Joint Commission-accredited hospitals are not the only ones subject to more rigorous rules. Requirements from CMS, DNV, the Healthcare Facilities Accreditation Program (HFAP), and other organizations have also become stricter in recent years. The increasing focus on sound credentialing and privileging processes is most clearly reflected in CMS' Conditions of Participation (CoP) and interpretive guidelines, which require organizations to develop a clinical competence framework and use it to perform privilege evaluations within a time period not exceeding 24 months.

In addition, the CoP's sections on quality and PI require that "the hospital must develop, implement, and maintain an effective, ongoing, hospitalwide, data-driven quality assessment and [PI] program." Hospitals accredited by DNV or the HFAP are also subject to direct surveys by CMS, and may find the concepts in this book to be of value as they strive to increase the efficiency and effectiveness of their practitioner competency management programs and demonstrate compliance with CMS standards.

PI goes beyond legal liabilities and mandates

Besides legal liabilities and simply meeting OPPE/FPPE requirements, what is the driving force for practitioner PI? The world of healthcare is changing drastically on many levels. One of the biggest changes is the increased focus on quality improvement reflected in innovative payment structures and healthcare consumers' expectations of transparency. As hospitals, payers, and patients make conscious efforts to align with practitioners based on quality of care, outcomes, and performance, OPPE and FPPE give practitioners the framework to proactively manage their data in this era of transparency.

The principles of OPPE and FPPE affect patient care, as well as hospital and practitioner reimbursement. With healthcare reform, reimbursement is rooted in quality of care as opposed to the fee-for-service models of the past. Pay-for-performance, bundled payments, and shared savings models encourage organizations to reduce variations in quality and utilization and standardize care around best practices. Organizations that manage costs well while maintaining high quality standards will thrive best under these models.

Given these payment models, it is likely that quality data will be factored into payer contract and agreement negotiations. An early example is the hospital inpatient value-based purchasing program, which CMS proposed in January 2011 and, according to the proposal, will be implemented in fiscal year 2013. The program will make value-based incentive payments to acute care hospitals based either on how well they perform on certain quality measures, or on how much their performance improves on certain quality measures. The greater a hospital's performance outcomes or improvement during the performance period beginning July 1, 2011, for a defined period, the higher the hospital's value-based incentive payment for the fiscal year would be.

Many hospital leaders aspire for greater transparency and analysis of individual practitioner performance, believing that this focus will significantly assist hospital quality improvement efforts and promote the understanding of resource consumption, clinical quality, and utilization patterns to improve clinical efficiency. Some hospitals and practitioners are willing to go to greater depths. Hospitals with employed practitioners (especially hospitalists) are incorporating quality and performance goals, often tied to bonus structures, into their employment contracts. It only makes sense to include these same metrics in OPPE/FPPE programs where appropriate.

Several large hospital systems are forming practitioner-driven, clinically integrated accountable care organizations (ACO) that focus on delivering higher-quality care while managing medical costs. These programs measure performance across key competency areas very similar to OPPE and FPPE requirements. The goal is to negotiate payer contracts based on quality and outcomes of care, and many ACOs tie practitioners' bonus payments to their performance. Through such initiatives, hospitals and practitioners hope to provide optimal value to patients, payers, and employers through collaborative best practices, evidence-based medicine, and improved efficiencies.

Additionally, patients now have more access to practitioner quality and performance data. As the consumers of healthcare services, technology-savvy patients access performance data through websites with paid subscriptions, such as UCompareHealthCare and HealthGrades. Responding to market need, some media sources provide access to similar healthcare data free of charge. For example, USA Today allows its readers to review hospital readmission rates and mortality rankings for common diagnoses, such as pneumonia, congestive heart failure, and acute myocardial infarction.

Insurance companies also encourage patients to make educated decisions when choosing practitioners. Many insurers (e.g., UnitedHealthcare and Aetna's Aexcel) provide practitioner ratings to patients directly on their websites, guiding those patients to practitioners with better-quality outcomes and more efficient cost of care.

CMS already shares data publicly through Hospital Compare (www.hospitalcompare.hhs.gov) and is moving toward sharing core measures and more detailed practitioner-level quality data with the public through Physician Compare (www.medicare.gov/find-a-doctor).

To simply frame OPPE and FPPE as regulatory compliance mandates is missing the mark of their intent. These evaluations are fundamental to a robust practitioner PI framework and a cultural shift toward more data-driven practices. It is imperative that the OPPE and FPPE models at every organization create a meaningful quality framework that is aligned with organizational strategy and reporting initiatives and is directly connected to organizational improvement goals in patient care and clinical outcomes.

The crux of these mandates is to improve patient care through PI by reengineering medical staff governance structures, improving performance feedback reporting at the individual practitioner or aggregate group level, and conducting quality/PI projects.

Editor's note: The Complete Guide to FPPE: Strategies for Medical Staff Professionals, Physician Leaders, and Quality Directors is available for purchase at www.hcmarketplace.com or by calling 800-650-6787.

Expired reappointments: What to do when you find them

Sun, 01 Jul 2012 04:00:00 GMT

The MSP's voice by Sheri Patterson, CPCS

Expired reappointments: What to do when you find them

While auditing your credentialing database, you come across dates that send a chill down your spine. You quickly investigate only to confirm your worst fear: expired reappointments.

This is a scenario that occurs more often than any of us care to admit. There is a plethora of advice out there on how to handle the situation, from granting temporary privileges to hiding the file (which would only add to your compliance headaches instead of resolving them). The key in this situation is to remain calm and methodically go through the following steps to correct the issue:

1. Bylaws. Once you determine you have an expired reappointment, go to your bylaws to review the process for reinstatement. Facilities handle expired reappointments in varying ways, and when soliciting advice, MSPs often share their process, which may or may not be the process outlined in your bylaws. It is critical that your bylaws are followed to the letter to ensure equality in treatment of all practitioners and compliance with your organizational governing process.

2. Leadership. Alert the appropriate medical staff and administrative leadership to the situation. A practitioner on your staff whose reappointment has expired is providing services in your facility without granted clinical privileges or medical staff membership. This has both legal and fiscal ramifications that your leadership team needs to promptly be made aware of (i.e., billing for services provided by a practitioner that does not have clinical privileges at your facility and receiving these funds).

3. Practitioner. Notify the practitioner(s) involved. They need to be made aware that their medical staff membership and clinical privileges at your facility have expired. Provide the practitioner with the necessary forms and offer to assist them with preparation and completion. This demonstrates excellent customer service.

4. POC. Research how this occurred and develop a plan of correction (POC) to ensure this will not happen again. Include a monitoring period in your POC and document your reappointments for the next year to show 100% compliance with your plan.

5. MEC. Follow your bylaws process and work with your medical staff and administrative leadership to inform the Medical Executive Committee (MEC)of the situation, outline your process for correction, and move through the reinstatement process with your affected practitioner(s). Document specifics in your meeting minutes to cover discovery, notification, POC, and reinstatement of the practitioner(s) involved. Adding a topic to your regular MEC agenda for reporting of reappointment statistics will ensure that your monitoring program remains on track and your POC fulfillment is reported to the governing body.

6. Survey. The surveyors have arrived at your facility and they have the one file you were hoping they would not request. Stay calm and don't try to hide what occurred. Arm yourself with your POC, reported monitoring of reappointments to the MEC, documented procedure for reinstatement of the practitioner, and move forward.

Editor's note: Sheri Patterson, CPCS, is an interim MSP at The Greeley Company, a division of HCPro, Inc., in Danvers, MA.

Credentialing Resource Center Journal, July 2012

Sun, 01 Jul 2012 04:00:00 GMT

Get your reappointments on the right cycle

Without an efficient process in place-which includes a reasonable timeline-the importance of reappointment can become overshadowed by rushing to meet deadlines or processing unnecessary paperwork.

During a recent survey by the Louisiana Department of Health and Human Services, the organization was dinged for mailing out one batch of reappointment letters late.

"There is so much going on in the medical staff office that it is good to have your rule that says, 'This is how it is going to be done.' It holds our feet to the fire," explains Van Winkle.

To keep track of reminder dates for each applicant, Van Winkle advises setting up alerts on your computer calendar/appointment program. "Otherwise, you aren't going to think about it," she says.

If your quality department stores practitioners' OPPE reports, this department must also be notified in advance of when these files will be needed.

Stalling the process

Obtaining these verifications at reappointment is no quicker than at initial appointment. And the onus is still on the applicant to provide this information and turn in a completed application.

These holdups are why it is important to start the reappointment process early. Another reason is what can happen once medical staff leaders start reviewing the file.

Taking it to the board

The file will also be viewed by the credentials committee and a division chief or department chair, so allow enough time for these reviews to happen as well.

If your credentials committee and board meet once a month, you still want to give yourself some leeway with reappointments.

There are also pieces she will wait to verify until the file is about to go to committee, such as license verification. Van Winkle says this is easy to do because these items can be verified online.

"That way the doctor can get in [at any time] and it is not just paper floating around his office," says Van Winkle. "I am sure online applications are the wave of the future as we go paperless."

How should we address reappointment in our bylaws?

Due diligence: Handling imposters and questionable physician history

Nothing left unturned

"Google is a wonderful tool for us," Brown says. "We try to do as many searches as we can to make sure that the provider is bona fide."

"We try to get validation of all those items so that we fill every gap within their medical history life, and so that there's nothing left unturned," Brown explains.

Getting everyone involved

Within your facility, the entire medical staff should be attuned to who belongs and who does not, and should not be afraid to ask for identification.

"You need a credentialer who really has a backbone," she says. "If you have really passive people doing credentialing, it doesn't work and someone could slip through the system."

By keeping communications open, reporting suspicious activities or concerns, and creating comprehensive policies, MSPs can fulfill their role as the first line of defense in patient safety.

New policy lays the term 'board eligibility' to rest

ABMS establishes time limits between residency and certification

Member boards may choose to waive time restrictions for physicians under extenuating circumstances, such as acute illness or military deployment.

"They can't just be board eligible for seven years, miss the end date, and then just start again. There will have to be a reentry plan if they want to get back in," says Horowitz.

Policy change makes credentialing clear-cut

The bigger picture

The Complete Guide to FPPE

Tying quality metrics into clinical competence

Fri, 01 Jun 2012 04:00:00 GMT

Tying quality metrics into clinical competence

Your quality department may do a great job collecting quality data on your physicians, but if the information just sits in a file in the quality office, it is a waste of time and resources. Distributing this information in a clear and concise manner and to the proper channels is just as important as collecting the data, and to do so, there must be a strong link between the quality department and the medical staff services department.

"If quality is just gathering data in a vacuum and it goes nowhere, that does no one any good. It has to get somewhere where someone has the ability to act," says William Mills, MD, MMM, CPE, FACPE, CMSL, FAAFP, senior vice president of quality and professional affairs at Upper Allegheny Health System. The health system comprises two hospitals, one in Olean, N.Y., and the other in Bradford, Pa.

Although it is usually not the MSP's job to collect quality data, it is his or her job to get this data to medical staff members and leaders and to educate them on if and how it will be used in the reappointment process.

