MEDICAL STAFF MATTERS

1. MEDICAL STAFF MATTERS Credentialing for Excellence Darla S. Holland, M.D. Kaiser Permanente Southern California/IMQ

2. Objectives for today • Discuss the elements of robust pre-application/initial application process • Describe how Medical Staff Professionals can support Medical Staff Leaders in their attempts to maintain a high functioning Medical Staff

3. Objectives (continued) • Discuss some challenging credentialing situations • The Low Volume Practitioner • The No Volume Practitioner • Allied Health Practitioners • The Physician With Challenging Behaviors • The Impaired or Ill Physician • The Aging Physician • The Physician Working Under Contract with the Hospital

4. Objectives (continued) • Provide tips for “herding cats”

5. Begin at the Beginning Dr. Cutter is an initial applicant for membership to the Medical Staff. He went to college at UT Arlington, Medical School at UTMB in Galveston, did a surgical residency at Baylor and Vascular Fellowship at County USC. CV shows no gaps in time. He just finished his fellowship Did some moonlighting at The Holiest Medical Center while in fellowship Board eligible in surgery

6. Contrast Dr. Cutter with Dr. Mobile • Dr. Mobile is a new applicant to the Medical Staff. He went to Medical School in Guadalajara, graduating in 1974, did his residency in internal medicine at Albert Einstein and became Board Certified in Internal Medicine in 1977 (boards are not time limited). He practiced from 1977-1979 in Florida, 1979-1985 in Texas, 1985-1996 in Albuquerque, and from 1996 through present in Portland, Oregon. He has three closed malpractice cases (one with payment of $440,000 four years ago for alleged failure to diagnose a DVT in a post operative patient who had undergone a total hip replacement. The other two cases were closed without judgment. There are two open malpractice cases.

7. More about Dr. Mobile In one case he was merely a covering physician. The other case resulted from a retained foreign body (a guidewire was sheared off during the insertion of a central line four years ago). Dr. Mobile is applying for privileges to admit and care for hospitalized patients and for ICU privileges, including Swan Ganz placement and privileges to do EGD and colonoscopies

8. Now for Dr. Rust….. • Dr. Rust went to Medical School at NYU • Boarded in Emergency Medicine • Had difficult twin pregnancy six years ago and had to go on bed rest for three months. After her children were born she stayed home. Now they are in Kindergarten and she wants to go back to work. She has 50 hours of CME every year.

9. Initial Application Criteria • Can the applicant have a restricted license? • What is the interval in which you examine malpractice activity? • Must the applicant be Board Certified or “eligible”? Is there an interval beyond training for which the individual must have passed Boards in order to be considered? • Is the individual familiar with call requirements?

10. Initial Application (cont) 5. Is the individual applying to a closed department? • What does the Public Records check reveal? • Is there any thing concerning in a Google Search or Social Media query? • Can the individual explain gaps in practice? • Does the individual need to have a personal interview?

11. New Applicant Issues…. • Dr. Cutter • Straightforward…remember to get information from the moonlighting job as he is not in a training program there • May need to be assigned a mentor that has a different relationship than a proctor

12. New applicant issues Dr. Mobile • Need to query every practice experience, if possible • Needs to provide evidence of current competence (outcomes) from privileges that are outside the scope of his training and certification • Needs to have privileges tailored for his training/experience

13. New applicant issues Dr. Rust…. Is she a candidate for a re-entry program? -Best template for Reentry program comes from City of Hope -Program describes a process for individuals previously on their Medical Staff and out for three years or less -Describes very tight supervision, including cosigning of orders

14. Re-entry programs • Most hospitals will not bring anyone on staff with no activity for more than one reappointment cycle • Numerous programs exist to assess competence in individuals out of practice • In California two most well known are PACE in San Diego and the Cedars Sinai Reentry program.

