Free Form Friday: CRC symposium free seat contest winner

Congratulations to Kim Pepmeier Everett, medical staff office coordinator at Good Samaritan Hospital in Vincennes, IN, for winning a free seat to the 2012 Credentialing Resource Center Symposium! Everett submitted an agenda tracking form that she and her colleagues in the medical staff office created a few years ago. If an item needs to be reviewed by multiple committees, it is documented on the form. This ensures that the item is reviewed by all necessary committees, and in the proper order.

“By utilizing the agenda tracking form, many phone calls have been eliminated asking, ‘What committees need to approve this item?’ or ‘Does the MEC need to see this document to review by the sections and services?’ Those questions are answered with the receipt of the electronic PDF file [of the agenda tracking form and item for review]. We truly don’t know how meeting agendas were developed prior to the use of this form! It’s been a lifesaver for the medical staff office,” says Everett regarding the form.

Here is a copy of the agenda tracking form.

Interested in winning next month’s free seat at the CRC Sympsosium? E-mail kkondilis@hcpro.com for details.

Featured webcast: Assessing the competence of low- and no-volume practitioners

Create strategic solutions to privileging low- and no-volume practitioners with advice from two leading medical staff and credentialing experts. In this online program, Yisrael M. Safeek, MD, MBA, CPE, FACPE, an experienced physician leader and former Joint Commission surveyor, and Sally Pelletier CPMSM, CPS, a national credentialing and privileging expert, walk medical staff leaders and medical services professionals through steps to develop a working strategy to establish competency for low- and no-volume practitioners.

Take a peek at the agenda:        

• Contributing factors to the increase of low- and no-volume practitioners
• Governance documents that hamper the hospital’s ability to effectively manage low- and no-volume practitioners (i.e. link membership and privileges)
• How does low volume affect competence
• Matching privileges with competence
• Building a strategic approach to low- and no-volume practitioners (e.g. intended practice plan, medical staff development plan)
• Working strategies to address low- and no-volume
• A medical staff culture that feels an obligation to the low- and no-volume practitioners
• Types of data sources
• How to compile and present the data in a meaningful way

This webcast will be presented on Tuesday, February 21 at 1 p.m. To learn more or to register, click here.

Patient Satisfaction Blog Series for CRC 2012

Courtesy and Respect? Don’t have to; I’m the Physician!

As I mentioned in my last post, there are three physician-specific questions on the Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS survey:

• During this hospital stay, how often did doctors treat you with courtesy and respect?
• During this hospital stay, how often did doctors listen carefully to you?
• During this hospital stay, how often did doctors explain things in a way you could understand?

This post will deal with tips to improve your scores on the courtesy and respect question.  Hopefully you have bought into the concept that improving patient satisfaction improves quality.  If you haven’t yet, then try these suggestions and see what happens.

Since approximately 85% of communication is non-verbal, pay particular attention to your body language. We have all been in situations where the body language was so loud, that the spoken words could not be “heard.”  Clear your mind prior to beginning the encounter.

Brush up on your polite behaviors such as:

• Knocking on the door before entering
• Making eye contact with the patient and visitors
• Introducing yourself and the members of your team
• Addressing the patient by their preferred name

Do not discuss the patient in the third person when they are present.  They are not just the “gallbladder in room 203” but actually a person, too.

These are just a few of the proven methods to improve patient satisfaction and your score on this question.  Try these out this week; next week I’ll be sharing about listening skills.

Editor’s note: William Mills, MD, MD, MMM, CPE, FACPE, CMSL, FAAFP, is a featured speaker at the 15^th annual Credentialing Resource Center Symposium, May 10-11. He will be speaking on using patient satisfaction scores to drive improvement as well as how to privilege low- and no-volume practitioners. For more information, click here.

Holy Moly, He Wants to Come Back!

Okay, here are the questions:

• What do you do when the physician requests his privileges be restored after he returns from rehab for his cocaine and sexual addictions?
• What do you do when the 67-year-old internist, who retired five years ago, has just been hired by administration to be your new hospitalist?
• What do you do when your favorite cardiologist returns from a medical leave of absence after suffering a significant stroke?

