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2012 OMSS Annual Assembly

Friday, October 12, 2012 7:30 am – 4:00 pm

Sacramento Convention Center (Room 204)

7:30 AM – 8:00 AM Registration and Breakfast

8:00 AM – 8:15 AM Welcome and Introductions Paul Phinney President-Elect CMA Dustin Corcoran, CEO CMA

8:15 AM -9:45 AM CMA Resolutions and Reports

Lytton Smith, MD Chair, CMA-OMSS

9:45 AM – 10:15 AM OMSS Elections

Lytton Smith, MD Chair, CMA-OMSS

10:15 AM - 11:15 AM Physician-Hospital Alignment – Part 2: Impact on the Medical Staff

Long Do, JD Tom Curtis, JD Jimmy Chung, MD Larry DeGhetaldi, MD

11:15 AM - 12:00 PM Strategies for Managing the Blended Medical Staff

Robert Reid, MD Tom Tremoulet, MD

12:00 PM – 1:15 PM Lunch Legislative/Regulatory Update Medical Staff: Open Forum

Jodi Hicks, Vice-President CMA Government Relations Lytton Smith, MD Chair, CMA-OMSS

1:15 PM – 2:30 PM eHealth and Integrated Care Pamela Lane, MS

2:45 PM – 4:00 PM Trends in Credentialing and Privileging Stephen Anthony Greenberg, MD

4:00 PM Adjourn

Hospital Physician Alignment:The Physicians’ Perspective

Jimmy Y. Chung, M.D.CMA‐OMSSCMA OMSS10/12/2012

Hospital/Physician AlignmentHospital/Physician Alignment

• Hospital employing physiciansHospital employing physicians• Hospital buys independent practices• Hospital creates foundation• Hospital creates foundation• Clinical integrationACO• ACO

• Joint ventures• Co‐management plans• Exclusive contracts

Driving forcesDriving forces

• Healthcare ReformHealthcare Reform• Increasing costs/decreasing reimbursementsQ li i• Quality metrics

• Value‐based Purchasing• EHR/Meaningful Use

Challenges for physiciansChallenges for physicians

• Lack of capitalLack of capital• Unable to collectively bargain

k f k l d / (lik )• Lack of knowledge/resources (like FMV)• Lack of time (physician leaders are also fulltime practitioners)

What hospitals should doWhat hospitals should do

• Maintain a physician‐positive culturep y p• Allow room for physician autonomy and self governance

• Be transparent with goals of the hospital• Allow physicians to own some goalsR l d i ti H d i ?• Regular and open communication: How are we doing?

• Hire a CMO/VPMA• Groom physician leaders• Groom physician leaders• Create incentives based on quality (rather than productivity)p y)

What physicians should doWhat physicians should do

• Keep doing what you do bestp g y• Open communication• Learn about quality and regulations• Be willing to change your ways• Know the difference between “standard of care”

d “ id b d b t ti ”and “evidence‐based best practice”• Identify shared goals and incentives• Prepare for incentives based on quality (rather• Prepare for incentives based on quality (rather than productivity)

• Read your contracts carefullyy y

What medical staffs should doWhat medical staffs should do

• Maintain autonomy and self governancea ta auto o y a d se go e a ce• Take ownership of quality• Review bylaws to strengthen medical staffReview bylaws to strengthen medical staff position (it’s a living document)

• Make sure bylaws include provisions on contractsy p• Maintain separate funds (may need own TIN)• Retain independent legal counselp g• Elect strong leaders who are visionaries with excellent communication skills

What are the common goals?What are the common goals?

• Before letting emotions take over all partiesBefore letting emotions take over, all parties must compare notes and find common goals.

• There must be some room for compromise on• There must be some room for compromise on both sides.L k f “ i i ”• Look for a “win‐win”

Case 1Case 1

• Hospital is under pressure to improve EDHospital is under pressure to improve ED throughput and meet metrics

• Decides not to renew contract with current• Decides not to renew contract with current physician group, and instead puts out an RFP.ED fi h b k b i l b• ED group fights back; submits proposal, but also garners emotional support from other h i i d i l dphysicians and community leaders.