15. Public Records Check To do or not to do (some counties are still doing this manually on paper….) Redundancy that yields information about civil litigation, potential substance abuse concerns, and potential character concerns

16. Proctoring/Focused Practitioner Practice Evaluation • Most common concerns identified at Survey • FPPE was not done at the initial granting of privileges (the individual has a very active practice but has not completed proctoring • FPPE is not consistently done in all departments • FPPE is not done for Allied Health • Surveyors/staff cannot identify which practitioners have not yet completed their proctoring requirements

17. Reciprocal Proctoring Question: Can we accept proctoring from another institution? Answer: Yes, but…… • The Proctoring Reports MUST have been completed within the past two years. • If OPPE data is used in the consideration, it must include elements referable to the privilege, and…..

18. Reciprocal Proctoring At least ONE case must be completed in the new facility using the staff, equipment and policies of the hospital requiring the proctoring For an outside proctor of a new service…… The Medical Staff must consider the evidence that this individual is indeed an “expert” before granting temporary privileges. It is not possible to proctor and expert.

19. Ongoing Professional Practice Eval (OPPE) • Standards have been in place for at least two survey cycles • Needs to take place at an interval that is more frequent than annual • Needs to reflect the performance of a single individual (must NOT attribute on single element to multiple practitioners) • “One should be able to look at the OPPE profile and know the type physician being monitored”

20. As a Medical Staff Professional… Who is your BFF?

21. Key individuals • Quality/Performance Improvement Director • Risk Manager • Hospital Counsel (and if applicable) the Medical Staff Counsel • Information Management (Medical Records) Manager

22. Quality Management • Source of potential OPPE indicators (always try to use metrics that Quality is already collecting) • Medical Staff needs to know when FPPE triggers are met and if an FPPE is ongoing/being reported • Can provide the data necessary to make intelligent credentialing decisions

23. Risk Manager • Has information about internal cases/trends that may lead to litigation. • Usually has a handle on what issues stand out as potentially problematic areas.

24. Hospital Counsel • Important source of advice about Licensing Board reporting, timeliness of actions, and denial of Medical Staff Membership • Can provide communication tools or draft letters to applicants.

25. Information Management • Provide reports about Medical Records completion • Provide other metrics, particularly about completeness of records.

26. Reappointments • High Volume practioner • Low volume -low volume in your hospital but high volume elsewhere -low volume in my hospital but no volume elsewhere -no volume

27. High volume practitioner • Make sure that it is clear that the quality data is indeed present as the Chief considers the file at the time of reapproval • Better if the reports/ data can be initialed

28. Low Volume Practitioners • High volume elsewhere (i.e. Call coverage) obtain quality data or OPPE profile from another hospital Alternatively Letter of Recommendation can be obtained if it reflects the time period that one is examining • Low volume elsewhere Again, the burden of evidence lies with the applicant

29. No volume practitioner • Very few privileges are able to be considered “Ride-a-bike” • Are privileges part of a “cluster” where there is implied competence • Is the individual a candidate for a Leave of Absence?

30. Contracted Physician Groups • Focus on OPPE Performance Metrics that can be benchmarked • Urge regular scrutiny of these metrics as part of the contract oversight process. • When possible use metrics that are publically reported

31. Telemedicine • MS.133.01.01 Elements of performance • A 1. All licensed independent practitioners who are responsible for the patient’s care, • treatment, and services via telemedicine link are credentialed and privileged to do • so at the originating site through one of the following mechanisms: 1. The originating site fully privileges and credentials the practitioner according • to Standards MS.06.01.03 through MS.06.01.13. 2. The originating site privileges practitioners using credentialing information • from the distant site if the distant site is a Joint Commission–accredited • organization. 3. The originating site uses the credentialing and privileging decision from the • distant site to make a final privileging decision if all the following • requirements are met: • 1. The distant site is a Joint Commission–accredited hospital or ambulatory care • organization. • 2. The practitioner is privileged at the distant site for those services to be provided • at the originating site.

