Appropriate disclosure is essential to ensure that medical staffs that are granting clinical privileges to practitioners have sufficient information to make informed decisions. Following is the third installment of my three-part blog series on proper disclosure and sharing of information.
What to disclose and when
It is important for MSSDs to work in close collaboration with their legal departments to determine what information they will disclose and when. For the most part, organizations only disclose formal corrective action taken by the MEC; however, how your organization defines formal corrective action may vary, so you should ensure that legal counsel weighs in. Some organizations may choose to be more liberal and disclose any disciplinary action that is taken, even if it is not considered formal corrective action taken by the MEC; rather action taken by the department chair.
I highly recommend challenging the legal team and the credentials committee members at your institution (who should also be involved in this discussion) with this question: “What would we want another organization to disclose to us?” This is a great way to determine what you will disclose to other organizations upon receipt of a request and appropriate third-party release form.
General verification letters and online queries
Responding to affiliation verification requests can be burdensome for MSSDs who have a large medical staff. However, it is important to remember the significance of these verifications and the liability that your organization may face if appropriate disclosure is not made. For most organizations, the number of providers who have had corrective action that warrants disclosure is small. Keeping a running ‘reportable actions list’ of those who have action that fits your hospitals criteria for disclosure and ensuring that the MSPs who respond to the verification requests are aware of which providers are on the reportable actions list, is essential to protecting the organization from potential liability for failing to disclose pertinent information to other entities.
As a general rule of thumb, if a verification letter comes in regarding someone on the reportable actions list, it is best to limit who can respond to such requests to either the legal team or the department director, to ensure appropriate and consistent disclosures.
A general affiliation verification letter is fine for the practitioners who are not on your reportable actions list. If a general affiliation letter is used, however, it should indicate that the practitioner is not only in good standing, but that there have not been any quality or behavioral concerns that have risen to the level of corrective action. If an MSP receives a verification that does not confirm that there have been no quality issues or corrective action against the practitioner, the MSP should follow up with the third party and obtain further confirmation/clarification. Failure to receive a sufficient response from the third party may lead to the organization determining that the application is incomplete and the burden to obtain the sufficient information is on the applicant.
Many organizations are implementing online verifications, which make the verification process more efficient. However, a process must still be in place to identify providers who are on the reportable actions list—and for whom you shouldn’t be issuing a general form letter. There should be a trigger in the database that will flag a provider who is on the reportable actions list to ensure that the general verification letter is not available online—instead, there should be a message that indicates that a written request is required for that practitioner, along with a third-party release form.
As disclosure issues continue to arise, MSPs and medical staff leaders must be aware of the importance behind not only ensuring that all pertinent information is received during the credentialing process, but also that they themselves are disclosing relevant information to other entities. I always recommend conferring with legal counsel whenever there is a question regarding what to disclose. Be good stewards and remember: What would you want to know?
This week and next, HCPro will offer resources that can help you meet current and future medical staff challenges. First, tune into Practicing Medicine Longer: Legal and Clinical Considerations for an Aging Physician Population on Tuesday, March 11, from 1:00 to 2:30 p.m. Eastern. Speakers Stephen H. Miller, MD, MPH, and Elizabeth “Libby” Snelson, JD, tackle the cultural, clinical, and legal considerations that medical staffs must address to help physicians who want to stay in practice longer.
This program has been approved by the National Association Medical Staff Services for 1.5 continuing education units. You can find more information about the webcast here.
Next Tuesday, March 18, from noon to 1:00 p.m. Eastern, Marla Smith, MHSA, will offer a free demo of HCPro’s Physician Profile Reporter. Log in to find out how Physician Profile Reporter can help you compile all sources of relevant data to produce a single, reliable performance report for a low price. The webcast will explore indicator types—review, rule, and rate-based definitions; acceptable and excellence targets; and regulatory vs. optional physician profile information.
I hope you’ll join us for either or both of these Tuesday events. And as always, thanks for reading!
Appropriate disclosure is essential to ensure that medical staffs have sufficient information to make informed decisions when granting clinical privileges to practitioners. Following is the second of my three-part blog series on proper disclosure and sharing of information.
Steps to ensure appropriate disclosure during credentialing
MSPs can play a direct role in keeping patients safe from practitioners with known competency issues in a number of ways, from making sure their bylaws require specific disclosure from practitioners, to thoroughly reviewing credentialing information from practitioners applying for membership and/or privileges. MSPs must also follow up when other entities, evaluators, or peer references do not provide complete information, or when the information provided is vague or raises additional questions or concerns.
Step 1. Ensure that the questions on your credentialing application are thorough. It is important that you ask the practitioner the right questions to ensure that all possible scenarios are covered for which he or she would be required to disclose information to your organization during the credentialing process.
You must also ensure that your attestation form (as well as your bylaws) indicates what the practitioner must disclose to you, and within what time frame, whenever something occurs after he or she has signed the application. For example, you would want to the practitioner to attest that, if any pertinent information on the application changes (including but not limited to licensure complaints, changes to affiliations, sanctions, etc.) he or she is required to notify you within a specified number of days.
