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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.

Doctor accused of unnecessary stents: What happened to the peer review process?

It’s every hospital’s, doctor’s, and patient’s worst nightmare—a doctor allegedly committing fraud, a stack of lawsuits, and claims of complications after surgery. Each member involved in the cardiac stent cases at St. Joseph Medical Center in Towson, MD, continues to be more entwined as the story unfolds.

The Maryland Board of Physicians investigated and this month met with Mark G. Midei, MD, for “gross overutilization of healthcare services” and “willfully making a false report or record in the practice of medicine,” among other violations of the Maryland Medical Practice Act, according to a June 11 Baltimore Sun article.


9 tips for conducting peer review in the face of discoverability

They call Missouri the “Show Me State,” but perhaps that name is better suited for Florida. In the September issue of Credentialing & Peer Review Legal Insider, I spoke with George Indest, an attorney with The Health Law Firm in Almonte Springs, FL about the consequences of Amendment 7. Amendment 7—otherwise known as the Patient Right to Know about Adverse Medical Incidents Act—makes  what would normally be considered protected peer review information discoverable to the public. Originally meant to help patients do research on their healthcare providers, the amendment has stifled peer review efforts across the state since it was implemented in 2004. As case law continues to define the amendment, many medical staffs are choosing to minimally document peer review activities to protect physicians from the career damaging effects of discoverability.

However, choosing to keep only sketchy documentation of peer review activities can have a negative effect on peer review as a whole. According to Indest, inadequate documentation can result in  the inability to obtain meaningful feedback from the healthcare providers involved in specific incidents of adverse care due to their inability to identify the specific incident or patient about whom feedback is being sought, inability to comply with certifying or accrediting organizations’ guidelines and requirements, failure to be able to show compliance with state requirements for peer review activities.

To avoid these undesirable consequences, Indest recommends the following: 


Video: Online medical staff training courses released

We just launched our new medical staff online training library and wanted to share some of the sample clips. If you need to train new members of the medical staff who don’t have the time or resources to commit to the off-site events, these courses allow new members to train from work or home.

There are four courses presented by The Greeley Company, each with more than 100 minutes of slides and video (broken down in smaller segments for convenience). They focus on orientation for new members of the medical executive committee, credentials committee, peer review and quality committee, and department chair. At the end, learners take a 20-question interactive quiz to receive their continuing education certificate.

You can watch the introduction below:

Medical staff leadership online training library (Intro)


Here are some snippets of the actual courses:


Contest winner: Physician report card

Congratulations to our May contest winner, Iracema Navarro, medical staff coordinator at Promise Hospital, San Diego! This sample policy of the physician report card won Iracema and a colleague free registration to The Greeley Medical Staff Institute Symposium.

Iracema developed this physician report card form in 2007 when Promise Hospital was devising a way to comply with The Joint Commission’s requirement for ongoing professional periodic evaluations.

Iracema talks about the evolution of the physician report card as it expanded to include more items to review:


Credentialing, confidentiality of medical staff minutes, quality improvement, and peer review information policy

The June issue of Credentialing & Peer Review Legal Insider offers some tips for maintaining protections under the Health Care Quality Improvement Act by properly maintaining your peer review documentation. Medical staffs that fail to keep their peer review documentation confidential may inadvertently waive their right to the peer review protections offered under HCQIA and make what should be undiscoverable documents discoverable. To protect that immunity and discoverability, medical staffs and hospitals should adopt a confidentiality of quality improvement information policy. If you currently lack a strong confidentiality policy, check out  The Greeley Company’s credentialing, confidentiality of medical staff minutes, quality improvement, and peer review information policy. Feel free to adapt this to suit your facility’s needs. Just be sure to check with your legal counsel before implementing this or any other policy.

Back from sunny Las Vegas with some great OPPE tips

I just returned from Las Vegas where HCPro and The Greeley Company hosted the 13th annual Credentialing Resource Center Symposium. It was great meeting the attendees and hearing all of the questions that they posed to our knowledgeable speakers during the sessions.

We started the symposium on Wednesday with two pre-conferences: Credentialing Basics Bootcamp and OPPE Done Right. I sat in on OPPE Done Right, presented by Greeley consultants Robert Marder, MD, CMSL, and Mary Hoppa, MD, MBA, CMSL. I learned some great tidbits from this session:

  • The Joint Commission now expects at least two OPPE cycles to be completed or your hospital will get dinged. If your organization is Joint Commission-accredited, be sure that your OPPE schedule will allow you to complete two full cycles before your next survey. The Greeley Company recommends six- to eight-month cycles.


Contest winner: OPPE for low-volume providers

Congratulations to the March contest winner, Mindy Hays, CPMSM, medical staff coordinator at Lindner Center of Hope, Mason, OH, for her entry on ongoing professional practice evaluation (OPPE) for low-volume providers!

Here’s what Mindy has to say about OPPE at her institution:

“This standard has been challenging for everyone to meet. It can be especially challenging trying to meet the standard for low/no volume practitioners. As such, we have added the following language in our Professional Practice Evaluation policy to address the low/no volume practitioners:


Keeping peer review documents confidential may become trickier as medical staffs go electronic

I am currently writing an article about how medical staffs can protect their peer review documents from discoverability under HCQIA. One sure way to lose your immunity is to fail to keep your peer review documents confidential, and confidentiality is getting harder to maintain as medical staff processes go electronic.

Annemarie Martin-Boyan, Esq., senior counsel at Temple University Health System in Philadelphia encourages medical staff leaders and medical staff services professionals to think twice before sending an e-mail containing a potentially confidential document. “I got a question recently from a peer review committee that wanted certain reports generated out of our incident reporting system to be posted in advance of the meeting so that people could be prepared for the meeting,” she says.


Working with External Peer Reviewers: 10 Questions Medical Staffs Should Ask

Deciding when to initiate external peer review can be a daunting task for medical staffs. Even more daunting is the process for ensuring that the external peer review process is fair and protected.  When engaging an external peer reviewer in your facility’s peer review process, be sure to ask yourself the following questions:                            

 1.  Have you taken steps to preserve maximum confidentiality of the external peer review report, including invoking the state peer review document privilege as well as attorney-client privilege if the expert is retained through legal counsel for the institution?

 2.  Have you selected, or has the external peer review organization selected, an individual with impressive credentials, including but not limited to board certification, and without red flags or skeletons in his or her closet?

 3.  Have you supplied the complete medical record and any other supporting documentation that is relative to the particular matter the expert is reviewing?

 4.  Have you determined whether the expert is willing to testify in a hearing if necessary?

 5.  Has the expert reserved the possible hearing dates, as well as adequate time for pre-hearing preparation and discussion?

 6.  Have you provided a letter of defense and indemnification from the institution to the expert?

 7.  Is the expert’s written report clear, unambiguous, and factually accurate? Will it resonate with the hearing panel or other decision-making body such as the medical executive committee or board of directors?

 8.  Have you reached an understanding with the expert as to when the written report will be completed and available? 

9.  Has the expert reviewed any rebuttal or response of the accused physician and has he reflected that review in his report? 

10.  Is the expert an individual who will relate well to your hearing panel, should a hearing be necessary? 

Constance H. Baker is an attorney with Venable LLP in Baltimore.