Of course, these scenarios cause more questions than answers. You suddenly wish you had declined the invitation to be chief of staff of your medical staff. The fact remains that demographics apply to physicians as well as the general public.

Alcohol and substance abuse is 12-14% in the general population and is the same or somewhat higher in the physician population. (P Hughes, Prevalence of Substance Abuse Among US physicians, JAMA, 1992) Sexual addiction, especially cyber addiction to pornography, is present in 6-8% of the general population and one out of five are women. (Carnes, Am J Prev Psychology Neurology, 1991, 3:16-23) Dementia is present in 13.9% of individuals 71 and older and 9.7% of these have Alzheimer’s disease. (Plassman, et al, Neuroepid, 2007) Stroke recovery is possible, but of course, varies widely depending on age, severity of the injury, rehabilitation efforts, and support to name a few. None of us are immune from these possibilities.

Okay, now a few answers. Patients are more important than physicians. Don’t get caught in the trap of treating physicians as “special people.” First and foremost, you should have a concrete policy for dealing with all of the above possibilities. It must be iron clad, fair and equitable, be consistent with HIPPA and the American Disability Act, should be patient-safety focused but also allow for the physician to return to your medical staff. This begins with a viable and credible Physician Health Committee, an engaged credentials committee, OPPE and FPPE plans on steroids, legal advice, and a “Fitness to Work” evaluation from an objective and independent physician.

Want more from Dr. White? R Dean White DDS, MS, of Dean White Consulting, will be speaking about how to create a physician re-entry process at the 15^th Annual Credentialing Resource Center Symposium, May 10-11. For more information, click here.

Patient Satisfaction Blog Series for CRC 2012

Pat Sat/HCAHPS/P4P – Huh?

This is the first of a series of five postings that will attempt to make sense of some the above. Patient satisfaction has risen to the top of many a list as the government and other payers are establishing pay for performance (P4P) initiatives. One of the reasons everyone is working on this is there is a clear connection between patient satisfaction and quality. Check out the New England Journal of Medicine for more information on this (2008; 359:1921-1931).

Because patients, payers, and politicians now care about patient satisfaction, the next three posts will provide tips for improving scores on the three physician specific questions on the HCAHPS questionnaire. The last post will tie it all together to show physicians and MSPs how patient satisfaction affects physician performance.

To start, what is HCAHPS? The Hospital Consumer Assessment of Healthcare Providers and Systems is a 27-question survey developed by Centers for Medicare and Medicaid Services with the following goals in mind:

• To produce data about patients’ perspectives of care that allow objective and meaningful comparisons of hospitals on topics that are important to consumers
• To create incentives for hospitals to improve quality of care by making public survey results
• To enhance accountability in healthcare by increasing transparency of the quality of hospital care provided in return for public investment (also by making public the survey results)

Although this survey covers a number of areas, my blog posts will cover these three physician-specific questions:

• During this hospital stay, how often did physicians treat you with courtesy and respect?
• During this hospital stay, how often did physicians listen carefully to you?
• During this hospital stay, how often did physicians explain things in a way you could understand?

Until next time, try to get your arms around the fact that improving patient satisfaction will improve quality.  For many of us, this fact will be difficult to swallow, but swallowing (internalizing) this will be critical for our success in the future.

Editor’s note: William Mills, MD, MD, MMM, CPE, FACPE, CMSL, FAAFP, is a featured speaker at the 15^th annual Credentialing Resource Center Symposium, May 10-11. He will be speaking on using patient satisfaction scores to drive improvement as well as how to privilege low- and no-volume practitioners. For more information, click here.

Solving the low- and no-volume issue

If you read this week’s Credentialing Resource Center Connection e-newsletter, you know there is an upcoming webcast regarding low-and no-volume practitioners. And hopefully you all immediately clicked on the link to sign up! If you did, unfortunately, you were taken to a link for a previous webcast.
Here is the correct link. Now you have no excuse not to sign up!
Here is a reminder of what this webcast will offer:
Create strategic solutions to privileging low- and no-volume practitioners with advice from two leading medical staff and credentialing experts. In this online program, Yisrael M. Safeek, MD, MBA, CPE, FACPE, an experienced physician leader and former Joint Commission surveyor, and Sally Pelletier CPMSM, CPS, a national credentialing and privileging expert, walk medical staff leaders and medical services professionals through steps to develop a working strategy to establish competency for low- and no-volume practitioners.