• Med staff fears losing friends, colleagues.

Case 1 (cont.)Case 1 (cont.)

• Hospital collects 3 proposals for considerationHospital collects 3 proposals for consideration. • Organizes panel of board members, administration and med staff members toadministration, and med staff members to evaluate the 3 groups.E ll h i l• Eventually chooses national group

• Med staff is unhappy, accuses hospital of choosing profits over physician loyalty

• Med staff starts to feel paranoia: who’s next?p

Case 1 (cont.)Case 1 (cont.)

• In the meantime… The national group agreesIn the meantime… The national group agrees to hire all the original group ED physicians at partnership level commensurate with their years of experience.

• No one is forced to quit or leave town.• Since the original fear amongst fellow physicians and community leaders was losing valued friends and colleagues, this is seen as a “win‐win”…. But is it?

Case 2 (Cont.)Case 2 (Cont.)

Larry deGhetaldi MDLarry deGhetaldi MD

Palo Alto Medical Foundation(1,000 CMA members)(1,000 CMA members)

CMA Large Group Forum Trustee

Perspective

• Physician hospital executivePhysician hospital executive• Physician president of a medical foundation

80 h i i S di l ff• 180 physicians on Sutter medical staff AND Dignity medical staff

ConflictsConflicts

• Paying for value versus paying for volumePaying for value versus paying for volume– Leading MD compensation systems (incentive misalignment)misalignment)

– Stark rules limit hospitals and Med Foundation– FFS payment models<cap payment models– FFS payment models<cap payment models– TCoC management rules

• Who controls the distribution of shrinking pie?• Who controls the distribution of shrinking pie?• Long term success depends on decreasing hospital use• More care delivered in resourced and effective primary p ycare medical homes

Medical FoundationsMedical Foundations• (1206l) A clinic operated by a nonprofit corporation exempt from federal income taxation under paragraph (3) of subsection (c) of Section 501 of the Internal(3) of subsection (c) of Section 501 of the Internal Revenue Code of 1954, as amended, or a statutory successor thereof, that conducts medical research and health education and provides health care to itshealth education and provides health care to its patients through a group of 40 or more physicians and surgeons, who are independent contractors representing not less than 10 board certifiedrepresenting not less than 10 board‐certified specialties, and not less than two‐thirds of whom practice on a full‐time basis at the clinic.

• 1981 to present– PAMF, Santa Barbara Sansum, Sharp Rees‐Stealy– Rapid growth to support multi‐specialty group practicesRapid growth to support multi specialty group practices– Growing to include hospital based physicians– Average age of MDs < 10 years of community peers

Hospital Out‐Patient ClinicsHospital Out Patient Clinics

• (1206d) Clinics conducted operated or(1206d) Clinics conducted, operated, or maintained as outpatient departments of hospitalshospitals.

• Rural hospitals employing physicians

California vs. NationCalifornia vs. Nation• National trends

– Group Practice Growth; integrated systemsp ; g y– ACOs; Medicare and Commercial; Duals Pilots– Increase in the numbers of employed physicians– Paying for value; bundled payments; coordinated care; readmission penalties

C lif i• California– 1206 L, KP Model, 1206 D vs the corporate bar– Success of the delegate model– Success of the delegate model– Strong hospital systems with varying physician “strategies”

– Rapid movement of physicians into group practice

From the Hospital’s PerspectiveFrom the Hospital s Perspective• Readmission penalties

/ /• Seismic/nurse staffing ratios/labor unrest• Two “anti‐hospital” ballot initiatives ‘on hold’Ph i i i t ti• Physicians integrating

• Loss of profitable centers (ancillaries)• Complex Stark/physician compensation rules• Complex Stark/physician compensation rules• Push to be in integrated systems; governance consolidatingg

• Global Cap? ACOs? Need to control• Reactions vary: Master Medical Foundations to ‘realizing the value of investing in primary care’

Ho to Recr it MedicalHow to Recruit Medical Staff Leaders in aStaff Leaders in a

“Blended” Medical Staff

Robert Reid, MD

Santa Barbara Cottage Hospitalg

2012

CMA Organized Medical Staff SectionCMA Organized Medical Staff Section

Annual Assembly

Medical Staff LeadershipMedical Staff Leadership

T d ' M di l St ff l d d t bToday's Medical Staff leader needs to be a agent of change to achieve the level of

ll b ti d t l b fit t icollaboration and mutual benefit to survive in our continued whitewater change milieu f h lthof health care.

