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?
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.
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.
Everyone knows the adage that a picture is worth a thousand words. A picture that informs might be worth even more words, and a chart that displays and analyzes data in an informative way can be even more valuable. Today’s Monday memo tip comes from Guenther Baerje, BSIT, CPCS, CPMSM, HACP, a regular contributor to CRCJ’s MSP Voice column, and is taken from the January edition of the newsletter:
The amount of data being demanded from [MSPs] is increasing daily. The amount of data being pushed to us and our physicians is equally staggering.
The ability to gather data and display it in a way that our medical staff leadership can digest and quickly identify trends and patterns is therefore critical. And it’s not something we should turf to the quality department. OPPE and FPPE are medical staff standards, not quality department standards.
To display data in a way that makes us valuable requires that we learn how to produce infographics. I recently had a physician come under a focus review. I obtained a report listing all the physician’s procedures and mined out the coded complications.
Looking at the data in this way made the department ask different questions, which led to a productive conversation and meaningful review of the physician’s skill sets.
Thanks for reading!
Mary Stevens, managing editor, Credentialing Resource Center
More physicians are delaying retirement and practicing longer, and medical staffs across the country are wondering how to help physicians stay in practice longer while promoting quality care. The fact is, many medical staffs aren’t prepared for an aging physician population. If your organization is looking for guidance about this topic, I hope you’ll join us for a webcast Tuesday, March 11, from 1:00 to 2:30 p.m. (ET).
The presentation, Practicing Medicine Longer: Legal and Clinical Considerations for an Aging Physician Population, features two renowned speakers: CRCJ editorial advisor Elizabeth “Libby” Snelson, JD, president of Legal Counsel for the Medical Staff, PLLC; and Stephen H. Miller, MD, MPH, voluntary clinical professor of surgery and family and preventive medicine at the University of California San Diego. They’ll tackle the cultural, clinical, and legal considerations medical staffs must address to help physicians who want to stay in practice longer, and will provide time to answer your questions.
Audience members will find guidance on establishing a policy for aging physicians, protecting against age-discrimination lawsuits, and eliminate unnecessary barriers for physicians who want to stay in practice longer. In addition, this webcast will provide ideas for reducing the stigma of identifying physician impairment, and for supporting physicians when a practice issue is identified.
This program is pending approval by the National Association Medical Staff Services for up to 1.5 continuing education units. More information is available here.
If you want to help a physician perform successfully in a medical staff leadership role, you must develop a written job description for that role. This is a basic function of establishing and communicating clear expectations. Physicians are generally committed to doing a good job at everything they do; that’s part of what drew them to medicine in the first place. Once physicians know what is expected of them, they give it 110% effort—provided they buy into the expectation. If they don’t buy into it, or worse yet, don’t even know about it, there is precious little chance they will comply with the expectation. In fact, expecting physician leaders to fulfill their responsibilities without fully orienting them to their respective positions sets them up to fail.
Need help creating job descriptions for your various medical staff leader positions? Check out The Medical Executive Committee Manual, available at www.hcmarketplace.com, which offers narrative and sample forms that you can recreate for your facility.
Some hospitals have mastered OPPE, and we try to bring their success stories to you. But there are plenty of places where “OPPE” is a four-letter word. Compiling physician performance data and generating reliable physician competency reports that comply with OPPE and physician performance standards are not easy tasks.
If you’re looking for OPPE answers, join us next month for a free 60-minute webcast to see how HCPro’s Physician Profile Reporter can help you. This customized software program compiles all sources of physician performance data into one database, enabling MSPs to generate reliable performance reports that can be easily distributed to each medical staff member—and it won’t bust your facility’s budget.
HCPro leverages the The Greeley Company’s expertise to offer practicable, economical tools for tracking and reporting physician performance. During the webcast you’ll to see how the Physician Profile Reporter can help you:
• Compile data from a variety of sources to produce physician-specific reports for OPPE monitoring and physician feedback
• Use multiple types of indicators to measure all dimensions of physician performance
• Set targets for both Excellent and Acceptable performance that recognize physician excellence as well as improvement opportunities
• Organize the report according to The Joint Commission and ABMS core competencies framework
• Create a medical staff culture that encourages physicians to accept performance data feedback and use it to improve