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Monday memo: Take a look at the latest issue of CRCJ

news01The newest issue of Credentialing Resource Center Journal is here! Read about the new Healthcare Facilities Accreditation Program (HFAP) standards for OPPE and FPPE in acute care and critical access hospitals. Most facilities conduct competence assessment and peer evaluation in one form or another. Now, however, HFPA-accredited facilities must implement structured ongoing and focused processes for assessing physician competence.

Also in this issue, Steven Miller, MD, MPH; and Elizabeth “Libby” Snelson, JD, answer questions concerning legal and clinical considerations for late practice physicians; and Guenther Baerje describes what happens when a medical staff has a health center, loses it during a disaster, and then gets it back again—a sense of devotion he calls the “Northridge Effect.”

Many readers had a familiar credentialing question to the 2013 MSP Survey Salary: “Can you be more specific?” We tried in the 2014 edition, and I asked CRCJ readers to take the retooled, sharpened MSP Salary Survey and enter to win a credentialing best-seller from the HCPro book roster. There’s still time, but don’t delay—April 18 is the final day for input.

Best regards and thanks for reading!

Mary Stevens

MSP Salary Survey says…

graphic-barOur very early MSP Salary Survey results may speak to the stability of the field as a career choice, the changes it’s undergone in the past two decades, or an increasing volume of work. Maybe all three … maybe none of these. We’ve had great responses so far, and plenty of them, but results will change as more people take the survey. I’m looking forward to analyzing what’s behind the final numbers, but there’s still time to take the MSP Salary Survey. You can click here to access it, or connect by copying this URL into your browser: In the meantime, here are some of the early results:

  • In what is currently a statistical dead heat, roughly 20% say their department credentials 101-200 practitioners; another 20% pin the number at 201-400. So far, the highest response—closer to 21%—say their department credentials more than 1,000 practitioners.
  • 41% of respondents say their department reports to the chief medical officer/vice president of medical affairs.
  • Among those who oversee other departments or services, close to 50% oversee continuing medical education.
  • More than a third of early respondents report their organization has only one full-time MSP.
  • 27% of respondents have five to 10 years in their current position, and 22% have been on the job for more than two to just less than five years. Sixteen percent have held their current job for 11 to 15 years.
  • 39% have been in the medical services field for more than 20 years; 20% reported five to 10 years in the field. Another 17% have been in the field for 16 to 20 years.

As always, thanks for reading!

Disclosure requirements—Sharing of information, Part 3

hosp02Appropriate 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?

Monday memo: Tuesday events

TIPThis 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!


Disclosure requirements—sharing of information, Part 2

Medical-LawAppropriate 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?

Monday memo: OPPE, FPPE, and ambulatory sites

TIPIn 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!

Monday memo: Spend an hour, save some time

TIPIs 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.

Click here more information or to sign up. If you can’t attend tomorrow’s demo, email Marla Smith, MHSA, HCPro Consultant in Medical Staff Quality, at to schedule your free demo.


Monday memo: Use a consent agenda to keep meetings moving

TIPWhen 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.

Plan ahead
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.

Monday memo: Making the tough call

TIPIt’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.

Monday memo: Get the picture?

TIPEveryone 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!

Best regards,

Mary Stevens, managing editor, Credentialing Resource Center