QuestionsQuestions

• What does it take to effectively developWhat does it take to effectively develop physicians for key leadership positions in their Medical Staff Organizations?their Medical Staff Organizations?

H b k th 80/20 l d• How can you break the 80/20 rule and engage more staff members in leadership

l f lfilli k f tiroles or fulfilling key functions.

What do you want in a Medical S ff L d ?Staff Leader?

• Enjoys the respect of colleagues• Has energy and ideas• Has energy and ideas• Can bring about change

C k ith d i i t ti• Can work with administration• Understands how hospitals work• Can tolerate confrontation• Able to leap tall buildings at a single bound

The Criticality of Peer RespectThe Criticality of Peer Respect

• A physician leader who is not perceived asA physician leader who is not perceived as an outstanding clinician will not be followedfollowed

• Usually are the busiest clinicians on your staff and would not appear to have time tostaff and would not appear to have time to serve or learn the role

O t t th i l d i ll d• One way to get them involved is called “Structured Dialogue”

Structured DialogueStructured Dialogue

• In six months develop a panel of your best doctors who:doctors who:– Understand the hospital

U th h it l– Use the hospital

– Are willing to lead in pursuing a shared vision

Structured DialogueStructured Dialogue

• We called this a Medical Advisory Panel or MAP and key to success is:MAP and key to success is:– How it is structured

H it t– How it operates

Medical Advisory Panel - StructureMedical Advisory Panel Structure

• CEO with MS leadership input, selects co-CEO with MS leadership input, selects cochairs (1 procedural & 1 cognitive doc)

• Co-chairs select a panel of 13-15 docs:– Represent various sections or departmentsRepresent various sections or departments– Not necessarily the chairs– Abrasiveness not a disqualifying traitAbrasiveness not a disqualifying trait– Key criterion – are they at the top of their

clinical game? Respected by their peers?

Medical Advisory Panel - OperationMedical Advisory Panel Operation

• Goal: Advise the hospital from physicianGoal: Advise the hospital from physician point of view how to better serve the communitycommunity

• Our panel met weekly during first phaseW t F id i 0700 0900– We met Friday mornings 0700-0900

• We paid doctors 100/hr in f facknowledgement of the value of their

time. (May not need to do this)


• Each panel member is asked to selectEach panel member is asked to select someone from his or her section / department who:department who:– Is well respected

Will consult with colleagues and make a ½– Will consult with colleagues and make a ½ hour data-driven presentation to the panel with a status report and 3 – 5with a status report and 3 5 recommendations for improvement


• The hospital supplied financial and demographic data as neededdemographic data as needed

• Administration was not present at initial discussions. VPMA & CNO were present– CFO called in several times to explain

hospital finance

Two SurprisesTwo Surprises

• The presenters were easy to recruitS h d t b k d– Some were honored to be asked

• The presentations were superb– Desire not to look foolish in front of their

highly respected peers


• At conclusion of presentations panel wouldAt conclusion of presentations panel would score the recommendations from 1 – 5:

Improves clinical outcomes– Improves clinical outcomes

– Increases service to patients

Strengthens other services– Strengthens other services

– Improves market share

I t ff ti– Is cost effective

• The scores were fed into a spread sheet

Clinical Priority Setting Process

ManagementBoard of Trustees

Clinical Priority Setting Process

Medical Advisory Panel prioritized recommendations

Medical Staffset guidelines;appoint presenters

ClinicalPresenters

written documents;oral presentations

Clinical Presenters and peerparticipation in

sections/services


Among the recommendations were someAmong the recommendations were some inexpensive “Quick Fixes” that were accomplished immediately (e g portableaccomplished immediately. (e.g. portable EMG machine for neurology; changing linen daily in the on-call rooms)y )– Reinforced the validity of the process

– Demonstrated administration’s commitment toDemonstrated administration s commitment to acting on recommendations.


