RSSAuthor Archive for Anne Roberts, CPCS, CPMSM

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Anne Roberts, CPMSM, CPCS is a nationally recognized credentialing and privileging specialist who has consulted on various credentialing, privileging, and medical staff issues. She is the senior director of medical affairs at Children’s Medical Center in Dallas where she oversees medical administration, medical staff services, graduate medical education, continuing medical education, and clinical research.

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.

Handling physician HIPAA violations

The American Recovery and Reinvestment Act (ARRA) of 2009 establishes a tiered civil penalty structure for HIPAA violations. The U.S. Department of Health and Human Services (HHS) has the discretion to determine the amount of the penalty based on the nature and extent of harm resulting from the violation. HHS determines whether the individual that violated HIPAA laws exercised reasonable diligence, corrected the error within 30 days, or was willfully negligent.

Hospitals have put in place several auditing processes and safeguard procedures  to ensure that any potential HIPAA violations are discovered quickly and handled appropriately within the specified time frame. As a medical staff leader, you may be faced with the question of how to handle situations where a physician may have violated HIPAA privacy laws.

Partnering with your compliance team to ensure that your policies are clear will help guide you when and if the situation arises. While the disciplinary action taken may vary slightly from the disciplinary action that the hospital takes against one of its employees, partnering with human resources and the compliance office to ensure that the processes align is important.

Some examples of HIPAA violations that could involve physicians and ways to address them include:

  • A physician or resident leaves documentation in the cafeteria with patient information included. The paperwork is discovered by an employee and turned into compliance. Because  the individual who discovered the paperwork is an employee and is required to undergo HIPAA training, then you likely do not need to disclose the breach. However, you would want to ensure that the physician or resident who left the documentation in a public place is provided with further education in regards to the violation and the possible repercussions if another patient or family member picked up the information. You may want to consider having the physician or resident repeat his or her HIPAA training requirements and perhaps even put together a lecture for an educational conference.
  • A physician logs into the medical record of a relative or friend to check on the patient’s condition. If the physician does not have a doctor-patient relationship established, then this is a violation of HIPAA. In this situation, your compliance office will likely want to provide full disclosure of the issue to the family. As with the first example, you would want to consider requiring additional education not only to the physician involved but all members of the medical staff in regard to what is considered appropriate access to patient records and what would be considered a breach.

These examples are some common experiences that can occur in hospitals; however, there are many situations which can be egregious and could even lead to individuals being held criminally liable for breaches. Any major or egregious violations that require formal disciplinary action against a physician, (beyond simple education as suggested in the less egregious situations above), would require the organization to follow their due process procedures for the medical staff.

Is your OPPE data really complete?

When reviewing a physician’s ongoing professional practice evaluation (OPPE) profile, do you as a physician leader feel that you have a complete picture of the physician’s practice in your hospital? Because the goal of a successful OPPE process is to evaluate the physician’s current competency and current practice within your organization, ensuring that you have meaningful and complete data on every physician is important. The Joint Commission’s standards indicate that medical staff leaders must base decisions to modify, continue to grant, or terminate a physician’s privileges based on this ongoing assessment. To make a decision affecting privileges, the medical staff must perform a thorough review.

Each clinical division should develop quality indicators that are specific to its practice that it can track and that it has deemed meaningful. The indicators should assist the division chief in assessing the clinical practice within his or her division. Additionally, there should be practitioner-specific indicators that can be attributed to an individual’s practice.

From an organizational perspective, OPPE should include information regarding activity and rule indicators. Activity indicators show the number of admissions, the number of procedures performed, the average length of stay data, and so forth. Rule indicators provide data related to compliance with specific medical staff rules, such as completion of documentation in a timely manner, behavior complaints, medication errors or pharmacy interventions, and for organizations that do not have electronic medical records, legibility of notes.

Additional information that medical staff leaders should include in their OPPE reviews may include: 

  • Cases that have been referred to divisional M&M or case review or to the peer review committee(s)
  • The number of automatic suspensions for failure to maintain current credentials or insurance
  • Positive feedback from patients or peers
  • Correspondence related to a physician’s practice, such as documentation of a leave of absence during the review period

Gathering comprehensive data for ongoing review is a continuous and cumbersome process that involves the collaboration of many departments including, but not limited to, medical staff services, quality, performance improvement, medical records, pharmacy, and billing. Some organizations have added additional FTEs in the quality or medical staff services department to coordinate this process. Such FTEs include data analysts and quality nurse coordinators who can assist with interpreting the data and ensuring attribution of the data to the appropriate providers for the profile reports.

The times of only reviewing this data every two years at the time of reappointment have passed and the intent of OPPE is now to continuously monitor all practitioners granted privileges. Hospitals that have undergone Joint Commission surveys in the last few months to a year can attest that one of the primary focuses of the surveys has been determining whether the organization’s OPPE process is meaningful.