Upper Allegheny Health System gives physicians quarterly report cards, which include quality metrics for:

Core Measure Sets
Order set usage compliance
Lengths of stay
Results from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Press Ganey patient surveys

The report cards use multiple colors to represent levels of success so physicians can get a quick snapshot without having to read through a detailed report.

The credentials committee also sees these report cards at the time of a physician's reappointment, going back two years since the physician's last appointment or reappointment. According to Mills, no one at the health system has lost privileges because of a poor report card, but one physician who was really falling off the quality wagon was reappointed for only one year instead of two and told to improve his scores.

Mills is in favor of tying quality data into reappointment because he believes there is a link between quality and clinical competence.

"I can make a very strong case that if you are falling off on your quality metrics, your current clinical competence should be called into question," he says. "They need to be hand in glove."

Assessing quality data is a good way to get a real-time look at whether core measures are being met, says Dianna Jernigan, RN, MSN, director of quality, education, and informatics at Cobre Valley Regional Medical Center in Globe, Ariz.

Her hospital also collects and disseminates quality data to medical staff leaders on a regular basis. Although the overall scorecard is distributed monthly, department chairs look at the core measure scores on a weekly basis so they can address concerns with physicians immediately.

Because the medical staff is charged with maintaining the clinical quality of the institution, it needs a way to identify individual concerns or global areas of trouble that need to be addressed. The best way to do so, according to Mills, is by collecting and analyzing quality data.

Accountability

About nine months ago, Cobre Valley Regional Medical Center created a quality dashboard (see Figure 1 on p. 5), which is a quick snapshot of its quality measures related to reimbursement and billing, such as:

HCAHPS results
Core Measure Sets
Patient safety initiatives

In the past, before implementing the dashboard-which is also color coordinated to make results easy to read-someone in the medical records department would create a report regarding core measures. That report usually didn't make it past administration. Now, the dashboard is distributed to the medical executive committee and medical staff directors, and it trickles down to medical staff members.

The medical staff directors are held responsible for their department's scores. "The directors have access to their scores at all times, and the expectation is when they come to quality council that they are prepared to report what their scores are, if there is an action plan in place, and what is affecting their scores. They have a lot more knowledge and accountability about the whole process," says Jernigan.

Although the dashboard form is not even a year old, it has already effected positive change at the organization. The med-surg ICU director focused on changing the culture of his department by implementing hourly rounds and bedside reporting at shift change. According to Jernigan, these interventions increased the department's patient satisfaction scores.

The process for improving scores and creating an action plan should be a collaboration between the physician leaders and the quality department members because for many physicians, the quality piece is new.

"They might have some ideas, but they don't know how to formalize them. We will help them make an action plan," says Jernigan. She is currently working with the company that distributes the hospital's patient surveys because it has an electronic tool for setting up action plans.

Education

As is the case with any change, physicians who don't want it to happen will ignore it. As the administrator for medical staff members, it is often up to the MSP to educate physicians about process changes and their importance.

When it comes to reporting quality data, there are several reasons medical staff members need to get on board. The Hospital Value-Based Purchasing Program, a part of the Affordable Care Act, will reward hospitals for the quality of care they provide to patients. This means patient satisfaction will need to become a big focus. Surveys such as HCAHPS address patient satisfaction, and these survey results are often captured in quality data reports.

Mills also predicts outpatient and office-based core measures coming down the pike for physicians. "The government is testing the waters with hospitals first because it is easier, but eventually the doctors are going to get slammed with it too," he says.

Upper Allegheny Health System uses a few methods to make sure this information stays in the forefront of physicians' minds. One way is through CME. Because MSPs are usually in charge of CME, they can make sure some of the offerings center on quality metrics. MSPs also help set medical staff meeting agendas, which means they can reserve five or 10 minutes every few months to have a physician leader speak on various topics, such as educating committee members on new quality metrics and core measures or informing them about the medical staff's quality performance.

Educating physicians about quality metrics and getting them on board with scorecards may not be as hard as you think. Mills says the Hawthorne effect comes into play in this situation, where subjects improve their behavior simply because they know they are being measured.

However, Jernigan believes the change is more deliberate. "You don't know where you are if you don't measure. I think [the dashboard] helped us focus. We have been focused on patient satisfaction scores for awhile, but we really took a look at the core measures and how people could affect it. Those have increased significantly over the past few months now that we are able to look at it better and it is out there for everyone to see," she says.

And there is the most obvious factor driving change, which is that physicians want to do what is best for their patients-including improving quality scores.

"These quality metrics are out there, not because it is cutting-edge science, but because they are tried and true," says Mills.

Help physicians improve their HCAHPS scores

There are three physician-specific questions on the Healthcare Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient survey. To receive high marks on these questions, physicians need to be aware of their social cues and how they talk to their patients. William Mills, MD, MMM, CPE, FACPE, CMSL, FAAFP, senior vice president of quality and professional affairs at Upper Allegheny Health System, offers the following tips for improving physician-patient interaction.

Question 1: During this hospital stay, how often did doctors treat you with courtesy and respect?

Approximately 85% of communication is nonverbal, so:

If your body language reveals that you are angry, rushed, or frustrated, patients may perceive you as unfriendly, discourteous, and disrespectful
Reset your brain and carry no baggage into the patient encounter
Be keenly aware of facial expressions, body language, and other nonverbal language

Additionally, make sure to brush up on your polite behaviors:

Knock on the door before entering.
Make eye contact with the patient and visitors.
Introduce yourself and the members of your team.
Address the patient by his or her preferred name.
When discussing the patient with other members of your team in front of the patient, address the patient by name and not in the third person. Talking about a patient in the third person can make him or her feel disrespected, unimportant, and as if he or she is not even present.
Familiarize yourself with the patient's cultural and religious background and individual needs to increase the patient's perception of appropriate friendliness and courtesy.

Question 2: During this hospital stay, how often did doctors listen carefully to you?

Patients perceive that a physician truly listens to them and understands their concerns when the physician:

Sits down during the conversation portion of the visit
Asks open-ended questions and listens with empathy
Uses "reflective" listening (paraphrasing, clarifying statements, asking for understanding)
Offers a physical gesture, such as a handshake, a touch on the shoulder, or a pat on the knee
Makes eye contact with the patient and family
Pays attention to the patient and not the chart or his or her cell phone

Question 3: During this hospital stay, how often did doctors explain things in a way you could understand?

Patients often aren't doing their best thinking while hospitalized, so:

Provide more information than you believe is necessary
Provide the option of having another person in the room to hear the information, take notes, and ask questions.
Encourage patients to write down their questions in between visits. This allows them the opportunity to think about the previous interactions and formulate questions that specifically address their fears and concerns.
Ask patients if they need any more information.
Use word associations.

Are your medical staff leaders ready for an accreditationsurvey?

Fri, 01 Jun 2012 04:00:00 GMT

Are your medical staff leaders ready for an accreditation survey?

You know an accreditation survey is just around the corner, so you have been preparing by performing your own audits of the medical staff services department: Your credentials files are in order, your peer review proctor forms are complete, and your MSPs have reviewed medical staff bylaws and policies and procedures to make sure there are no outstanding loopholes. You feel confident when the surveyor shows up-that is, until he pulls aside a physician who is also a member of the credentials committee and asks, "So what is your goal in credentialing? Why did the organization implement [x] to the process last year?"

"The last thing you want the surveyor to hear is, 'The medical staff services director says [the process] is good, so it's good,' " says Terry Wilson, CPMSM, CPCS, director of medical staff services at Flagler Hospital in St. Augustine, Fla.

If your medical staff members cannot explain why they follow the processes they follow, they put your organization in jeopardy during an accreditation survey.

"The accrediting surveyors often know the MSPs know how things work, but they want to make sure the doctors do as well. They want to know if the doctors understand their own process, how it works, what needs to be changed if it isn't working," says Christina W. Giles, CPMSM, MS, president of Medical Staff Solutions in Nashua, N.H.

So before your next accreditation survey, take steps to ensure your medical staff leaders are just as prepared as you are. Giles believes that because it is the job of MSPs to educate and prepare medical staff leaders, grooming physicians for an accreditation survey is also in their realm of responsibilities.

Although MSPs may feel like they are juggling an already lengthy to-do list, there are a few steps that can make the process less stressful for both MSPs and physicians, such as:

Finding the best way(s) to communicate with physicians
Finding a physician leader to partner with
Making survey preparation a part of physician leadership responsibilities from the start

Point out the obvious

If your facility is achieving overall success and patient satisfaction, chances are your medical staff members are following the organization's policies and procedures and adhering to medical staff bylaws. They just might not realize it or be able to explain the nuances of those rules.

"[Physicians] do such wonderful work day in and day out and they take it for granted and don't realize sometimes how it meets the regulatory requirements that are out there," says Wilson. "I don't expect them to recite back what OPPE and FPPE stand for, but do they understand what those terms signify? Do they realize when they do chart reviews for elevations, that is a focused professional evaluation? It is just a matter of reminding them of what they actually know but sometimes don't realize that they know."

Because physicians have limited time and absorb information in different ways, experiment with various forms of communication. Spending a little time up front is a worthy investment if it means you find the most effective way to get your physicians ready for a survey.

"It is rewarding when you hear your words come out of medical staff members' mouths," says Jean Kerns, director of medical staff services at St. Mary's Hospital in Richmond, Va. "It is all in how you communicate with your medical staff leadership. They have time requirements and they cannot focus a lot of time on it. But if you keep repeating it enough times, it gets to be fact in their heads."

Kerns uses several methods in preparing her medical staff members for a survey. Because many physicians on her medical staff are also members of medical staffs at other organizations, she keeps her communications simple and straightforward.

Although email is a good way to disseminate information without time constraints, remember that many people's inboxes are now inundated with junk mail. You may only want to use this form of communication to send out reminders such as "don't forget postop notes," or "remember to put the date and time on H&Ps," not to ask physicians if they understand the credentialing process. Also, because most physicians check their email from a mobile device, they will probably only read the first few lines of a message. For this reason, Kerns says it is essential to make your point in two lines or less.

Other informal strategies Kerns uses to get medical staff members ready for a survey include putting tips and reminders in the medical staff newsletter and on the television in the physicians' lounge. Communicating through media is also a good opportunity to make survey preparation fun by incorporating games or quizzes. Giles recommends avoiding lecture-type communication.

"The less you make it like a hard study, the better," she says. "Put together a bunch of multiple-choice questions and ask [medical staff members] to answer them. If they are unclear on something, hopefully it will spark a conversation. Then it is not just them sitting there and you telling them what they need to know."

Although email and other electronic technologies make it easy to communicate with every member of your medical staff, don't underestimate the value of face-to-face time, says Giles. She recommends taking time at medical staff meetings to discuss survey preparedness.

As the MSP, get yourself on the agenda of the medical staff meeting you help facilitate. A 10- or 15-minute slot should be sufficient, and how often you present will depend on how well-informed committee members are. "It may not be necessary to do this every single month, but in some cases, if you have several new members to the credentials committee, it may be a good review time if it is on the agenda for six months," explains Giles.