• At the conclusion of all the presentationsAt the conclusion of all the presentations the panel wrote a report with prioritized recommendationsrecommendations– The spread sheet was very helpful

The recommendations were presented to• The recommendations were presented to the Board of Directors at their annual planning retreat and received a standingplanning retreat and received a standing ovation (unprecedented)

ResultsResults

• Most of the recommendations have beenMost of the recommendations have been subsequently implemented

16 “Quick Fixes”– 16 Quick Fixes

– 32 Major Recommendations• OR Efficiency• OR Efficiency

• Outpatient Cardiac Imaging Center joint venture

• Q.I. program for critical careQ p og a o c ca ca e

• ED throughput and patient satisfaction

• Support Community Clinics

ResultsResults

• The vision and strategic plan of theThe vision and strategic plan of the hospital has the benefit of the best thoughts of the most respected physicians g p p yin the community

• Physicians have a greater shared interest y gin that plan because of their participation.

• We now have a cadre of educated, respected physicians who are willing to lead.

These DoctorsThese Doctors• Enjoy the respect of colleagues

H d id• Have energy and ideas• Have brought about change• Can and have worked with administration• Understand how hospitals work including g

finance• Can tolerate confrontation• Probably not able to leap tall buildings at a

single bound

C h K d F ll S G tti it DCohn,K and Fellows,S. Getting it Done: Experienced Health care Leaders Reveal Field-Tested Strategies for Clinical andField Tested Strategies for Clinical and Financial Success. Chicago: Health Administration Press

Scripps Health: Physician Perspective

Tom Tremoulet, , MD, FACEP

Dept. Emergency Medicine, Scripps Memorial Encinitas

1

One Scripps: Transformation

From there...From there... To here...To here...

2

One Scripps: Physician Relationships

• Established 2000

• Precursor of co management approach

Physician Leadership Cabinet (PLC)Physician Leadership Cabinet (PLC)

• Elected physician leaders

• 100 percent adoption of recommendations• Precursor of co-management approach • 100 percent adoption of recommendations

3

One Scripps: Physician Leadership Academy

• Launched in Fall 2011

Developing LeadershipDeveloping Leadership

• Geared toward rising physician leaders

• Discussions center onDiscussions center on leadership competencies, communication strategies, managing health care

ti doperations and more

4

One Scripps: Physician Relationships

• Established 2009

Physician Business Leader Cabinet (PBLC)Physician Business Leader Cabinet (PBLC)

• Precursor of Accountable Care Organization

• Medical group leaders fromMedical group leaders from both independent and integrated models

• Recently formed as officialRecently formed as official board of Scripps ACO

5

One Scripps: Progress

Physician Co-ManagementPhysician Co-Management

“Change is going to happen much faster than most physicians or

hospital administrators imagine. And this change will be accompanied

by profound ambiguity as our profession and industry are restructured.

The survivors will thrive under business models that are not even

d fi d t d ”defined today.”

— James LaBelle, MDCorporate Vice President

6

Quality, Medical Management, Physician Co-Management

One Scripps: Progress

Physician Co-ManagementPhysician Co-Management

“We have to face the fact that there is a new paradigm. That paradigm

leads us to collaborationleads us to collaboration.

We will not succeed if we do not collaborate.”

— Juan Tovar, MDEmergency Medicine

7

Scripps Mercy Hospital, Chula Vista

Thank you.Thank you.Tom Tremoulet MD FACEPTom Tremoulet, MD, FACEPScripps Memorial Encinitas, Dept of Emergency Med.