Step 2. Ensure that the third-party release form (which should be a part of your credentialing application) is worded appropriately to allow the other entity or individual to disclose all pertinent information without the fear of retribution. A third-party release form should indicate that the practitioner who signs it grants permission and waives liability against all parties who release any information relevant to his or her credentialing and/or competence, so long as the information is provided in good faith.
Entities that are responding to inquiries should not provide detailed information without first receiving such release signed by the practitioner.
Step 3. Ensure that your competency verification forms or affiliation verification forms ask the right questions as well. If your verification request does not ask the right questions, you may not get full disclosure. For example, if you ask whether action has been taken ‘within the past two years’, the answer may be no; however, perhaps action was taken more than two years ago and the entity did not disclose it previously because it was not the policy at the time to disclose specific information.
Another example would be if you ask a clinical evaluator or peer reference if they are aware of any disciplinary action that “may impact his or her ability to exercise the requested privileges”—the answer may be no. However, these provider may be aware of disciplinary action that was taken, but they are not disclosing it to you because they do not feel that it would impact the applicant’s ability to exercise the requested privileges. Instead, you should ask questions that are open and applicable to any situation and are not limited.
In Part 3, we’ll explore the essential questions of information sharing: What should we disclose? And when?
CMS’ Physician Compare website is intended to assist patients in finding the “best” providers based on reported performance measures. Will the addition of quality measures to the Physician Compare website be useful in the credentialing/privileging process—if not now, then perhaps down the line? Definitely maybe, according to a very informal Credentialing Resource Center Insider poll of several experts in the field.
The consensus is that MSPs should keep an eye the quality measure data, if possible. The measures reported on hospitals are already incorporated into OPPE at many facilities. If providers know their performance data is publicly reported, and reimbursement will be tied to it, that could be an incentive to improve care. However, if the data collected is not physician-specific, its value will be limited in the credentialing and privileging process.
Are the new Physician Compare quality measures already collected in your data set? Is the website itself on your radar? Let me know.
As always, thanks for reading!
When it comes to disclosing disciplinary actions taken against a physician or other practitioner granted clinical privileges, no news can be bad news—meaning, if an entity does not respond to requests for verification of the practitioner’s status, there may be a reason for the non-response. Both the entity requesting the information and the entity disclosing the information play a significant part in ensuring appropriate information is disclosed and shared between organizations. Appropriate disclosure is essential to ensure that medical staffs granting clinical privileges to practitioners have sufficient information to make informed decisions. Following is the first of my three-part blog series on proper disclosure and sharing of information.
Relevant legal cases related to disclosure
Most Medical Staff Professionals and Medical Staff Leaders are aware of the Kadlec Medical Center vs. Lakeview Anesthesia Associates case, where disclosure was at the heart of the suit. Kadlec Medical Center obtained peer references from Lakeview Anesthesia Associates during initial credentialing of an applicant. However, the peer references did not disclose that Lakeview Anesthesia Associates was aware of disciplinary action taken against the applicant in question. The affiliated hospital, Lakeview Medical Center, responded with a general template verification letter that did not disclose whether there had been corrective action taken at the facility while the physician held privileges there.
One of the key takeaways from this case is that the receiving hospital that is credentialing the provider must ensure that they have done their due diligence during credentialing—accepting a general verification letter that does not attest to whether there have been any quality or other concerns related to the applicant can lead to negligent credentialing claims. This case also signifies that failure to disclose information can later result in the third party being held liable if there are negative outcomes that may have been prevented had the third party fully disclosed prior actions that were taken against the applicant.
The case in Texas
A Texas case that’s currently in the news is likely to be the next significant case where disclosure during the credentialing process is one of the key elements of the debate. Christopher Duntsch, a neurosurgeon who eventually had his Texas license revoked, had corrective action taken by Baylor Health Care System for concerns related to his clinical competence; the concerns were brought forth by his peers. After the action was taken, Duntsch went on to practice at other hospitals in the Dallas area. Concerns are emerging with regard to what information Baylor had prior to granting him clinical privileges; it has been alleged in some reports that Duntsch’s peers warned Baylor of their concerns about him prior to Baylor granting him clinical privileges.
There are also concerns being reported regarding what information Baylor disclosed to other entities when they requested verification of Duntsch’s status at Baylor. Other hospitals that subsequently granted clinical privileges to Duntsch allegedly were unaware of the competency issues at Baylor until after they were facing significant investigations of their own related to poor patient outcomes—including paralysis and the death of at least one patient.
In one report it is alleged that one of the surgeons who was called in to correct complications after one of Duntsch’s surgeries was so astounded by what he found that he thought Duntsch might be an imposter. The report indicates that the surgeon faxed a photo of Duntsch to the neurosurgery training program in Tennessee where Duntsch trained, to confirm his identity. It will be up to the courts to decide whether Baylor shares some of the liability for the subsequent cases with poor outcomes at the other hospitals, if Baylor is found to have failed to disclose pertinent information to the other hospitals.
In my blog post next week, I’ll discuss the necessary steps to ensure appropriate disclosure during the credentialing process. Stay tuned!