Take a peek at the agenda:

•     Contributing factors to the increase of low- and no-volume practitioners
•         Governance documents that hamper the hospital’s ability to effectively manage low- and no-volume practitioners (i.e. link membership and privileges)
•     How does low-volume affect competence
•     Matching privileges with competence
•     Building a strategic approach to low- and no-volume practitioners (e.g. intended practice plan, medical staff development plan)
•     Working strategies to address low- and no-volume
•         A medical staff culture that feels an obligation to the low- and no-volume practitioners
•     Types of data sources
•     How to compile and present the data in a meaningful way

This webcast will be presented on Tuesday, February 21 at 1 p.m. And one more time, here is the correct link to sign up.

Free Form Friday: Sample code of conduct policy

This code of conduct policy is referenced in February’s issue of Credentialing Resource Center Journal. With The Joint Commission’s announcement it is replacing the term “disruptive behavior” with “behavior that undermines a culture of safety” in its standards, now is an excellent time for organization’s to review their code of conduct policies. Although organization’s will not be required to eliminate the term from their own policies, they do need to make sure they have well-written standards that do not allow for any loopholes or misinterpretation.

R. Dean White, DDS, MS, provided HCPro with this sample policy, which can also be found in the book A Practical Guide to Managing Disruptive and Impaired Physicians, by White and Jonathan H. Burroughs, MD, MBA, FACPE, CMSL.

1.0  Policy

1.1       It is the expectation of the [hospital/entity] board of trustees that all members of the medical staff act in a professional and cooperative manner at the hospital, treating all patients and persons involved in their care with courtesy, dignity, and respect. These expectations are defined by the code of conduct.

1.2       Each member of the medical staff (individually, “physician”) granted privileges at the hospital shall be required to acknowledge and agree to be bound by the code of conduct at the time of appointment/reappointment to promote and focus awareness of the essential elements of this policy.

1.3       This policy sets forth procedures for reviewing and addressing behavioral incidents when a member of the medical staff conducts himself or herself in a manner that is inconsistent with this code of conduct.

2.0       Definitions

Disruptive or inappropriate behavior can be defined as an aberrant style of personal interaction between members of the healthcare team, patients, and/or their family members that interferes with the delivery of excellent patient care. The behavior could take the form of language, personal habits, or physical confrontation. Examples include:

• Using threatening, intimidating, or abusive language or gestures directed at patients, families, members of the healthcare team, or the hospital
• Making berating, degrading, derogatory, or demeaning comments regarding patients, families, members of the healthcare team, or the hospital
• Using profanity or similarly offensive language while speaking with anyone in the hospital
• Engaging in inappropriate or offensive conversations while providing patient care
• Engaging in nonconstructive criticism, addressed to a recipient in such a way as to intimidate, humiliate, berate, undermine confidence, belittle, or imply stupidity or incompetence
• Making physical contact with another individual that is perceived to be threatening or intimidating
• Making derogatory comments about the quality of care being provided at the hospital or by another member of the healthcare team
• Making medical record entries that criticize the quality of care being provided by the hospital or any other member of the healthcare team or that are not relevant to the delivery of care to the patient
• Refusing to abide by medical staff requirements as delineated in the medical staff bylaws, regulations, or policies
• Retaliating against or intimidating any employee or other individual for reporting behavior believed to be in violation of this code or in conjunction with completing any report regarding physician behavior

3.0       Harassment

An effective healthcare environment is one that is free from harassment of any kind, including sexual harassment. Harassing behaviors include:

• Verbal conduct, such as epithets, derogatory remarks, jokes or slurs, unwelcome sexual remarks, invitations, or comments, that is related to gender/sexual orientation, religion, mental or physical disability, medical condition, marital status, or any protected basis such as race, age, color, or national origin
• Visual conduct, such as displays of derogatory or otherwise offensive posters, cards, calendars, photographs, cartoons, graffiti, drawings, mail or electronic mail, or gestures, that is related to gender/sexual orientation, religion, mental or physical disability, medical condition, marital status, or any protected basis such as race, age, color, or national origin
• Physical conduct, such as assault, unwelcome touching, blocking normal movement, or interfering with work, that is related to gender/sexual orientation, religion, mental or physical disability, medical condition, marital status, or any protected basis such as race, age, color, or national origin

4.0       Objective

4.1       The objective of this code of conduct is to promote quality patient care by creating a safe, cooperative, and professional healthcare environment and to prevent or eliminate to the greatest extent possible conduct that:

• Disrupts the care of patients
• Adversely affects the operation of the hospital
• Affects the ability of others to do their jobs
• Intimidates or demeans any person’s ability or role in the hospital
• Creates a hostile work environment for hospital employees or medical staff members
• Adversely affects the community’s confidence in the hospital and the medical staff

4.2       Examples of both desirable and undesirable behavior are provided in the following subsection. This is a list of examples and is not intended to be all-inclusive.

4.2.1    Desirable behaviors include those in which a physician:

• Responds in a timely manner to patient needs
• Supports teamwork among caregivers
• Shows respect to peers, employees, volunteers, caregivers, physicians, hospital staff members, patients, and families
• Discusses problems in a constructive manner
• Demonstrates patience in stressful situations
• Complies with policies and procedures

4.2.2    Undesirable behaviors include those in which a physician:

• Is slow to respond or does not respond at all to patient needs
• Engages in inappropriate nonclinical conversations while providing patient care
• Exhibits extreme frustration and anger
• Belittles or demeans others
• Neglects to communicate effectively
• Makes negative comments to patients about their treatment in the hospital
• Uses threatening language, gestures, profanity, or threats of retaliation
• Displays passive-aggressive behavior
• Fails to comply with bylaws, policies, and procedures

5.0       Procedures

5.1       General guidelines/principles

5.1.1    Issues of employee conduct toward a medical staff member will be dealt with in accordance with the hospital’s human resources policies. Issues of conduct by members of the medical staff (physicians) will be addressed in accordance with this policy.

5.1.2    Every effort will be made to coordinate the actions described in this policy with the provisions of the medical staff bylaws and regulations. In the event of any apparent or actual conflict between this policy and the medical staff bylaws and regulations, this policy shall prevail.

5.1.3    The medical staff policy, “Behavioral Event Review Process,” outlines collegial steps (i.e., counseling, warnings, and meetings with a physician) that can be taken in an attempt to resolve complaints about inappropriate conduct exhibited by physicians.

5.1.4    The medical staff leadership and hospital administration shall provide orientation and education to make employees, members of the medical staff, and other personnel in the hospital aware of policies prohibiting sexual harassment and requiring respectful dignified conduct. The medical staff leadership and hospital administration shall institute procedures to facilitate prompt reporting of conduct that may violate this policy and prompt action as appropriate under the circumstances.

5.2       Procedural guidelines for responding to a concern

5.2.1    Nurses and other hospital employees who observe or are subjected to inappropriate conduct by a physician shall notify their supervisors about the incident. Any physician who observes such behavior by another physician shall notify any member of the behavioral event review committee (BERC), or his or her designee, directly. After learning of the occurrence of an incident of inappropriate conduct, the supervisor/BERC member shall request that the individual who reported the incident document it in writing. As an alternative, the supervisor/BERC member may document the incident as reported.

5.2.2    The documentation should include:

• The date and time of the incident
• A factual description of the questionable behavior
• The names of any patients or patient’s family members who may have been involved in the incident, including any patient or family member who may have witnessed the incident
• The circumstances that precipitated the incident
• The names of other witnesses to the incident
• Consequences, if any, of the behavior as it relates to patient care, personnel, or hospital operations
• Any action taken to intervene in or remedy the incident
• The name and signature of the individual reporting the complaint of inappropriate conduct

5.2.3    The supervisor/BERC member shall forward the report to the BERC. The BERC shall review the report and may meet with the individual who prepared it and/or any witnesses to the incident to ascertain the details of the incident.