Wilson says when her organization knows it is rounding the corner to a Joint Commission survey, the medical executive committee will take time at its meetings to discuss the following:

What happens during the survey process
Who the surveyor may want to talk to
The topics the surveyor usually focuses on

When medical staff leaders come to Wilson with questions, she tries to steer them in the right direction depending on their area of focus. For example, if it is a member of the quality committee, she encourages the person to brush up on the performance improvement plan; for credentials committee members, it would be reviewing the credentialing and privileging process.

Find a friend

Along with finding the best ways to communicate with medical staff members, it is also helpful to have a physician leader in your corner, says Giles. "You need one medical staff leader to back you, to be your spokesperson," she advises.

Giles says medical staff members will be more receptive to the medical director or vice president of medical affairs telling them to prepare for the survey. The key is finding a medical staff leader who is knowledgeable about the survey process and wants to emphasize the need for the medical staff to be available and attentive while it's going on.

Getting physicians engaged in the survey process is essential, says Kerns. "You have to have physician champions in a lot of these initiatives. If they are not engaged, you are out there floundering."

If Kerns has difficulty getting physicians engaged in the process, she is not averse to using her established relationship as administrator and physician champion to gain their support. "Sometimes I play the card, 'If you love me, just do it.' "

Don't wait until it is too late

Your organization may want to use medical staff leadership orientation or training sessions as another vehicle for teaching physicians about the survey process. The key is to teach leaders how their new role relates to your medical staff processes.

Giles says many organizations struggle in this area because they do not provide leaders with well-defined job descriptions. "That is one place we have not always done a good job, orienting them appropriately when they start working on a committee or become a department chair, to help them understand what they are doing and why they are doing it," she says.

This is another reason it helps to have a physician leader in your corner. Use his or her personal experience to identify what your organization does well and what it lacks in its orientation and leadership process. A thorough orientation should include not just the what, but also the why. If leaders know why these are their new responsibilities and why the process flows the way it does, they will naturally be able to answer a surveyor's questions.

Giles recommends instilling this information from the start of a medical staff leader's tenure, and then reassessing it with the individual or committee annually. If you're taking these steps to prepare, there is no reason to get hyped up when a survey is nearing.

"The more physicians know how the process works, the less stepped-up you have to get for accreditation prep. Because if they are doing their job and understanding what their job is and they are doing it every month, there really shouldn't be a whole lot of 'Oh gosh, we have to go back and check this and change that,' " says Giles.

When you are reviewing the survey process with medical staff leaders, this is also a good time to review your process for priming them, says Giles. Oftentimes, organizations think they are prepared because they have set up an orientation program, but they don't evalaute it to make sure it is still fulfilling its function.

Medical records

One challenge St. Mary's Hospital faced during its recent Joint Commission survey stemmed from switching to electronic medical records (EMR) the previous year. The organization was still working out the kinks in the system, so not everyone had access to all the necessary parts. Kerns says it was stressful when the surveyor asked someone to show him something in the system, and the person could not access it.

Also, the physicians are still learning how to navigate and fully use the system, so as Kerns puts it, "they cannot walk the walk and talk the talk." Still, she says the switch to electronic records is a helpful survey tool because it incorporates many regulatory standards and the organization's medical staff standards. Because physicians now have so much to worry about beyond patient care, such as meaningful use, Recovery Auditor audits, OPPE, and FPPE, the EMR system makes it easier to do their jobs and meet the regulatory requirements at the same time.

"Doctors hate change, but we tell them if they do it this way, they are meeting CMS and Joint Commission standards," says Kerns. "If they are documenting in the EMR, a lot of the standards are met. And I think physicians are constantly aware now, they are not just doing something because St. Mary's says they have to, there is a reason they are documenting the way they are documenting."

This new process helps physicians make the connection that preparing for a survey also positively affects patient care. "I certainly think it makes everyone focus to make sure they are not only doing it well, but looking at ways to do it even better. Throughout the hospital, we know that whatever is being done is being done correctly, and that we are providing good services because we are constantly monitoring things," says Wilson.

New Mexico law requires medical board reporting for terminated employees

Fri, 01 Jun 2012 04:00:00 GMT

New Mexico law requires medical board reporting for terminated employees

In the beginning of 2012, New Mexico expanded its state laws regarding reporting settlements, judgments, adverse actions, and credentialing discrepancies to the state medical board to include employed physicians.

Prior to this change, hospitals could terminate contracted or employed physicians at any time, without having to initiate the peer review process, and without reporting the action to the state medical board or the NPDB. With the change, New Mexico became the first state to initiate reporting requirements for employed physicians.

The state already requires healthcare facilities to report "adverse events," defined as "reducing, restricting, suspending, revoking, denying, or failing to renew clinical privileges," but the law change added the following language: "terminating employment for cause, or without cause when based on incompetency or behavior affecting patient care and safety, or physician being allowed to resign rather than being terminated for such reasons. This does not include those instances in which a peer review entity requires supervision of a physician for purposes of evaluating that physician's professional knowledge or ability."

Cynthia Grubbs, JD, RN, director of the Division of Practitioner Data Banks for the Bureau of Health Professionals at the U.S. Department of Health and Human Services, says New Mexico is the first state that she knows of to take such action. "We don't know all of the states' new laws that have happened, but this is the first I've heard of any state taking this action."

Although this law only applies to healthcare facilities in New Mexico, it could impact other states in the future, especially as the number of employed physicians continues to rise.

Creating the law

The New Mexico Medical Board begin pushing for a law change in May 2011, after receiving complaints from patients and other physicians about practitioners that were providing substandard care, says Becky Cochran, CPMSM, CPCS, director of medical staff services in San Juan Regional Medical Center in Farmington, N.M., and vice chair of the New Mexico Medical Board.

The medical board quickly realized that employed physicians were being terminated or asked to resign because of quality issues, which saved the hospital from initiating the peer review process and reporting adverse incidents to the state medical board or the NPDB.

"All of a sudden all of these hospitals or healthcare clinics were getting rid of doctors that weren't measuring up, and there was no mechanism to let the board know so we could step in and take action on their license or send them for more training," Cochran says.

Additional reporting requirements are currently out for public comment. If accepted, hospitals would have to report adverse actions within thirty days of the adverse action, rather than within thirty days of the final action.

"Before, the wording was a 'final decision' or a 'final adverse action,' and we know that can take months, maybe years to reach a final action," she says. "There wasn't anything to flag the medical board about an adverse action so we took out the language for final action. That way it gives the board the opportunity to know if there are problems with the physician so we can protect the public."

Impact on the NPDB

The new law could have a secondary impact on the amount of information available in the NPDB, Grubbs says.

If hospitals restructure how they take action and push more cases towards peer review rather than simply reporting a termination to the state medical board, it might improve protection for both the physician and the hospital. If there is an adverse decision or a suspension of privileges, that would be reported to the NPDB.

If hospitals decide instead to simply report terminations, the medical board may decide to take additional action.

"The medical board may have an increase in their investigations and sanctions that they take against practitioners, which would then increase the licensure activity within the National Practitioner Data Bank," Grubbs says.

The NPDB recently implemented a new process so that hospitals can send an electronic report to their state medical board when they file an NPDB report. Hospitals previously had to mail separate reports.

"It's more streamlined and it has a little bit more checks and balances to ensure the medical board actually receives it," she says.

Again, although the New Mexico law applies only to healthcare facilities within the state, other states may implement similar laws if the reporting system works.

"Each state is independent and gets to make their own laws, but I'm sure that there will be plenty of other legislative bodies seeing what the response is to this new law in New Mexico," Grubbs says.

The rising number of employed physicians

The reason for this law change hinges on the number of physicians employed by hospitals, a figure that has grown rapidly in the last decade.

A survey published by the American Hospital Association (AHA) at the beginning of the year indicated that hospitals employed 211,500 physicians in 2010, a 34% increase since 2000. Additionally, nearly 38% of hospitalists on the medical staff are employed by the hospital. Nearly 60% of hospitals are using hospitalists in 2010, according to the AHA survey.

Since 1990, the NPDB has been the main source of information for MSPs. In the early years of the data bank, most physicians worked independently, but those numbers have gradually shifted, and more physicians want the perks of being fully employed by the hospital, says Carol S. Cairns, CPMSM, CPCS, president of PRO-CON, a medical staff consulting company in Plainfield, Ill. In past years, MSPs could be confident that the data bank would have appropriate information on lost privileges or behavioral issues, but with employed physicians there may be missing information.

"As we begin to employ more and more physiciansand the percentages are changing quite a bit-a lot of times, quality and behavioral issues are managed through the contract or employment so the hospital just simply terminates or dismisses the person, or they don't renew the contract," Cairns says. "That's fine, but there is probably no reporting."

Cochran adds that if a physician does not go through the peer review process, the medical staff services department has no way of knowing there is an issue with the physician, even if an MSP hears a rumor or has a feeling.

"If we see a doctor that is all of a sudden not here, we may have some suspicion on our side that there are quality issues, but if they did not come up through the peer review process, we do not know that for a fact. There is no paper trail," says Cochran.

This will continue to be a problem as the number of employed physicians increases every year. According to Cochran, more physicians are coming out of residency looking for full-time employment, rather than practicing independently.

"They want set hours they can work, and benefits, and vacation," she says. "So the model has changed from the independent physician who likes working for himself and works 16 hours a day."

The downside for physicians is that most contracts have language that allows the hospital to terminate a physician for any reason. This gives hospitals a loophole where they can terminate or request that a physician resign because of behavioral or quality issues, avoiding a peer review process.

Subsequently, the law change offers additional protection for employed physicians. Cochran believes the change will challenge HR departments to rethink their process of terminating a physician. If they think there is a concern with competency, instead of simply terminating the physician or letting him or her resign, they will turn the case over to the medical staff process, which would allow that employee to be evaluated by his or her peers and have the right to a hearing if it affected the employee's privileges.

"What we are really asking for is transparency," Cochran says. "Transparency protects the public, transparency protects physicians, and transparency protects hospital entities too. It forces everything to go through a process where it's more transparent and the public is more informed."

Legal implications

It may be too early to determine how the legislative change might affect legal cases going forward. In one sense, there may be more information available from the state medical board if hospitals abide by the law.

"I think that there is a risk that hospitals who never wanted to report to begin with will also seek that path even if there is a state law, because reporting is something people like to avoid," Cairns says. "You don't like to report people to the data bank, but interestingly enough everyone wants the information out. So I think the same issues that have made organizations hesitant to report in the past are potentially the same issues even with this state law."

Cochran notes that there will be a fine from the state medical board for healthcare facilities that fail to report terminated physicians.

"It is a matter of trust and ethics," she says. "There is now a law to report, and the Board trusts that professionals in the healthcare arena are ethical and truthful and will follow the law by reporting appropriately."

Cochran says the New Mexico Medical Board will post information on its website and send letters to healthcare entities in the state, so they are all aware of the new law and cannot use the defense that they didn't know. "Education is a big part of this," she says. In her facility, Cochran has already notified members of the credentials and medical executive committees, as well as administration.

The change to the law will require additional advice from hospital attorneys on how to terminate a physician or revoke privileges, since it also mixes employment law into potential claims. "To me the complexity is going to require more advice from knowledgeable healthcare attorneys to inform organizations because it's not just simple employment law, it's also the data bank as well, and not all attorneys are familiar with medical staff processes," Cairns says.