Physician orientation: Take a customized approach

A question that I seem to get quite frequently from the field relates to the different ways to conduct physician orientation. I think that organizations have many options and should customize their physician orientation to best suits their needs. Everyone has different preferred methods of learning. Some prefer to listen to a speaker, others may be content with reading material, while some may need a lot of interactive learning tools. Therefore, customizing orientation to fit adult learning styles can be challenging. Below are some methods for providing physician orientation. Mix and match until you find a program that fits your facility’s needs.

In-house orientation
Most, if not all educators would agree that nothing can replace face-to-face communication. Meeting someone and having that personal communication establishes a more personable relationship. Many organizations still require some form of in-house orientation, whether it’s organization-wide or department-specific.


Qualifications of radiology staff

A standard interpretation that some MSPs may not have focused on is the element of performance #16 for MS.03.01.01:

MS.03.01.01, EP 16—For hospitals that use Joint Commission accreditation for deemed status purposes, the medical staff determines the qualifications of the radiology staff who use equipment and administer procedures.


Don’t overlook criteria required in the medical staff bylaws

When The Joint Commission moved the disaster privileging criteria standards out of the medical staff chapter of the Comprehensive Accreditation Manual for Hospitals and into the emergency management chapter, some organizations may have overlooked the following standard which requires that the information be in the medical staff bylaws:

“The medical staff identifies, in its bylaws, those individuals responsible for granting disaster privileges to volunteer licensed independent practitioners.”


Joint Commission updates blood transfusion requirements

In the latest issue of The Joint Commission Online newsletter, The Joint Commission announced that after receiving requests from the field to allow automated identification technology, such as bar coding, it has reconsidered its position regarding a two-person verification process for blood transfusions. After consulting with safety experts, referring to academic literature, and working with healthcare organizations that use this technology, The Joint Commission agrees that the use of automated identification technology can contribute to patient safety, and therefore a one-person verification process accompanied by automated identification technology is acceptable in lieu of a two-person verification process.  

The Joint Commission has updated the element of performance for National Patient Safety Goal 01.03.01 as follows:  

Revised NPSG.01.03.01 EP 1 (addition is bolded): Before initiating a blood or blood component transfusion:

  • Match the blood or blood component to the order
  • Match the patient to the blood or blood component
  • Use a two-person verification process or a one-person verification process accompanied by automated identification technology, such as bar coding

(See also NPSG.01.01.01, EPs 1 and 2)

The Joint Commission also announced that it will not be adding any new National Patient Safety Goals for 2011. Medical Staff leaders should focus on communicating the current National Patient Safety Goals to the medical staff and ensure that appropriate medical staff policies and procedures or rules and regulations are updated to reflect the requirements.

Avoid confusion when wearing multiple hats

Many times physicians wear different hats, meaning they hold different roles within the hospital and function under different scopes depending on which hat they are wearing. Physicians switch hats so often that it can sometimes be difficult for staff to identify which role a physician is functioning under. However, it can be an important clarification that the physician needs to make.

For example, if a physician is in a training program and moonlights in another area of the hospital, it’s important to ensure that the staff understand the difference in the scope of the practice that the physician may function under while wearing his “fellow-in-training” hat versus his “general attending” hat when he is moonlighting. If he or she is a sub-specialty fellow for example, he or she may require direct supervision when performing certain services as a part of the training program; however, when moonlighting as a generalist in another service, he or she would be granted privileges specific to that area. Because the Accreditation Council for Graduate Medical Education does not allow a resident or fellow to moonlight in the same area in which he or she is training, this helps to eliminate some of the confusion. However, the organization and training program director need to ensure that this potential liability is clearly addressed in policies.

Another example is when a physician holds a medical staff leadership position, or many leadership positions, and continues his or her clinical practice. Often times, medical staff leaders will need to make administrative decisions that require them to determine which is the most appropriate hat that the decision should be guided by. For example, a chief medical officer who also serves as a committee chair may make decisions not in his or her role as the CMO, but in his or her role as the committee chair. When addressing communication while wearing the hat of committee chair, he or she should be sure to address that the communication accordingly.

Tips for preparing the medical staff for regulatory surveys

With the Joint Commission performing unannounced accreditation surveys, organizations must be in a state of continuous readiness. In addition, in recent years, Joint Commission surveyors have focused on the participation of the medical staff during a survey. Below are some tips for medical staff leaders to help them prepare their medical staffs for upcoming surveys:

  • Ask each department chief to assign a member of his or her department to serve as the regulatory liaison. Host quarterly liaison meetings and provide the liaisons with regulatory updates, standard changes, policy changes, etc. Charge them with communicating these changes to the rest of the physicians in the department. The liaison also serves as the go-to person for the department whenever a physician has a question regarding regulatory readiness.


Incident report versus educational opportunity

As the medical affairs office at Children’s Medical Center in Dallas reviewed incident reports from across the hospital, we felt the need to clearly define what actions warrant an incident report (which requires the medical staff to track and trend subsequent actions) versus an event that represents an educational opportunity.

Incident reports are filed electronically through our organization’s intranet. All incidents involving physicians are routed to the medical affairs office for review and then presented to the appropriate medical staff leaders. Primarily, an incident report is classified as either a behavior concern, a rule or compliance violation, or a quality of care issue.