8

Trends in Trends in Trends in Trends in Credentialing and Credentialing and Credentialing and Credentialing and

PrivilegingPrivilegingPrivilegingPrivileging

Credentialing and Privileging

• Credentialingg• Privileging• Credentials Verification• Credentialing Review Process• Confidentiality of Credentials Files• Critical Credentialing Processes• Low Volume Practitioners• Proctoring• Proctoring• OPPE and FPPE• Negligent CredentialingNegligent Credentialing

2


CredentialingCredentialingAssessing and Validating qualifications of practitioner to provide

health care serviceshealth care servicesGathering information serving as foundation for decisionmakingPurpose – to ensure that all patients receive quality care by

qualified and competent practitionersPurpose – Protecting patients NOT to assisting practitioners get

privilegesprivilegesDoubts about practitioner qualifications must be resolved in

favor of patient safetyp y

3


PrivilegingPrivilegingDefines a physician’s scope of practice and the clinical services

he or she may providehe or she may provideBased on demonstrated competence Must meet medical staff criteriaData driven processEvaluation of adverse clinical occurrences (peer review)Assessment of clinical judgmentCredentials relevant to privilegesN d t t “j t i ” i ilNo need to grant “just in case” privileges

4


Providers Credentialed by Medical StaffProviders Credentialed by Medical StaffMedical Staff Members• PhysiciansPhysicians• Dentists/Oral Surgeons• Podiatrists• Clinical Psychologists• Contracted Practitioners• Locum Tenens

5


Providers Credentialed by Medical StaffProviders Credentialed by Medical StaffAdvanced Practice/Allied Health Staff Members• Physician AssistantsPhysician Assistants• Nurse Practitioners• Nurse Anesthetists• Nurse Midwives• Chiropracters• Optometrists

6


Items to Review During CredentialingItems to Review During Credentialing• License• Education and Training• Education and Training• Experience• Board CertificationBoard Certification• Health Status• Malpractice • Ethical character

7


Credentialing VerificationCredentialing VerificationPrimary Source Verification Whenever Possible• Verification of entire practice historyVerification of entire practice history• Contact the original source of the credential• Written documentation directly from the source• Can be obtained online if the website is deemed as primary source• May document telephone verification of information obtained directly

from primary source• Cannot accept copies of certificates/diplomas or anything handled by the

applicant

8


Credentialing VerificationCredentialing Verification• Professional Education and Training

Medical/dental/podiatric schoolInternship, residencies, fellowshipsUndergraduate/graduate for allied health personnel

• Current and previous affiliationsHospital/clinic/work history

• Professional peer referencesClinical competency

• State Licenses/DEA certificate• Board Certification

9


Credentialing VerificationCredentialing Verification• Consider sending photograph for ID purposes

Ask if the applicant is the person in the photo

• Use forms that are easy and quick to fill outQuestions with spaces for check marksOutstanding – Excellent – Average – Poor – UnknownFollow up on “average” or “unknown”

• Send requested privilege list to peer referencesAsk if there is a privilege on the list that they do not have information on the applicant’s

tcompetency

• State Licenses/DEA certificate• Board Certification

10


Credentialing VerificationCredentialing Verification• National Practitioner Data Bank report• Malpractice Insurance Certificatep• Sanctions/disciplinary actions

Medical Board of CaliforniaFederation of State Medical BoardsOffice of Inspector General

• Explanation of Time Gaps• Criminal Background ChecksC a ac g ou d C ec s

Criminal convictionsSex offender registrySocial Security Number validationDMV (DWI convictions, status of driver’s license)

11

Background Checks

• Hospitals may require applicants to the medical staff to consent to personal background checks (ex. criminal history, tax records, etc.)– Not an accreditation requirement or CMS Conditions of Participation to screen

the medical staff for criminal or credit history.M di l B d i fi i ti d b k d h k diti f– Medical Board requires fingerprinting and background check as a condition of licensure and to report convictions upon license renewal.

• Some consulting firms and security agencies promote “passing” criminal background and even credit checks as a requirement for medical staffbackground and even credit checks as a requirement for medical staff membership.

• Due to state licensing requirements related to background checks, it is redundant for medical staffs to also require a background check.

• Often unclear what will be done with negative information found in a background check, particularly when there is no clear policy about how it will be used and who will have access to the information.h ld b b l f d• Should be in bylaws if used.

12

Centralized Credentialing

• Hospital systems are moving toward centralized credentialing, as opposed to the traditional model of credentialing being conducted by the medical staff office at each hospital site.