Cairns advises organizations to use New Mexico's action as a catalyst for discussion of this issue by medical staffs and hospitals. Since the majority of hospitals already employ/contract with a variety of practitioners, it is important to proactively develop a plan of action. The goal would be to evaluate the concern and develop a policy guiding future courses of action that would be taken should an employed or contracted physician be dismissed for quality or behavior issues affecting patient care.

On the road to perfection

Fri, 01 Jun 2012 04:00:00 GMT

On the road to perfection

"Gentlemen, we are going to relentlessly pursue perfection knowing that perfection cannot be achieved. But, we will relentlessly pursue perfection; for in that pursuit we will achieve excellence."

I was recently reminded of the need to follow this mantra, which is credited to former football coaching legend Vince Lombardi.

Credentialing is, by nature, one of those things where perfection is needed every time. However, just like in life, "stuff" happens in the credentialing process that challenges perfection.

You know what kind of stuff I am talking about. An employee leaves and forgets to tell you what she was (or was not) doing. A personal event distracts someone in your medical staff services department from his or her usual routine of excellence. A disaster happens. Stuff happens.

Unfortunately, CMS does not allow "stuff" to interfere with the requirement to verify a renewal after the expiration date. And this makes perfect sense-if we lived in a perfect world. Nonetheless, that's the world we have chosen to live in.

This is perhaps why I so look forward to going electronic with primary source verifications. The promise is appealing: a Web crawler robot that searches the Internet for all of my particular physicians and then retrieves the verification for me! Even better, this can be done at any time and as many times as I want! Perfection seems more attainable with an electronic system that has less "stuff" to get in the way of completing its task.

Of course, this does not obviate the need for MSPs to be involved in the "relentless pursuit of perfection." Systems like this are designed to be front-loaded. Computer geeks have long said "garbage in, garbage out," and never has this been truer than when you embark on adopting an automated electronic licensure verification system.

My staff and I anticipate working several weekends to make sure the system is not loaded with garbage. We're willing to front-load the process and spend the time testing and retesting, running scenario after scenario to make sure it runs right. We're willing to pursue perfection.

The other appeal of all of this is saving human resources for more in-depth projects, which also puts us on the path to perfection. As a director, I hate to see smart people do mindless things. It drives me nuts! I'm paying someone good money to do something that really is not commensurate with his or her salary. I mean, going onto the Internet and looking up a license, printing it off, and updating the fields in a database are skills that a 10-year-old could master. It's not rocket science. I'd rather pay for the analysis of that collected information. That's where our value as MSPs comes in!

We have gained experience, industry-specific knowledge, and skill sets that cannot be learned overnight. This makes us good at what we do-very good, in fact! And it's why we should feel confident pursuing perfection.

If you've forgotten that path, take these words as an inspiring reminder that pursuing perfection does lead to excellence.

Editor's note: Baerje is director of medical staff management at Good Samaritan Hospital in Los Angeles.

Credentialing Resource Center Journal, June 2012

Fri, 01 Jun 2012 04:00:00 GMT

Tying quality metrics into clinical competence

Upper Allegheny Health System gives physicians quarterly report cards, which include quality metrics for:

Core Measure Sets
Order set usage compliance
Lengths of stay
Results from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Press Ganey patient surveys

The report cards use multiple colors to represent levels of success so physicians can get a quick snapshot without having to read through a detailed report.

Mills is in favor of tying quality data into reappointment because he believes there is a link between quality and clinical competence.

"I can make a very strong case that if you are falling off on your quality metrics, your current clinical competence should be called into question," he says. "They need to be hand in glove."

Accountability

HCAHPS results
Core Measure Sets
Patient safety initiatives

Education

And there is the most obvious factor driving change, which is that physicians want to do what is best for their patients-including improving quality scores.

"These quality metrics are out there, not because it is cutting-edge science, but because they are tried and true," says Mills.

Help physicians improve their HCAHPS scores

Question 1: During this hospital stay, how often did doctors treat you with courtesy and respect?

Approximately 85% of communication is nonverbal, so:

If your body language reveals that you are angry, rushed, or frustrated, patients may perceive you as unfriendly, discourteous, and disrespectful
Reset your brain and carry no baggage into the patient encounter
Be keenly aware of facial expressions, body language, and other nonverbal language

Additionally, make sure to brush up on your polite behaviors:

Knock on the door before entering.
Make eye contact with the patient and visitors.
Introduce yourself and the members of your team.
Address the patient by his or her preferred name.
When discussing the patient with other members of your team in front of the patient, address the patient by name and not in the third person. Talking about a patient in the third person can make him or her feel disrespected, unimportant, and as if he or she is not even present.
Familiarize yourself with the patient's cultural and religious background and individual needs to increase the patient's perception of appropriate friendliness and courtesy.

Question 2: During this hospital stay, how often did doctors listen carefully to you?

Patients perceive that a physician truly listens to them and understands their concerns when the physician:

Sits down during the conversation portion of the visit
Asks open-ended questions and listens with empathy
Uses "reflective" listening (paraphrasing, clarifying statements, asking for understanding)
Offers a physical gesture, such as a handshake, a touch on the shoulder, or a pat on the knee
Makes eye contact with the patient and family
Pays attention to the patient and not the chart or his or her cell phone

Question 3: During this hospital stay, how often did doctors explain things in a way you could understand?

Patients often aren't doing their best thinking while hospitalized, so:

Provide more information than you believe is necessary
Provide the option of having another person in the room to hear the information, take notes, and ask questions.
Encourage patients to write down their questions in between visits. This allows them the opportunity to think about the previous interactions and formulate questions that specifically address their fears and concerns.
Ask patients if they need any more information.
Use word associations.

Are your medical staff leaders ready for an accreditation survey?

If your medical staff members cannot explain why they follow the processes they follow, they put your organization in jeopardy during an accreditation survey.

Although MSPs may feel like they are juggling an already lengthy to-do list, there are a few steps that can make the process less stressful for both MSPs and physicians, such as:

Finding the best way(s) to communicate with physicians
Finding a physician leader to partner with
Making survey preparation a part of physician leadership responsibilities from the start

Point out the obvious

Wilson says when her organization knows it is rounding the corner to a Joint Commission survey, the medical executive committee will take time at its meetings to discuss the following:

What happens during the survey process
Who the surveyor may want to talk to
The topics the surveyor usually focuses on

Find a friend

Don't wait until it is too late

Medical records

New Mexico law requires medical board reporting for terminated employees

Although this law only applies to healthcare facilities in New Mexico, it could impact other states in the future, especially as the number of employed physicians continues to rise.

Creating the law

Impact on the NPDB

The new law could have a secondary impact on the amount of information available in the NPDB, Grubbs says.

If hospitals decide instead to simply report terminations, the medical board may decide to take additional action.

"It's more streamlined and it has a little bit more checks and balances to ensure the medical board actually receives it," she says.

Again, although the New Mexico law applies only to healthcare facilities within the state, other states may implement similar laws if the reporting system works.

"Each state is independent and gets to make their own laws, but I'm sure that there will be plenty of other legislative bodies seeing what the response is to this new law in New Mexico," Grubbs says.

Make your medical staff office paperless

Tue, 01 May 2012 04:00:00 GMT

Make your medical staff office paperless

Going paperless is a great way to become more green, embrace new technology, and become more efficient and organized. However, it involves just as much planning and proper execution as rolling out a new policy, or it will be met with just as much resistance and confusion.

At Methodist Le Bonheur Healthcare System in Memphis, the medical staff office (MSO) decided to incorporate more paperless processes when the healthcare system announced a push to become greener. Also at that time, the health system was implementing an electronic medical record and a computerized physician order entry system.

"So, overall, we are changing the culture of how the organization works," says Pat Busbey, CPMSM, corporate director of medical staff services at Methodist Le Bonheur.

Many of the medical staff committees now receive their agenda packets electronically prior to meetings. This includes any forms or documents they will need to discuss at the meeting that are not deemed confidential. Busbey says it was a learning process because committee members were used to having hard copies of the information at the meetings. But as they become accustomed to receiving an encrypted e-mail with the information they will need for the meeting, the meetings are becoming shorter and more efficient. Many members even bring their laptops or tablets to the meeting so they have the documents available.

"They have usually read it, digested it, and have very specific questions that can be addressed or they have already resolved their issues," says Busbey. "Whereas if I hand them a document that is several pages long to read during the committee meeting, it can cause confusion."

Additionally, if a member cannot attend the meeting, he or she still knows ahead of time what will be discussed and can relay his or her opinion or questions to another committee member to voice at the meeting.

For an item such as a policy language change, the electronic documents are projected on a screen during the meeting for committee members to view.

The amount of information disseminated electronically depends on the specific committee. For example, members of the credentials and peer review oversight committees don't receive their agenda items via e-mail because of confidentiality concerns. The medical staff coordinators still distribute any paper materials at the start of the meeting, then collect them afterwards to protect confidential information.

On the other end of the spectrum, some of Methodist Le Bonheur's medical staff committees are completely paperless and virtual. For example, the clinical standards subcommittee members receive all of their information electronically and discuss and vote on issues via e-mail as well. The committee only meets face-to-face if an in-depth discussion of an issue is necessary. "They work really well with that format," says Busbey.

Incorporating new technology

Many hospitals now purchase tablets for their physicians and residents. Meadows Regional Medical Center, Inc., in Vidalia, GA, purchased 20 iPad® devices for its governing board members to use during meetings.

"That transition went pretty well," says Karen Claxton, CPMSM, CPCS, medical staff operations manager at Meadows. "Then we moved into a brand-new hospital in February 2011. At that time, everything was so neat and clean, the CEO said, 'Let's quit with the paper. Let's just do it and see what happens.' "

Claxton says she placed an iPad at each committee member's seat at the next medical executive committee (MEC) meeting, and no one complained. She did staff the room with administrative folks who could help answer any questions, and she was surprised by how smooth the transition was.

All of the information that MEC members will need for a given meeting is loaded onto the iPad and ready to be viewed. Claxton turns on each iPad and opens up the agenda folder she has created to make it as simple as possible for committee members. Any documents that need to be reviewed are numbered according to their place on the agenda because the iPad sorts downloaded files alphabetically. This may not correspond with the order in which the documents will be viewed, and it saves committee members from looking around for the right document title.

This is just one of the steps required to prepare for the MEC meeting. Claxton says it is much easier and less time-consuming than the previous paper method.

In between meetings, any materials Claxton receives she converts to a PDF file and stores in a folder on her desktop. She can then send all of this information electronically for the chair to review and approve for the agenda. Before each meeting, Claxton gets the tablets set up at committee members' seats.

"So by the time you turn it on and do everything, it's maybe been one minute. For med exec, that is 10 iPads, so it's 10 minutes to put information on the iPads," she says.

That's a lot less time than it used to take to put together hard copies of the agenda packets. For the governing board meetings, it would take two staff members about eight hours to make paper copies, assemble the binders, and incorporate any last-minute changes. For the MEC, the process took several hours as well. Then after the meetings, some documents had to be shredded, or the bulky binders had to be stored, which ate up more time and space. Claxton can now simply delete the agenda folder and drop box from the iPad to dispose of confidential meeting documents.