In the final installment of the three-part webcast series “Overcoming Competency Assessment Challenges,” Carol S. Cairns, CPMSM, CPCS, senior consultant at The Greeley Company; and Sally J. Pelletier, CPMSM, CPCS, advisory consultant and chief credentialing officer at The Greeley Company, answered questions regarding practitioners in ambulatory settings, selective practice, and single practitioners in a specialty. We offered some of the questions and answers in the December issue of CRCJ.
Q: If we privilege practitioners at an ambulatory site, must we also do FPPE and OPPE?
A: The OPPE and FPPE terminology is from The Joint Commission. FPPE applies to organizations that are seeking or continue to have Joint Commission accreditation at the ambulatory and the acute-care site as well. If it’s a CMS accreditation process, or one of the other accrediting organizations, then a continuous performance monitoring process is required.
All of the accreditation bodies require some form of continuous competence assessment: The devil is in the details of the terminology. But if you’re a Joint Commission-accredited organization and you use FPPE and OPPE, then probably you need to conduct OPPE and FPPE on your ambulatory site practitioners.
This webcast, along with the entire series is available on our website. Click here for more information.
Thanks for reading!
Is case tracking for peer review taking up valuable time that you and your colleagues can’t spare? It might be a good idea to invest an hour in a free demonstration of HCPro’s Peer Review Case Tracking Database, an affordable solution for storing and tracking case review data and automating correspondence.
Tomorrow is the day and noon to 1 p.m. (Eastern) is the time. Learn how you can save time and effort with simplified data storage and tracking, along with automated reports and letters! The Peer Review Case Tracking Database provides:
• Easy-to-access Case Review Forms in one convenient location. Find physician-specific case details including referral sources, review indicators, referral issues, case summary, and questions.
• Rule Indicator Tracking Forms that enable you to generate automatic reports and rule creation letters. Search-rule indicator details including tracking of any rule incident or occurrence by a physician. The forms can capture rule-based incidents by provider.
• Easy-to-generate reports that allow users to demonstrate productivity and case outcomes. Provide statistical reports reflecting cases submitted, pending review and pending committee review as well as referral source, rule letters, indicators, and committee actions.
HCPro is working on a new book about ongoing professional practice evaluations (OPPE) and we’d like you to be a part of it. Our goal for the book is to feature case studies of organizations that have implemented an effective OPPE program or process and are excited about sharing their experience and forms with their peers.
The new book will be structured similarly to another HCPro book, The FPPE Toolbox. Your processes and forms could be reviewed by our field experts and included in our book.
If you’d like to be considered as a contributor to HCPro’s new OPPE book, please email me samples of your OPPE score cards, policies and procedures, and any other tools that relate to your OPPE process. The forms will not be used or printed without your consent. If we want to use your forms, we will contact you. Send your forms to email@example.com.
When used properly—with all parties agreeing on what types of items should and should not be included—the consent agenda guides committees quickly through routine business and on to higher priority issues. Following are some tips for effective use of MEC meeting consent agendas, from a recent Credentialing Resource Center Journal article.
Keep content simple and routine
A successful consent agenda process depends on medical services professionals and leadership understanding what belongs on a consent agenda—and what doesn’t—and making sure that all committees involved know this distinction as well. For example, if an item is informational only, and requires no further action by the medical staff, it can be placed under the consent agenda.
Compile the consent agenda and get it approved prior to the MEC meeting.
Keep everyone in the loop
Emailing the consent agenda or uploading it to a portal will allow committee members to review items prior to the meeting.
Timing is important
Inform department managers that if they want their topic discussed during the MEC meeting, they must submit their item at least a week in advance or run the risk of it not being included. Make it clear that if an item for the consent agenda isn’t provided in advance, it will be deferred to the next meeting.
It’s possible to navigate the call to the physician about undisclosed issues without casualties. Rosemary Dragon, CPMSM, CPCS, a regular columnist for Credentialing Resource Center Journal, offers some advice for initiating this difficult but essential conversation. You can read her complete MSP Voice column, including a script to follow, in the February 2014 issue of CRCJ.
After uncovering my first undisclosed issue while working a credentials file, I was told to call the physician to request a detailed explanation. I can’t remember what it was I had to ask about, but I vividly recall feeling horrified, ill-equipped, and small. Perhaps you can relate? I feared the wrath that I expected from him when I asked about this sensitive issue.
That first conversation was about as bumpy as a country road, but I eventually developed a script for these tough conversations. I learned that if I approached them skillfully, these conversations didn’t have to be confrontational; they could be a collegial exchange:
With these conversations, I also stick to a few rules of thumb:
• Use a gentle voice, and keep all communication friendly and professional.
• Stick to the facts. Don’t answer questions that are outside your responsibility. If the physician has a question for you that you can’t answer, tell him or her that you’ll have to look into it.
• Document the entire conversation. Providers may offer details verbally that they choose not to include in the written explanation.
Whether I am asking about a malpractice claim or a history of substance abuse, following a script helps to put the provider and me at ease. I hope this helps you to sail smoothly through your next tough conversation.