32. Telemedicine Standards (cont.) • 3. For hospitals that use Joint Commission accreditation for deemed status • purposes: The distant site provides the originating site with a current list of • licensed independent practitioners’ privileges. • 4. The originating site has evidence of an internal review of the practitioner’s • performance of these privileges and sends to the distant site information that is • useful to assess the practitioner’s quality of care, treatment, and services for use • in privileging and performance improvement. At a minimum, this informationincludes all adverse outcomes related to sentinel events considered reviewable by • The Joint Commission that result from the telemedicine services provided; and • complaints about the distant site licensed independent practitioner from • patients, licensed independent practitioners, or staff at the originating site. (See • also LD.04.03.09, EP 9) • Note 1: This occurs in a way consistent with any hospital policies or procedures • intended to preserve any confidentiality or privilege of information established by • applicable law. • Note 2: In the case of an accredited ambulatory care organization, the hospital must • verify that the distant site made its decision using the process described in Standards • MS.06.01.03 through MS.06.01.07 (excluding EP 2 from MS.06.01.03). This is • equivalent to meeting Standard HR.02.01.03 in the Comprehensive Accreditation • Manual for Ambulatory Care.

33. Telemedicine According to CDPH • Only options #1 and #2 are acceptable in California. • Hospitals must either do primary source verification and grant privileges OR • Use the distant sites credentialing packet and grant privileges. • The hospital may NOT accept another entity’s credentialing decision (in the state of California) • There must be a focused review (proctoring) for all telemedicine.

34. What is Telemedicine? • When tools facilitate patient care, the use of the tool is a matter of clinical judgment for a practitioner. • When the tool or media replaces face to face contact, telemedicine is implied. • Telemedicine privileges need to be granted for hospital practitioners • Great care needs to be exercised to assure that the individual delivering care is indeed the individual who has been privileged.

35. Credentialing the “Problem Practitioner” • Goal should be to keep the physician practicing • Counseling by the appropriate Department Chief or the Chief of Staff should take place and be documented in the Credential File. (documentation can take the form of a summary of the discussion or a letter to the practitioner) • In most cases, referral to Well Being Committee should occur.

36. Supporting the Medical Staff with “Problem Practitioners” • Regular reports to MEC by the Well Being Committee are essential • When concluding a counseling session, followup to the discussion should be defined and next steps outlined for any issue that recurs after an initial counseling session. • Tracking til resolution is important. • Impairment or illness can be considered; patient safety always trumps privacy.

37. Age and Professional Assessments • Airline pilots have their skills assessed regularly and routinely beginning at age 40 • California requires more aggressive assessment of driving skills at age 70.

38. The Aging Practitioner • Very few hospitals/organizations are doing a routine assessment of the aging physician • Theoretically, with a robust Ongoing Professional Practice Evaluation, skills are being evaluated continuously. Aging concerns would be picked up • The few that do begin at 70.

39. CPPPH (California Public Protection and Physician Health, Inc.) • Nonprofit entity sponsored by numerous medical societies including the CMA, malpractice insurers, the CHA • Drafting white paper, probably available this summer that will be vetted and revised • Anticipate that a specific age for screening be recommended • Anticipate that an instrument will be recommended (and will be administered in the Medical Staff Office) • Anticipate that screening would then trigger focused review

40. Developing Medical Staff Leaders • Encourage Bylaws revisions that call for longer tenures for leaders. • Encourage senior physicians to mentor interested physicians to develop leaders • Meet with Department Chairs to explore the components of a Credential File • Describe scenarios from past deliberations to give new leaders an understanding of how credentialing processes work

41. Developing Medical Staff Leaders (cont) • Recommend attendance at a Medical Staff Leadership Development Conference • Advise Medical Staff Leaders to establish regular revision process for Privilege Templates. • Connect with Medical Staff Peer Group and bring learnings to Medical Staff.

42. Final Thoughts • You are the glue that holds the hospital together. • You are indispensable to the Medical Staff Leaders and are usually the individual in a hospital to whom the leaders are the closest. As such you have enormous ability to influence. • In such a role you protect the safety of the patients of California, so……

43. THANK YOU! Darla S. Holland, M.D. Darla.S.Holland@kp.org 411 N. Lakeview Anaheim, CA 92807 714-279-4358 (office) 714-501-0759 (mobile) It’s not enough that we do our best; sometimes we have to do what’s required. Sir Winston Churchill