5.2.4    If the BERC determines that an incident of inappropriate conduct has likely occurred, the BERC has several options available to it, including, but not limited to, the following:

• Notifying the physician that a complaint has been received and requesting that the physician provide more information about the event(s)
• Sending the physician a letter of guidance about the incident
• Sending the physician a letter or warning or reprimand, particularly if there have been prior incidents and a pattern may be developing
• Having a BERC member(s), or the BERC as a group, meet with the physician to counsel and educate the individual about the concerns and the necessity to modify the behavior in question

5.2.5    These BERC efforts are intended to be collegial, with the goal of helping the physician understand that certain conduct is inappropriate and unacceptable.

5.2.6    The BERC efforts can be used to educate the physician about administrative channels that are available for registering complaints or concerns about quality or services, if the physician’s conduct suggests that such concerns led to the behavior. Other sources of support or counseling can also be identified for the physician, as appropriate.

5.2.7    The identity of an individual reporting a complaint of inappropriate conduct will generally not be disclosed to the physician during these efforts, unless the BERC members agree in advance that it is appropriate to do so. In any case, the physician shall be advised that any retaliation against the person reporting a concern, whether the specific identity is disclosed or not, will be grounds for immediate disciplinary action pursuant to the medical staff bylaws, regulations, and policies.

5.2.8    If the BERC prepares any documentation for a physician’s file regarding its efforts to address concerns with the physician, the physician shall be apprised of that documentation and given an opportunity to respond in writing. Any such response shall then be kept in the physician’s confidential file along with the original concern and the BERC documentation.

5.2.9    If additional complaints are received concerning a physician, the BERC may continue to use the collegial and educational steps noted in this policy as long as it believes that there is still a reasonable likelihood that those efforts will resolve the concerns. At any point in this process, however, the BERC may refer the matter to the physician health committee (PHC) for review and action in accordance with the medical staff bylaws and policies. When it makes such a referral, the BERC may also suggest a recommended course of action for the physician (e.g., behavior modification course, development of conditions for continued practice for the individual, and suspensions).

5.2.10  Whenever the BERC refers a matter to the physician health committee (PHC) for its review and action, the PHC shall be fully apprised of the previous warnings issued to the physician and the actions that were taken to address the concerns. The PHC may, at any point in the investigation, refer the matter to the credentials committee without a recommendation. Any further action, including any hearing or appeal, shall then be conducted according to medical staff bylaws, regulations, and/or policies.

6.0       Performance monitoring

As an element of the medical staff’s ongoing professional practice evaluation (OPPE) process, behavioral incidents involving physicians shall be tracked on an ongoing basis to identify any trends. Results will be provided to the division chief and the credentials committee as one of the criteria to recommend reappointment of the physician.

7.0       Confidentiality

7.1       All members of the medical staff and all hospital employees involved in the reporting and review of a behavioral incident are responsible for maintaining the confidentiality of information in connection with the incident. In addition, the involved physician must maintain the confidentiality of information relating to the incident. Except as otherwise provided by law, all communications to address the incident between department leadership, medical staff leadership, involved medical staff committees, and hospital executives are confidential and privileged.

7.2       The chief of staff and CEO should be notified of any breach of confidentiality by any person involved in reporting or reviewing a behavioral incident.

Source: R. Dean White, DDS, MS, Texas Health Harris Methodist Hospital HEB in Dallas/Fort Worth. Reprinted with permission.

Clarification needed for this week’s credentialing e-newsletter

This week’s issue of Credentialing Resource Center Connection, HCPro’s credentialing e-newsletter, referred to an out-of-date standard. The “Ask the Expert” segment discussed whether CMS and Joint Commission standards ever vary. The answer is yes; there are standards that vary between the two. CMS requires that The Joint Commission (and other accrediting bodies) develop standards that meet CMS regulations; however, these standards can also exceed CMS regulations.

The “Ask the Expert” segment referred to telemedicine  as an example of a CMS and Joint Commission standard that varies.  Unfortunately, since Ready, Set, Credential! published, CMS and The Joint Commission have developed new guidelines regarding telemedicine.