• Benefits: C b h i f idi t d di d i d ifi ti f d ti li– Can be a mechanism for providing standardized review and verification of credentialing information in a timely manner;

– May be easier to ensure that the process meets all legal, professional and accreditation requirements promulgated by public agencies and private organizations (ex. federal and state regulations, and Joint Commission and NCQA accreditation standards).

– May reduce “busy work” for the medical staff office.– Standardized credentialing/recredentialing information and format – Ease of update signature and distributionEase of update, signature and distribution

13

Centralized Credentialing

• Drawbacks: – Medical staff at the hospital may lose control of the credential file and its ability to

safeguard the privacy of medical staff members and their rights to view and access the credential file (often basis for separating out quality and peer review information)

– Centralized credentialing may “morph” into centralized privileging with privilegingCentralized credentialing may morph into centralized privileging with privileging decisions being made by individuals outside of the medical staff

– Credentialing process could become long, cumbersome and invite administrative intrusion into medical staff operations

R l lif I• Real‐life Issues: – Hospital systems direct that all physician and allied health professionals must apply for

medical staff membership through a centralized hospital system office. This would be done before the medical staff conducts a second independent review.

– Medical staffs are directed to submit credentialing information to a third party service that also has ties to health plans. No protections are in place to protect personal information.

14

The Medical Staff Credential File

• All applications and reapplications for medical staff membership and specific clinical privileges, including all attachments;All i f ti l ti t ifi ti f th li ti i f ti i l di• All information relating to verification of the application information, including reports from any Centralized Verification Organizations, and copies of any documents obtained in verification (such as reports from the National Practitioner Data Bank, the Federation of State Medical Boards, the Medical Board of , ,California, the federal Drug Enforcement Agency, etc.);

• Where any verification was obtained over the telephone, copies of notes summarizing the verification information obtained, which should be signed and d d b h i di id l h d h l h ll i di i h l hdated by the individual who made the telephone call, indicating the telephone number of the person contacted and the information received;

• Any and all correspondence from the physician or others relating to the physician's application;application;

• Letters of reference;• Verification from medical schools, residency programs and other training

programs;p g ;

15


• Proctoring reports and other evaluations;• Any quality data from CQI programs or QA quality screens that are used as a basis

f i ti ti di i li f th h i ifor investigation or discipline of the physician;• Data on physicians submitted to external benchmarking registries• Any departmental evaluations or credentialing recommendations;

N i th h it l t ( i f h t ) i th• Nursing or other hospital reports (or summaries of such reports) concerning the physician;

• Excerpts from the minutes of any medical staff or other peer review committee meetings where discussion or actions concerning the practitioner were held ormeetings where discussion or actions concerning the practitioner were held or taken; and

• Any other information specific to the individual practitioner which may bear upon that practitioner's qualifications for continued medical staff membership and privileges or participation on a provider panel.

Information related to quality, performance or peer review may be in separate file

16


Bylaws should describe Credentials Files/Separate Files

• Where files are located – especially if in different places• Whether some “files” are electronic• What information is in each file (credentials file, quality file)

– Application, verifications, references, peer review, proctoring, “quality profile”

• How adverse information gets into file– Notification to member– Member’s opportunity to add information to filepp y– Member’s opportunity to request deletion from file

• Access to information in the files– Medical staff personnel to discharge medical staff functions

G i B d– Governing Body– Member

17

Credentialing and Privileging Roles: Medical Staff Office

• Application intakepp• Verifying application information • Providing staff support to the medical staff credentials

committee to ensure that the applicants to the medical staff meet medical staff, state, federal, and accreditation requirementsq

• Maintain records of the medical staff's continuing education• Conducts reviews of the credentials and licenses of staff as

well as continuing education information to ensure the medical staff members maintain qualifications

18

Credentialing and Privileging Roles: Medical Staff

• Your medical staff coordinator is a critical person in the pcredentialing and privileging process

• A good medical staff coordinator is invaluable• The more they bug you, the more you have to appreciate

them!

19

Credentialing and Privileging Roles: Hospital Administration and Governing Board

• Ensure that the medical staff itself establishes adequate controls to ensure quality and that medical staff members prove to the appropriate medical staff committees that they meet those controls.