She estimates that Meadows saves $500 per month in administrative costs associated with the MEC and governing board meetings. The organization has started incorporating iPad devices into other meetings as well.

"I see in the very near future that none of our committees will use any type of paper," says Claxton. "There is no way I would go back to that paper stuff. The time saved, the ease of making a change at the last minute, just everything improved."

Her one piece of advice for other hospitals making the switch to iPad devices is to make sure enough staff members who know how to use them are available to help committee members. She says if committee members feel comfortable with the technology, there will be less pushback for doing something differently.

Credentials files

Methodist Le Bonheur Healthcare also uses an electronic medical staff application and credentials file. At the time of inception, the health system was developing a centralized credentialing organization. "Rather than having the centralized credentialing organization send packets to all of the organizations that were utilizing the data, we created an electronic credentialing record. Any organization can just pull up the record in CACTUS and review it," says Busbey.

To take full advantage of an electronic file, Busbey encourages MSOs to set up two monitors at each computer. This allows MSPs to view the credential record on one screen and any other programs they need to work in on the other screen. Busbey says it made sense for her MSO because they use the credentialing program the majority of the day.

"For a small investment in a dual screen system you avoid minimizing and maximizing all day long," she explains.

The MSO also invested in a computerized fax system and an Adobe® software program to organize and reduce the volume of material printed. The Adobe program allows the MSPs to mark up documents they receive without printing them out, writing on the hard copies, and then scanning them back into the computer. Busbey says this is especially helpful with information systems security forms that applicants must fill out to gain access to Methodist Le Bonheur's computer system. By not having to print out the forms and hand-deliver them, nothing gets lost, and the process moves much more quickly.

"With this method, the IS department notifies the physician immediately with the directions to log on to training, allowing the physician to begin computer training and orientation while we are completing their application. Our whole goal being when we are done with their application and it's approved by the board, they can start working," says Busbey.

Her next goal is to provide credentials committee members with a way to electronically access the files on their own, at their own leisure. Right now, committee members must meet with members of the MSO to view the files. The organization is working with its credentialing software company to develop a secure login for those committee members. Busbey says it is simply a matter of working out the security issues for the quality information.

Even as they work to incorporate technology into the credentials committee, and as many of the committees become paperless and virtual, Busbey says there is still merit in having a credentials committee that meets face-to-face.

"I see that there is a discussion that takes place that is key in decision-making. When we have a file that we need to review in depth, there is benefit to having all of those people discuss it at one site."

Get the malpractice information you need

Tue, 01 May 2012 04:00:00 GMT

Get the malpractice information you need

Whether it's intentional or not, practitioners may not always provide you with the malpractice information you need to complete their credentials file for appointment or reappointment. They may not know what information they need to submit or how to access it, they may think it is not their responsibility to obtain it, or they could be trying to hide their past malpractice history. Whatever the reason, developing a thorough professional liability form that is part of your medical staff application for appointment or reappointment will ensure your medical staff office (MSO) gets the information it needs.

When developing a liability history form, keep in mind that you are trying to get information about any claims a practitioner was named on and the practitioner's insurance coverage history. It is up to your organization to decide how far into a practitioner's history to look. It could be five years, 10 years, or day one of medical residency. Your organization may think it is worth having a practitioner's complete malpractice history. Or it may decide that it is not good use of the MSP's time to collect that much information. The important aspect is to make sure the look-back period is consistent from one practitioner to the next.

Your professional liability form should give practitioners the opportunity to explain any gaps in coverage history or details of a claim. If you simply ask yes-or-no questions, your medical staff leaders will not have the complete information they need to make a proper credentialing decision.

"Our issue was that when we asked for information regarding a malpractice claim or case, we didn't always get all the information we needed. [Practitioners] would just check yes to the answer and not provide any information or only a limited amount of information. Then if you got information from the insurance company or data bank, you were not sure if it was the same case the physician was referring to," says June Hogg, director of medical staff services for WakeMed Health & Hospitals in Raleigh, NC.

The medical staff office at WakeMed developed a new professional liability explanation form that makes practitioners provide the information the health system needs regarding malpractice history. The form states it must be filled out for "each pending or settled professional liability claim or lawsuit and any payment made on behalf of the applicant." The form also asks for information such as:

Date of incident and date claim was filed
Patient name and relationship to patient (e.g., surgeon, attending practitioner, consultant)
Liability carrier at time of incident
Additional named defendants
Status (open, closed)
Method of closing (e.g., dismissal, settlement, judgment)

The practitioner is also asked to provide a summary of the incident, and include any additional documents that are relevant to the case that the credentials committee would find beneficial.

When an MSP receives the completed form (along with the rest of the application) he or she first looks to see whether there are any open cases. If so, the practitioner must provide verification of the facts as reported from a second source, which can be either the insurance company or the attorney. Once the case is closed, the practitioner is expected to report back to the MSP with the conclusion. If the practitioner does not provide this information at the time the case was closed, it will be a red flag at reappointment time.

"We track malpractice history," says Hogg. "At their next reappointment, if we do not know what the resolution was, we make them answer at that time."

The NPDB can be used as a secondary source for closed claims that resulted in payment, says Hogg. However, an MSP should never rely on the data bank to provide a complete history of a practitioner's malpractice dealings.

"You cannot depend on the NPDB to give you an accurate picture of malpractice history. I guarantee physicians keep their settlements off of there a lot of the time," says Debbie Lyle, CPCS, credentialing specialist at San Juan Regional Medical Center in Farmington, NM.

Lyle also advises against relying on insurance carriers to provide all the malpractice history your organization needs because what information they will give out varies. According to her, some carriers only supply a five-year history; others only supply the information if an indemnity was paid.

Again, this is why having a form that puts the responsibility on the practitioner, not the MSP, is helpful. "The burden is on the physician to provide this information and make sure we get a secondary source that verifies the facts as reported by the physician," says Hogg. "The form tells the practitioner up front what information we need, which prevents us from having to go back to the practitioner for additional information."

Hogg adds that her MSO does not have a hard time getting the completed forms back from practitioners because it is part of the application. The form is listed on the cover sheet checklist attached to the application, and practitioners know their application is considered incomplete without the liability explanation form.

Take it case by case

A methodical liability history form not only saves the MSP's time, it also helps medical staff leaders make proper credentialing decisions. This does not mean that a credentials committee should deny a practitioner's appointment or reappointment because he or she was named on a claim. The form can actually help practitioners because it gives them the opportunity to explain the case.

For example, in New Mexico, a practitioner can be named on a claim and it can be resolved without the practitioner ever knowing about it. Lyle says this often is the case for practitioners and residents at university hospitals because those hospitals have the ability to settle without having to involve those named on the claim.

When committee members and department chairs are reviewing malpractice history, some factors to look for are:

Was the practitioner a resident or in training at the time?
Did the practitioner have direct care of the patient or was he or she part of a care management team?

These factors can affect how heavily a malpractice claim is weighed when making a credentialing decision. It is essential to look at the facts of an individual case, and not just think, "This practitioner was named in X number of cases. I do not want him or her on the medical staff."

"It has to be a process administered with judgment," says Robert McCann, Esq., partner at Drinker Biddle & Reath, LLP, in the Washington, DC, office. "You might have a practitioner with clusters of lawsuits but that does not necessarily mean that anything is wrong. Litigation tends to cluster in some areas."

An example of this, according to McCann, is when the FDA announces a drug is no longer recommended for a particular medical condition. That usually leads to a host of lawsuits, especially when lawyers start advertising the message on television.

Hogg adds that people are a lot quicker to sue nowadays. "Back in the day when you saw a malpractice case you would say, 'Oh no!' because you did not see them as often. Now, it is not uncommon to see them. We live in such a litigious society. Those that are not in the medical profession tend to get more alarmed about malpractice history. Our board of directors-who don't all have a medical background-get alarmed when they see malpractice history. That is why it is important for us to give them all of the facts of the case."

Although an open mind is necessary when reviewing malpractice history, there are red flags that MSPs and medical staff leaders should keep in mind.

One is a sentinel event. Did the surgeon operate on the wrong leg or arm? McCann says regardless of how pristine the rest of the surgeon's record is, a sentinel event should raise a red flag.

Although volume of claims should not be pinned down to a specific number, high volume does merit attention. "Even if that physician has the worst luck in the world, something else is going on there," explains McCann. "Ninety-five times out of 100, a physician with a lot of cases is just a bad physician."

If there are multiple claims, Lyle advises looking for trends. Even if all the cases were dismissed, if they all center on a surgeon cutting the same tube every time, that is a concern. Lyle says her hospital recently had a case in which a practitioner up for reappointment was named in a handful of claims. The quality executive committee determined that there was a trend of failure to diagnose, and the case was sent to the peer review committee to decide whether the practitioner needed additional education.

The practitioner's specialty can be another red flag. A spine surgeon or OB/GYN with three cases in five years is not as alarming as a dermatologist with three cases in five years, says McCann. The surgeon or OB/GYN might also generate a larger monetary claim than the dermatologist. However, McCann adds that a higher-risk specialty should not be used as a get-out-of-jail-free card.

"I think if a physician holds him- or herself out as a neurosurgeon, yes, it is more risky, but you really hope that person holds themself to a higher standard to be a good neurosurgeon," he explains.

One of the biggest red flags is whether a practitioner is honest about his or her history. As Lyle mentioned, sometimes omitting information is unintentional, so the first step is finding out if the practitioner knowingly left off important information regarding malpractice claims.

"If it is at reappointment, I call the physician. Most of the time, I find they have not been notified yet [of the claim]. At initial appointment, it is usually a different story. I will write them a letter saying they were involved in a malpractice case and did not disclose the information. Then I let them explain. Depending on the explanation, if it is blatant, flat out that he did not tell us, that is when everything stops and goes to the credentials committee," says Lyle.

Hogg says that any information that is falsified is a reason to deny or revoke someone's privileges. It is up to the credentials committee to decide whether the practitioner willfully lied about his or her malpractice history and whether it should result in a recommendation to revoke or deny privileges.

What number should I write into my bylaws?

Your medical staff bylaws should have some language about a practitioner having an acceptable malpractice history. However, both McCann and Lyle advise against putting malpractice screening standards into medical staff bylaws. McCann instead recommends putting these into policies and procedures, which are easier to revise than bylaws.

"You don't want to be overly prescriptive in your bylaws about this because you want some flexibility both to adjust the standards and apply them with judgment," he says. "You might have a standard that five cases are too many. You have a practitioner with only four cases, but they all involved patient deaths. I just don't see it as a good issue to be prescriptive about in the bylaws."

Keep in mind that anything written into the medical staff bylaws has to be followed. Any screenings regarding malpractice history must be used uniformly, which leaves the credentials committee with no opportunity to evaluate cases on an individual basis using the aforementioned factors, and also opens up your organization to claims of negligent credentialing.

McCann says what is more important, especially regarding negligent credentialing, is to document where and how the information was obtained. "Careful documentation is always critical in terms of protecting the organization. It is one thing to say you did it, it is a better thing to show you did."