Centralization of physician performance data

The structure for collecting and trending practitioner data varies from organization to organization. In many, all FPPE and OPPE data is collected, tracked, and trended by medical staff services departments. Incident reports related to patient grievances or other clinical concerns may be tracked and trended through the risk management department while peer review and individual practice deviations may be tracked and trended through the quality review department. In addition to hospital performance, division chiefs may keep division files on any issues that are reported and/or addressed by them.

It is important for organizations to have a clear picture of a practitioner’s performance. Centralizing where practitioner data is tracked will eliminate the possibility that there is performance data missing when conducting performance reviews. Although different departments may handle and/or address different issues related to performance, there should be one central repository for physician data. Departments should then forward all data to this area for safe keeping and filing in the practitioners quality file.

One of the first steps in developing a central repository for practitioner performance data is education. Organizations should spend time educating their division chiefs on how to address concerns that are brought to their attention; when collegial intervention is appropriate and when an issue must be escalated or forwarded to another department and/or a formal medical staff committee. Division chiefs should be educated on how to document performance issues and how to document the steps that they have taken to resolve the concerns. Ensuring that all concerns are well documented helps protect the division chief as well as the organization should an issue arise later which requires further scrutiny or results in due process.

Should an investigation be initiated, having all data centralized saves time and ensures a more thorough review. Having a one-stop shop for all incident reports, collegial interventions, peer review referrals, and all other clinical performance data allows the committee conducting the review to have a full picture of the practitioner’s performance. Organizations should also include all positive feedback in the quality file and should always respond to a practitioner when a review is conducted and the care he or she provided is deemed to have met or exceeded the standard.

Centralization of practitioner performance data not only benefits the committees or division chiefs conducting performance reviews, but also helps protect the organization from claims of negligence should they conduct reviews without all of the information available.

A little play, a little work

Happy National Medical Staff Services Awareness Week! I hope you have had a chance to celebrate all of the hard work produced from your MSSD. This week is not just about celebrating though, it is also about teaching. This is your opportunity to show someone new (or remind someone a bit more seasoned) all of the great things that happen on a daily basis in your office. Practitioners and patients need to recognize that without the MSSD, their lives would be very different. How would practitioners prove they are competent and know how to provide quality care to patients? And how would patients get access to those exceptional practitioners?

Since this is your week, I have a suggestion: Take 10 minutes each day this week to explain your job to someone you have never explained it to before. Not sure what to say or how to condense your duties into a 10-minute conversation? Here is a cheat sheet from NAMSS. (For the quieter MSPs out there, print out a copy of the fact sheet and leave it on someone’s desk.)

MSPs:

• Are employed by hospitals, managed care organizations, group practices, and other healthcare settings across the United States
• Are experts in provider credentialing and privileging, medical staff organization, accreditation and regulatory compliance, and provider relations in the diverse healthcare industry.
• Credential and monitor the ongoing competence of the physician and other practitioners who provide patient care services in hospitals, managed care organizations, and other healthcare settings
• Attain certification in one or both of the following:
  • Certified Professional in Medical Services Management (CPMSM). This certification is directed toward the broader responsibilities of MSPs and those who are charged with managing, improving, and implementing processes. Certification focuses on professionals who deal with governance, bylaws, medical executive committee responsibilities, and the overall compliance with internal policies and procedures as well as state, federal, and accreditation agencies.
  • Certified Provider Credentialing Specialist (CPCS). The CPCS certification focuses on the responsibilities of credentialing specialists in various healthcare environments (i.e., hospitals, CVOs, PHOs, physician groups, ambulatory facilities, and managed care/health plans). The CPCS exam is for those professionals who specialize in processing initial and recredentialing applications, who perform primary source verification, and who ensure compliance with appropriate accrediting agencies.

This is obviously just the tip of the iceberg, but it serves as a great starting point.

And don’t forget, HCPro is offering you and your colleagues a 15% discount on all of HCPro’s medical staff and credentialing products through Nov. 12. Visit the HCMarketplace and enter EO107658A during check out to receive your discount.