• State law mandates that medical staffs make reports of activities and recommendations relating to, among other things, credentialing, available to the governing body, but only "as frequently as necessary and at least quarterly.“

• Entitles the governing body to review medical staff reports of its activities and recommendations so that the governing body can perform its oversight function.

• Does not provide the governing body with independent authority to conduct the credentialing function or otherwise require the release of peer review records themselves to the governing body.

20

Flow of Information in Credentials Review

• Medical Staff Office ensures a complete application• Department Review

– Greatest responsibility done by most appropriate peers– Interview of applicant often desirable– Department Chair needs to do thorough review of fileDepartment Chair needs to do thorough review of file– Department Chair provides written report to Credentials Committee– Any variation from the optimal should be evaluated and commented upon

• Credentials Committee– Should function as devil’s advocate– Can request additional information or additional review

• Executive Committee– Should function as devil’s advocateShould function as devil s advocate– Can request additional information, defer for further review, recommend approval or denial

• Governing Body– Should be informed about variations from optimal and medical staff’s evaluation– Makes final decision about appointment, privileges or denial

21

Access to and Sharing Credential Files

• Sharing credential files with the hospital governing board– California law gives the board members of all corporations, including hospitals, the right of access to

corporate records.corporate records. – Unknown if a court would conclude that peer review records or medical staff credential files are

corporate records of the hospital.– Interests of the medical staff and the hospital can be best served under a scheme whereby the

medical staff is deemed the owner and custodian of peer review records and credential files while the hospital may have access to such files as granted by the medical staff only on a "need‐to‐know" basis.

– If the medical staff is appropriately performing peer review and forwarding recommendations to the Board, and the Board is promptly reviewing the Medical Executive Committee‘s (MEC's) actions and

ki fi l d i i th d i i t t ( b h lf f th B d) h ld t d i f timaking final decisions, the administrator (on behalf of the Board) should not need information beyond that which is provided to him or her by the regular reports of the MEC in connection with such activities, however, as mandated by the law.

22

Sharing Credential Files

• Real‐life Issues: – Hospital system informs hospital entities that it intends to have all physician credential

files uploaded to a “cloud” system that would allow all hospital to view all credentialfiles uploaded to a cloud system, that would allow all hospital to view all credential files for any medical staff member.

– Medical staffs are directed to submit credentialing information to a third party service that also has ties to health plans. No protections are in place to protect personal i f tiinformation.

– Out‐of‐State hospital system HQ demands records for a specific physician who has no pending disciplinary action. Medical staff refuses to release records, citing peer review protection concerns and medical staff ownership. HQ threatens to terminate medical staff coordinator for failure to comply with request. Finally, corporate office sends a representative who physically removes the file from the medical staff office.

23

Critical Credentialing Processes

• Incomplete applications – should not be processed• We are accountable for information gathered or not gatheredWe are accountable for information gathered or not gathered• Undiscovered information that should have been known• Known information that was ignored• Creativity sometimes required to get information• Read between the lines• Gaps• Follow up when appropriate – use telephone if necessary

24

Design Meaningful Forms

• Standard application form asks about reductions in privileges, membership, licensure or DEA issues, 805 reports

• Ask about voluntary relinquishment of licensure, membership, or privileges

• Reprimands, mandatory consultation, concurrent case review, adverse employment situations

• Request peers to evaluate in ACGME’s 6 core competencies:Patient careMedical/clinical knowledgePractice‐based learning and improvementInterpersonal and communication skillsInterpersonal and communication skillsProfessionalismSystems‐based practice

25

Evaluating 6 Core Competencies

Patient care robust peer review/peer references

Medical/clinical knowledgerobust peer review/peer references

Practice‐based learning and improvementPractice based learning and improvementcompliance with order sets, practice guidelines

Interpersonal and communication skillsd t ti i d t l i tdocumentation in record, consents, complaints

Professionalismpeer review, patient satisfaction, complaints

Systems‐based practicecompliance with policies, guidelines

26

Design Meaningful Forms

• Privilege Forms– Core Privileges – what is the meaning of “core”?– Crossing out certain of the “core” – Laundry list of every procedure