Make your proctor evaluation form straightforward, user-friendly

Tue, 01 May 2012 04:00:00 GMT

Make your proctor evaluation form straightforward, user-friendly

If your medical staff office (MSO) has a hard time getting completed proctor evaluation forms back, it may be a sign that your evaluation form is too onerous. Vicki Tauer, MSM, CPCS, CPMSM, supervisor of medical staff services at Fairfield Medical Center in Lancaster, OH, says this is how her MSO discovered it needed to edit its FPPE proctor evaluation report.

"The feedback was happening verbally and nonverbally in that we just weren't getting [the forms] back. We were extremely frustrated trying to get the information from our proctors. So we realized fairly quickly that our forms were not working," explains Tauer.

Previously, the form was three pages long, had a lot of check boxes, and contained a summary page where the proctor had to write a narrative. One form had to be filled out for each case the proctor reviewed.

In addition, Tauer says there was a lot of information for the proctors to read on the form. "That doesn't work because they don't have time to thoroughly read the forms. They want it real quick and simple," she says.

Keep in mind that a physician's time is valuable and those who agree to be proctors are volunteering with what little free time they have. This should be another consideration when creating an evaluation form.

Creating the form

To craft a form that physicians would support, Tauer started by looking online to review examples of other organizations' evaluation forms. She worked with a small group of medical staff leaders dedicated to the credentialing and peer review processes.

By the end of 2011, Fairfield Medical Center rolled out its new form. "It is fairly recent, so there will be some things we need to work out. But just talking to the physicians who have completed the new form, you can see the relief on their face. And we are getting the completed forms returned to us," says Tauer.

One major change is that the proctor does not need to fill out a separate evaluation form for each case he or she reviews for the same practitioner. Instead, the proctor lists the cases he or she reviewed then gives his or her overall impression by answering the questions on the form with all the cases in mind.

The form focuses on a physician's grasp and implementation of the six core competencies. Tauer says the old form did so as well, but the method for evaluating was flipped around. "Before we were pulling specifics out of the core competencies and asking specific questions regarding those. Now we are looking at the general core competencies and asking, 'Do they meet all of these things that are listed under the core competencies? Is it satisfactory or unsatisfactory?' Then we ask them, 'Where did you get that information? Are you comfortable that this physician demonstrates competency for these privileges?' "

The form also explains what is meant by each competency and how to spot its use, which can be interpreted differently by physicians. By giving examples, proctors have specific points to measure. For instance, a proctor may not know how to spot or assess interpersonal and communication skills. On Fairfield Medical Center's evaluation form, suggested measures include:

Communications and behaviors with patients are effective and appropriate
Communications and behaviors with other clinicians are effective and appropriate
Demonstrates emotional resilience and stability, adaptability, flexibility, and tolerance of ambiguity and anxiety
Uses effective listening, nonverbal, explanatory, interviewing, and writing skills to elicit and provide information

Tauer says her goal was to make the form user- friendly. "It is an official document, but it is easy to understand. We wanted to keep it as simple as possible and easy to evaluate [practitioners]," she explains.

The form is also flexible so it can be used for the various FPPE triggers, such as:

New applicant
New privilege(s) for existing practitioner
Practitioner with low volume or returning from leave of absence
Focused review as result of OPPE

It is also important to develop a form that is thorough enough to protect your organization from a claim of negligent credentialing. According to Tauer, a well-crafted evaluation form can serve as documentation proving the organization properly evaluated the individual in question. "If you don't document it, it did not happen. That is what has been drilled in my head the last 25 years," she says.

Potentially being named in a peer review lawsuit is another reason (in addition to the time and effort involved) physicians might be hesitant to serve as a proctor. However, physicians need to remember that there are laws in place to protect them. Tauer says she encourages all of her department chiefs and medical staff leaders to talk with the organization's legal counsel so they are clear on what they and proctors can and cannot do.

Fear of legal repercussions or filling out paperwork should not discourage a physician from participating in peer review, says Tauer. "Physicians need to realize FPPE is about the patient. It is not about grading anybody, it is not about pointing fingers at anybody. It is about making the patient safe and the hospital a great hospital," she says.

Because Fairfield Medical Center's proctor evaluation form is so new, the MSO does not have any data regarding form completion and turnaround time. However, Tauer says her gut feeling is that this part of the MSP's job is getting easier.

"My customers seem to be happier," she says. "And it is giving us the data and information we need to go forward with what we need to do."

Editor's note: Tauer is the March winner of the 15th Annual Credentialing Resource Center Symposium free seat contest. To see her award-winning form, please turn to p. 10.

OIG exclusion database: Assess your query frequency

Tue, 01 May 2012 04:00:00 GMT

The MSP's voice by Sheri Patterson, CPCS

OIG exclusion database: Assess your query frequency

MSPs have a plethora of information to monitor, update, and report. Among the most critical is the OIG exclusion status of your practitioners and organizational entities. The OIG provides monthly reports listing persons and entities excluded from federal program participation for the provision of items or services. A memorandum issued by CMS in 2009, states the following: "... no Medicaid payments can be made for any items or services directed or prescribed by an excluded physician or other authorized person when the individual or entity furnishing the services either knew or should have known of the exclusion."

The excerpt above dictates, in a nutshell, the necessity for regular, frequent monitoring of OIG exclusion status of practitioners providing healthcare services within your organization. The OIG website provides both a searchable database and downloadable report that can be checked against your current staff. Updated monthly, this can be checked either manually or automated by credentialing software.

Organizations with large practitioner staffs or with one-person medical staff offices find this task quite time-consuming if done manually. As a result, they may adjust the frequency of monitoring to accommodate the time and staff it takes to perform this task. A recent survey I conducted revealed the following:

Frequency of OIG exclusion queries: 54% monthly, 27% at initial and reappointment only, 19% annually or other time frame
Fifty percent don't have a policy outlining query frequency or what to do if a practitioner is found on an exclusion list

MSPs constantly struggle to balance staff, time, and resources to ensure that all regulatory and organizational requirements are met and workload decisions are made based on these needs. Frequent queries of the OIG exclusion database should be high on the needs list to ensure compliance with federal program participation and reimbursement for your organization. Although CMS does not specifically mandate monthly queries, the aforementioned memo states,"States should require providers to search the HHS-OIG website monthly to capture exclusions and reinstatements that have occurred since the last search."

Penalties (known as civil monetary penalties or CMPs) are severe if your organization requests reimbursement for an item or service provided by an excluded person or entity. Below is an excerpt from the Federal Register Notice posted on the OIG website.

"CMPs of up to $10,000 for each item or service furnished by the excluded individual or entity and listed on a claim submitted for Federal program reimbursement, as well as an assessment of up to three times the amount claimed and program exclusion may be imposed. For liability to be imposed, the statute requires that the provider submitting the claims for health care items or services furnished by an excluded individual or entity 'knows or should know' that the person was excluded from participation in the Federal health care programs (section 1128A(a)(6) of the Act; 42 CFR 1003.102(a)(2))."

From one MSP to another, here is my recommendation: Assess the current workload of your MSO and rework to include monthly queries of the exclusion database. Consult with your quality/risk departments and administration for policy development and assistance. Include verbiage outlining your plan of action when an exclusion is discovered, and make sure your organization follows that plan.

Editor's note: Sheri Patterson, CPCS, is an interim MSP at The Greeley Company, a division of HCPro, Inc., in Danvers, MA.

Credentialing Resource Center Journal, May 2012

Tue, 01 May 2012 04:00:00 GMT

Make your medical staff office paperless

"So, overall, we are changing the culture of how the organization works," says Pat Busbey, CPMSM, corporate director of medical staff services at Methodist Le Bonheur.

For an item such as a policy language change, the electronic documents are projected on a screen during the meeting for committee members to view.

Incorporating new technology

This is just one of the steps required to prepare for the MEC meeting. Claxton says it is much easier and less time-consuming than the previous paper method.

"So by the time you turn it on and do everything, it's maybe been one minute. For med exec, that is 10 iPads, so it's 10 minutes to put information on the iPads," she says.

Credentials files

"For a small investment in a dual screen system you avoid minimizing and maximizing all day long," she explains.

Get the malpractice information you need

Date of incident and date claim was filed
Patient name and relationship to patient (e.g., surgeon, attending practitioner, consultant)
Liability carrier at time of incident
Additional named defendants
Status (open, closed)
Method of closing (e.g., dismissal, settlement, judgment)

The practitioner is also asked to provide a summary of the incident, and include any additional documents that are relevant to the case that the credentials committee would find beneficial.

"We track malpractice history," says Hogg. "At their next reappointment, if we do not know what the resolution was, we make them answer at that time."

Take it case by case

When committee members and department chairs are reviewing malpractice history, some factors to look for are:

Was the practitioner a resident or in training at the time?
Did the practitioner have direct care of the patient or was he or she part of a care management team?

Although an open mind is necessary when reviewing malpractice history, there are red flags that MSPs and medical staff leaders should keep in mind.

One is a sentinel event. Did the surgeon operate on the wrong leg or arm? McCann says regardless of how pristine the rest of the surgeon's record is, a sentinel event should raise a red flag.

What number should I write into my bylaws?

Make your proctor evaluation form straightforward, user-friendly

Creating the form

Communications and behaviors with patients are effective and appropriate
Communications and behaviors with other clinicians are effective and appropriate
Demonstrates emotional resilience and stability, adaptability, flexibility, and tolerance of ambiguity and anxiety
Uses effective listening, nonverbal, explanatory, interviewing, and writing skills to elicit and provide information

The form is also flexible so it can be used for the various FPPE triggers, such as:

New applicant
New privilege(s) for existing practitioner
Practitioner with low volume or returning from leave of absence
Focused review as result of OPPE

"My customers seem to be happier," she says. "And it is giving us the data and information we need to go forward with what we need to do."

Editor's note: Tauer is the March winner of the 15th Annual Credentialing Resource Center Symposium free seat contest. To see her award-winning form, please turn to p. 10.

The MSP's voice by Sheri Patterson, CPCS

OIG exclusion database: Assess your query frequency

Organizations with large practitioner staffs or with one-person medical staff offices find this task quite time-consu

Thoracoscopy - Procedure 22

Mon, 23 Apr 2012 15:27:00 GMT

Thoracoscopy - Procedure 22

Develop policies specific to the roles of APPs

Sun, 01 Apr 2012 04:00:00 GMT

Develop policies specific to the roles of APPs

An increasing number of nonphysician practitioners are looking to expand their knowledge and skill sets to increase their scope of practice. However, many healthcare organizations lack the proper policies and strategies to assess the competency of these nonphysician practitioners to allow them to take on new privileges. One of the initial and most basic steps for your organization is identifying which practitioners require privileges.

The CMS regulations regarding privileging requirements list physician assistants (PA) and advanced practice registered nurses (APRN), including nurse practitioners (NP), clinical nurse specialists, certified nurse-midwives, and certified registered nurse anesthetists, among those nonphysician practitioners that may be granted privileges by the medical staff.

Nonphysician practitioners are often grouped under the term allied healthcare professionals (AHP) without distinguishing between privileged and non-privileged practitioners. Sally Pelletier, CPMSM, CPCS, a senior consultant and director of credentialing services at The Greeley Company, a division of HCPro, Inc., in Danvers, MA, uses the term advanced practice professional (APP) to distinguish these privileged nonphysician practitioners from non-privileged healthcare professionals.

"AHP is used in very general terms and it doesn't necessarily mean the same thing from one institution to another," Pelletier explains. "The term APP refers to practitioners who must go through a medical staff privileging process, such as PAs and APRNs, whereas allied health professionals could encompass not only these practitioners but also those that do not need to be privileged, such as surgical scrub technicians, dental technicians and assistants, or nurses who accompany physicians to facilitate rounds. In accordance with Joint Commission standards, these disciplines typically go through an HR process."

Once you have identified and defined APPs as a group within the organization, review your policies and procedures for privileging APPs to determine if they adequately meet the requirements laid out by your accrediting agency. The Joint Commission requires APPs to be privileged though the medical staff, and requires OPPE and FPPE as with the medical staff. The Healthcare Facilities Accreditation Program and Det Norske Veritas also require performance monitoring, but do not offer specific methods for evaluating performance.

Although your policies and procedures spell out the process for credentialing and privileging members of the medical staff, and much of that can be applied to APPs, Carol S. Cairns, CPMSM, CPCS, a senior consultant at The Greeley Company, notes that some changes to policies are necessary. For example, the organization may choose to privilege APPs but not grant them membership on the medical staff. The policy should clearly outline the APPs' rights and responsibilities in this regard.

"Most organizations have an ‘AHP policy,' but given changes in accreditors' requirements over the past few years, the policy might be out of date and not reflective of industry standards. In this instance, the old policy could serve as a resource for formatting but could be a hindrance in development of a new policy," Cairns says. "Sometimes it is just better to start fresh."

She adds that when the organization's existing policies are compliant and for the most part reflective of current practices, the medical staff could revise these policies to reflect the changes needed specific to APPs. Thereafter, policies should be updated on an annual basis.

One important aspect of policy development is creating specific, detailed forms for the delineation of privileges for APPs. Physician delineation forms often take precedence when organizations focus on policy development, and are therefore more specific than forms created for APPs, says Pelletier. Privileging forms need to be more specific to the particular type of practice, such as a PA in orthopedics or an NP in the neonatal ICU. She notes that organizations often struggle with defining the criteria and scope for what should be included on APP privilege forms.

"A nice method to help create the structure is to have a committee that's devoted to creating these types of forms for the APPs," Pelletier recommends. "This committee can be made up of physician assistants and nurse practitioners who know what belongs on these forms and understand the regulations."

In addition to MSPs, organizations can also include physicians, especially those who endorse the concept of APP utilization. If the organization has a significant number of employed APPs, representatives from human resources are also helpful to round out the committee and provide supplementary perspectives when creating forms.

‘Training up' APPs

Along with delineation of privileges, organizations are often at a loss when it comes to evaluating the competency of APPs. "It's hard to do competency assessments for APPs because we aren't privileging them well to begin with, and health information management often does not code these practitioners," notes Cairns. "It's difficult to determine what they're doing within an organization and there aren't good competency measurements for this group. That's what hospitals struggle with."

Organizations should determine methods for tracking APP activity and monitoring performance, which will make it easier to evaluate competency. Requiring APPs to maintain activity logs and designating an APP committee to carry out FPPE and OPPE processes could improve the amount of data available for APP activity.

Another issue healthcare organizations face with regard to APPs is the expansion of privileges. APPs can increase their value and efficacy within their organization by learning additional skills and procedures, but there are rarely guidelines to explain how to manage this process. Cairns and Pelletier refer to this role expansion as "training up."

"APPs want to expand their scope of practice because they're working side by side with their collaborating supervising physicians, and those physicians are teaching them additional skills and want to expand their knowledge and their value to them, so it becomes an issue of ‘I want to teach this APP how to do something, but how do we do that?' " Cairns says. "The field is struggling with what methodology should be used to accomplish this goal. So, in practice, this is ‘being done' in some organizations without a defined or approved process."

Both Cairns and Pelletier conducted numerous surveys of the healthcare field, reaching out at seminars and through online resources to ask organizations to share their policies for expanding the roles of APPs. Unable to find any policies, they collaborated to create a form for organizations to customize when developing procedures for training up APPs. The form can be found on p. 4.

Prior to using the policy, your organization must evaluate two major issues:

Whether your culture supports expanding the roles of APPs
Whether your professional liability carrier covers training up of APPs

If your organization answers yes to both questions, the policy can then be adjusted to suit your particular needs, says Cairns.

Handling the expansion of roles with APPs differs from granting new privileges to physicians because of the way in which APPs learn new skills. Evidence of competency is required for granting privileges, but according to Pelletier, an APP gaining on-the-job experience does not provide sufficient evidence of competency. Instead, she notes, APPs bring "a certain level of knowledge and a competent skill set to be able to train up in those areas."

Pelletier stresses that direct supervision by a physician is key when training APPs on new procedures, and that supervision is incorporated into the policy. "The direct supervision piece provides a more risk-averse factor for the institution," Pelletier says. "Once that APP is fully trained up and the physician trainer feels that they are competent to do it without supervision, that's when [the APP] would go through a privileging process to allow them to perform that particular privilege or procedure independently."

One last step that must be factored into a training-up process is patient consent. For procedural privileges under direct supervision, the patient must consent. It would not be necessary for education discussions-cognitive interactions-but if an invasive procedure (e.g., a lumbar puncture) is planned, the patient needs to give consent.

Developing clear and specific policies will help your organization better assess the competency of APPs and allow for the expansion of roles among APPs to provide greater value to your organization.

Editor's note: Pelletier and Cairns will present on this topic at the 15th Annual Credentialing Resource Center Symposium. For more information, visit www.credentialingresourcecenter.com.

Sample policy for expansion of privileges for APPs

Policy and procedure

Background

The presence of APPs in hospitals has grown exponentially during the past decade. For purposes of this policy, APPs are defined as physician assistants (PA) and advanced practice registered nurses, with this latter group including certified registered nurse anesthetists, certified nurse midwives, nurse practitioners, and clinical nurse specialists. Collaborating and supervising physicians have realized the value of APPs and often seek to expand the role of APPs. Furthermore, APPs seek to increase their knowledge and skill base and thus their scope of practice. The pending physician shortage provides a third incentive for organizations to create mechanisms to expand privileges for APPs. Academic hospitals inherently have a framework in place for on-site education and training. However, in community hospitals, this is not typically the case.

Thus the first step in this process must be that the healthcare organization's leadership (governing body, senior administration, and medical staff) determines that its mission and culture would support expansion of privileges for APPs through an on-site education and training program. One aspect of this decision would be to assure that the facility's professional liability carrier would include this activity. Once the decision is made to move forward, the organization is now ready to determine the policy and procedures necessary to accomplish their goal.

Objective

The objective of this policy is to make certain that patient safety and quality are adequately protected by establishing a safe and effective training process to increase the capabilities and competencies (cognitive and procedural) of each APP who requests additional clinical privileges for which they have limited or no training and experience. The mechanism by which this training process is accomplished will be through the granting of privileges under direct supervision.

Policy

Any practitioner seeking clinical privileges (including privileges under direct supervision) to provide care, treatment, or services must first be granted permission to do so by the governing body based upon a recommendation by the medical executive committee.

Requests for clinical privileges are processed only when the potential APP applicant meets the governing body's current minimum threshold criteria. Potential APP applicants who do not meet these criteria will not have their applications processed. In the event there is a request for a privilege for which there is no established criteria for APPs and/or the privileges were previously granted only to physicians, the governing body must determine whether it will allow APPs the privilege in question. If the governing body allows the privilege for APPs, criteria will be developed in accordance with medical staff policy.

APPs who do not meet established eligibility criteria and cannot demonstrate the requisite competence for the requested expansion of privileges may be allowed to "train up" through privileges granted under the direct supervision of their collaborating or supervising physician or designee.

For the purposes of this policy, direct supervision means that the collaborating or supervising physician or designee is acting as a preceptor1 and is therefore required to be physically present.

Procedure

APPs and their collaborating or supervising physician will submit a written request to "train up" to the medical staff services department. A prerequisite is that the physician preceptor(s) must have the privilege(s) being requested by the APP. The request will include:

a.The specific privilege(s) requested

b.The name(s) of preceptor(s)

c.The anticipated length of training

d.Competency measures

e.Patient population (if applicable)

Set a strong meeting agenda

Sun, 01 Apr 2012 04:00:00 GMT

Set a strong meeting agenda

A medical staff meeting agenda is more than just a piece of paper with an aesthetically pleasing outline. It is a tool to make your meetings efficient and informative, which in turn will keep medical staff involvement in these meetings high. Coordinating meetings and setting agendas usually falls into the hands of medical staff office employees. And although they are not voting on the issues, their involvement in medical staff meetings should not be downplayed.

"My office tries to take on the burden of the management of the meeting so that we can organize an efficient meeting for the medical staff and help them accomplish their business," explains Terry Wilson, BS, CPMSM, CPCS, director of medical staff services at Flagler Hospital in St. Augustine, FL. "We have always said we are not the decision-makers for the medical staff, but we keep things coordinated and moving in the right direction for them."

To keep the right information flowing in the right direction, it is important to have a plan in place for tracking committee meetings and agenda items. This can be a challenge, especially if your medical staff office (MSO) is responsible for multiple meetings.

This was the case at Good Samaritan Hospital in Vincennes, IN, where the three members of the MSO share meeting management duties. According to Kim Pepmeier Everett, medical staff office coordinator, there was a lack of communication that caused confusion regarding sending agenda items through the proper channels.

"Let's say Larissa [a member of the MSO] organizes a surgery section meeting and takes an item to that meeting, then finds out it needed to go to another committee before it went to the surgery section. Or it goes to the medicine service and Carol [another MSO member] must follow up with it, but she does not realize because communication fell out along the way," explains Everett.

To solve this problem, the MSO developed an agenda item routing request form. Along with a spot for basic information relevant to the request, there is a chart to track which medical services and committees have reviewed the information, whether they have approved it, and when it is projected to go to the next group that needs to review it. A copy of the form is available on p. 7.

In the few years since its inception, the form has greatly improved the flow of information from committee to committee, according to Everett, who describes the form as a "snapshot pathway of where each item needs to go or has been."

Because this form and all relevant documents that accompany an agenda item are stored electronically, if one committee makes a change to a document, it automatically saves over the old version. This helps ensure that the next committee reviewing the document is looking at the most up-to-date version. In the past, with multiple copies of paper forms, Everett admits that it was not always a guarantee the MSO gave committees the right version of documents.

When they created this form, the MSO at Good Samaritan also decided to standardize the names of agenda items. So an item titled "hip replacement care paths" keeps that title, instead of being changed down the line to "orders for joint replacements." Standardizing the names makes it easier to research agenda items, says Everett, because her office does not worry about something being listed in different files under different names.

The agenda item routing request form helps coordinate behind-the-scenes action. Everett says her medical staff leaders may not know the form exists but would probably notice a difference in meetings if it were not used. "When we are in a meeting and they ask if a committee has already approved it, we do not have to say, ‘I don't know, let me check.' We know that every item on the agenda is an appropriate agenda item," she says.

Reviewing the agenda

Ultimately, the decision regarding which items make it on the agenda lies with the committee chairperson. Wilson advises building a strong and trusting relationship with these folks so setting the agenda is not a struggle. "Seldom do they make changes to my agenda because they trust my judgment when organizing their meetings," she explains.

One reason is because she does her homework before sitting down with committee chairpersons to discuss their agendas. She keeps a separate folder full of potential agenda items for each of the committees of which she is in charge. These items are a combination of new requests and old items that warrant a follow-up. When someone asks to have an item placed on the agenda, Wilson says she goes on a fact-finding mission by asking:

What is the main point?
Why does it need to be on the agenda?
What month's agenda should it go on?
Are there any supplemental pieces of information that need to be reviewed?

"When I present it to the chairman, he has all of the information he needs to determine whether it needs to be discussed at the meeting," says Wilson.

Setting meeting times

Another essential part of drafting a meeting agenda is laying out the time for each item on the agenda. No one wants to sit through a three-hour-plus long meeting, especially physicians, who have limited free time. To keep meetings from running over schedule, each agenda item should be allotted a certain amount of time.

Bobbie Smith, CPMSM, CPCS, medical staff services manager at Charleston (WV) Area Medical Center (CAMC), says long meetings became a problem for her medical executive committee (MEC). "The MEC meeting was running over three hours, so a few years ago, the chief decided we had to get a better handle on the meetings or we were going to lose attendance," she says.

Now the meetings are structured in a way so that routine informational reports, such as a consensus report, that do not require voting action are not discussed unless someone has a question or concern. Committee members receive these reports in the agenda packet one week prior to their meeting and are instructed to review the reports before the meeting. Smith says there is usually nothing in that section that raises questions.

The new business section of the agenda is for items that require discussion. There is a time allotment for each of these items; if an item needs additional discussion, it will be tabled and carried over to an upcoming meeting.

"If we think it requires more input than what members of the committee will be able to give, we allot for a brief discussion, and then advise the committee members to take it back to their departments and garner input from other members in the department. Then they can bring it back to the next meeting," says Smith.

Sitting down with committee chairpersons ahead of time to make sure they understand the items on the agenda also cuts down on meeting times. Either you can answer questions they have about a topic, or you can make sure the person who can answer those questions is present at the meeting. At CAMC, each recording secretary meets with his or her chairpersons for a preplanning meeting.

Getting the word out

What happens after a meeting is just as important as what happens before. The MSO needs to make sure decisions that are made during meetings are communicated to the medical staff and any other appropriate parties. "You have a great meeting, you accomplish your goals, but then if it is not communicated, what good does it do?" says Wilson.

How information is distributed will depend on the urgency and nature of the information. Wilson and Smith say they use a combination of the following:

Weekly medical staff newsletters
E-mail blasts
Individual medical staff mailings
Flyers in the physicians' lounge

Although it is important to communicate decisions to the medical staff, Wilson advises against bombarding them with too much information. "If you give them too much information, they may feel overwhelmed and then not pay attention to anything you send," she says.

Telemedicine standards set

Sun, 01 Apr 2012 04:00:00 GMT

Telemedicine standards set

CMS recently approved the final language of the Joint Commission standards regarding credentialing and privileging telemedicine providers, making it easier for a hospital to utilize telemedicine services by allowing the hospital to use the credentialing and privileging information on file at the telemedicine provider's originating site in order to grant privileges at its own facility.

Although The Joint Commission already allowed hospitals to use credentialing and privileging information from other Joint Commission-accredited hospitals or ambulatory care facilities, CMS did not allow this "credentialing by proxy" until it released a final rule in May 2011. In that rule, CMS stated that a hospital or critical access hospital seeking telemedicine services (the originating site) can use the credentialing and privileging information from the telemedicine provider's site (the distant site) as long as the distant site is in compliance with CMS' Conditions of Participation (CoP). If the distant site is a telemedicine entity-such as a teleradiology company-it does not have to be a Medicare participant.

The goal is to relieve the burden, especially for rural and critical access hospitals, of having to credential practitioners who have active privileges at another hospital. "I think the hope from both CMS and The Joint Commission is that this should help reduce any barriers or burdens that providers saw as it relates to taking advantage of technology and telemedicine services," says Bruce D. Armon, Esq., managing partner of Saul Ewing LLP's Philadelphia office.

Although hospitals can feel comfortable knowing they are in compliance with CMS regulations and Joint Commission standards, they still bear the responsibility of making sure anyone providing services to their patients is qualified to do so and privileged accordingly. Not only is this in the best interest of your patients, it can also prevent your organization from facing negligent credentialing charges.

"If you are being sued because someone misreads an x-ray, your hospital is going to get sued. Saying the distant-site hospital was responsible for credentialing is not going to stop someone from suing you," explains Kathy Matzka, CPMSM, CPCS, a medical staff consultant in Lebanon, IL.

Get it in writing

In using the distant site's credentialing and privileging information, the originating site must have confidence in the distant site's processes and ability to meet its standards. One way to gauge this, according to Armon, is based off of other working relationships the two sites already have. As is the case with disruptive physicians, past behavior is a good indicator of future behavior.

Specific to credentialing, the originating site needs to make sure the distant site follows certain Medicare CoPs and has a credentialing process that meets the requirements of the originating site's medical staff bylaws. A common difference among hospitals involves the requirement to conduct criminal background checks. If the originating site's bylaws state a criminal background check is conducted for all applicants, the originating site must find out whether this is included in the distant site's credentialing process.

Criminal background checks and other aspects of credentialing should all be worked out through the written contract between the two organizations. The revised Joint Commission standards make it clear that there must be a written contract stating that the distant site's process meets specific Medicare CoPs [482.12 (a)(1) through (a)(9) and 482.22 (a)(1) through (a)(4)]. But the contract should also make it clear what each organization expects from the other.

"If you were the originating hospital and I was the distant site, and you did not have any experience with my hospital, the written agreement between us should give you the comfort you need so that you can rely on the credentialing I am doing of my physicians who are going to be providing clinical services for your patients," says Armon.

Matzka recommends taking this a step further by having a member of the medical staff office (MSO) evaluate the distant site's processes.

In addition to credentialing processes, it is also important to know as best you can the practitioners you are partnering with, which can be difficult if they never set foot in your facility. Armon suggests looking at:

The quality of services they provide
Receptiveness with staff physicians
Professional reputation
Independent references

Duties of the medical staff office

The originating site is still responsible for determining what privileges to grant the practitioner at its site, and making an informed decision requires the skills of the MSO. According to Matzka, the originating site should still perform some credentialing checks. These include:

License verification (The Joint Commission now requires the practitioner's license to be active or recognized by the state of the originating site)
NPDB query
Office of Inspector General Excluded Parties List query
AMA profile (optional)

Your organization may be required to do more of its own credentialing, depending on your state regulations. For example, applicants in Illinois must use a universal state application for medical staff membership or privilege requests. Telemedicine providers outside of Illinois would need to fill out this application as well. Arkansas requires healthcare organizations to use a state CVO. Originating sites in Arkansas would still have to use that CVO for telemedicine providers that it grants privileges to.

Another credentialing aspect to think about is expirables. Members of the MSO keep track of when practitioners' privileges and licenses are going to expire. So which MSO should be in charge of this? Matzka says it can be either the originating or distant site, as long as it is clear which site is doing it and there is documentation it is happening.

While not specifically required, some hospitals may choose to create a credentials file for practitioners seeking privileges through telemedicine services. In some cases, the distant site may give you more information than you need, and it is your job to pull out the important pieces. Just as you would with another applicant, decide what information is required in the file for medical staff leaders to review.

"Some of the telemedicine companies will give you a CD with 300 pages of a practitioner's file. The way the standards read, you do not have to present the whole credentials file, but you should give the medical staff enough information to make its recommendations," says Matzka. "What you want to present to your medical staff from the information you receive from the distant site is anything that is required in your bylaws."

The new regulations also allow for the medical staff to make recommendations by relying solely upon the privileging decisions made by a distant-site telemedicine hospital or entity. In this case, instead of having a credentials file, it may instead have a single file that contains information concerning all telemedicine practitioners providing services at the hospital. This file needs to identify which telemedicine services privileges the hospital has granted to each practitioner on the list.

Although telemedicine is opening up the doors for improved patient care, all of that can quickly go out the window if credentialing and privileging guidelines are not followed. "When you do not have a hands-on treating physician under the same roof, you still have to ensure you can provide the highest quality of care in a timely manner," says Armon.

The flip side

The Joint Commission's finalized standards regarding credentialing and privileging and telemedicine also help telemedicine entities, says Heather Johnson, director of physician services at Virtual Radiologic (vRad). The teleradiology company based in Eden Prairie, MN, previously offered credentialing and privileging information to the hospitals it worked with, but some were reluctant to accept the information before Joint Commission standards were finalized. This meant that hospitals either went through the cumbersome process of doing the credentialing at their facility or shied away from telemedicine altogether. And once they did credential telemedicine providers, they were less likely to switch providers to avoid having to go through the process again.

"We have had a large amount of hospitals we already work with transition over and accept our credentialing and privileging, which is very helpful to the hospital, but also to vRad," says Johnson. "It allows more flexibility because at the end of the day, we can add more radiologists quickly, and that improves patient care because it expands their access to subspecialty coverage, extended coverage hours, and overall improved turnaround times."

The company can give a hospital as much or as little credentialing and privileging information on a provider as it needs. vRad always provides the hospital with a copy of the current delineation of privileges as well as the privilege letter it uses. Beyond that, it is up to the hospital to decide how much information it wants. Johnson says it is always accessible; the hospital merely has to ask for it.

All of vRad's radiologists are credentialed the same way. The organization is accredited by The Joint Commission, so its credentialing policies fall in line with Joint Commission standards. It also has bylaws that dictate its credentialing process. Johnson says the process is very thorough, and it's rare that a hospital requires a credentialing piece that vRad does not provide. "It is helpful because we have a process for credentialing and it is something we can share with our hospitals to help them feel comfortable," says Johnson.

The teleradiology company also conducts ongoing and focused professional practice evaluations and reappoints its radiologists based on the quality data it collects. Most of the quality data vRad collects is provided by the hospitals it contracts with by over-reading preliminary scans. vRad also over-reads a certain percentage of final interpretations to include in quality data files.

vRad also produces anonymous performance reports, which are distributed to its radiologists. The report shows the range of discrepancy rates and how an individual compares to other radiologists. They also can review any of their discrepancies.

All of this quality data specific to a radiologist is available to hospitals that are working with that radiologist through an online portal that provides up-to-date statistics.

When deciding what information to collect about a telemedicine provider, Johnson says hospitals should consult their bylaws. If they are able to use the telemedicine entity's credentialing and privileging information, she advises doing so. If not, they may want to consider changing their bylaws.

"There is a reason CMS and The Joint Commission changed their standards," says Johnson. "We see hospitals that do not take advantage of it and what a burden it can be on the medical staff. It ultimately affects patient care as well. So it is great to see hospitals embrace it and use it to the extent they can."