G d i il– Grouped privileges• Usual abdominal procedures• Complex abdominal procedure

• Proctoring FormsProctoring Forms– Patient identifier– Date– Diagnosis and procedures– Direct observation versus chart review– Rating technical skills– Rating interpersonal and communication skills

27

Red Flags

• Information that is not consistent• Time gapsTime gaps• Peers or affiliated organizations with questionable content• Frequent moves from one facility to another• Frequent moves from one location to another• More than normal time to finish residency• Changing residency programs more than once• Excessive litigation for specialty or no malpractice coverage

A di i li ti l f i il b hi• Any disciplinary action, loss of privileges, membership

28

Determining Competency

• Medical staff reapplication requirements for mandatory cognitive testing for medical staff members at a specified age– Concerns about age‐discrimination– Bylaws provision

• Hospitals retroactively imposing cognitive or competency testing prior to medical staff reapplication

• Real‐life Issues:H i l i ll d i l fil d fl h i i h idi– Hospital reviews all credential files and flags physicians who are providing a standard of care that does not meet “core measures” as determined by a third party. A warning is placed in those credential files without notification to the physician or their consent, to be used in the event that future disciplinary p y , p yaction is taken.

29

Applicant Not Recommended

• Deferral by MEC or Governing Body for more information• Recommended denial permits applicant to exercise Fair Hearing process before

final action• “Fair Review” process to allow informal hearing if application denied on non‐

t bl b i f il t t lifi tireportable basis – eg, failure to meet qualifications• If applicant informed that application will most likely be denied, he/she can

withdraw the application – not reportable to the NPDB• Best practice is to keep applicant off of the medical staff if any doubts remain• Best practice is to keep applicant off of the medical staff if any doubts remain

30

Credentialing and Tele‐Medicine

• Both CMS and the Joint Commission allow hospitals to rely on the credentialing of telemedicine providers of other hospitals by proxy.

• AB 415 (2011), brought California’s hospital licensing standards for telemedicine provider credentialing in line with the CMS and Joint Commission standards that allow reliance on another hospital's provider credentialing by proxyallow reliance on another hospital s provider credentialing by proxy.

• Make sure the other hospital is accredited

31

Temporary Privileges

• Two circumstances for granting temporary privileges– Fulfill important patient care need– Applicant for new privileges has complete application that raises no concerns and is awaiting review

and approval by MEC and Governing Body

• Not same as “emergency privileges”g y p g• Should not be used routinely• For patient care need, still requirement to determine licensure and current

competence• Granted on recommendation of medical staff president or authorized designee• Must be specifically delineated• Granted for no more than 120 days

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Key Bylaw Provisions

• Qualifications for membership• Applicant or member has burden of providing all information necessary to

determine current competence• If applicant or member fails to provide the information, it should result in an

t ti ithd l f li ti h i i htautomatic withdrawal of application – no hearing rights• If there are questions related to health status, applicant or member may be

required to undergo physical examination• Interviewing applicant may be requirement• Interviewing applicant may be requirement• Proctoring for new members (or new privileges) begins with first cases• Member may be advanced from provisional although not from proctoring

requirementrequirement• Credentials files – information within them, location, access, confidentiality• Temporary privileges – specify circumstances and requirements for granting• Circumstances (triggers) for focused professional practice evaluationCircumstances (triggers) for focused professional practice evaluation

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Low and No‐Volume Physicians

• The number of physicians who have shifted their practice of medicine from hospitals toward their private office and outpatient facilities has been steadily increasing.

• Credentialing physicians and other practitioners who perform few if any procedures at the hospital has provided significant challenges for medical staffsprocedures at the hospital has provided significant challenges for medical staffs.

• No single blueprint that should be followed in these cases, but medical staffs should have the flexibility to craft strategies that are tailored to their situation. – That medical staffs should consider methodologies and standards that addressThat medical staffs should consider methodologies and standards that address

safely credentialing and privileging 'low‐ and no‐volume' physicians and provide opportunities for these physicians to participate in medical staff governance.

• CMA Recommendations:– Privileging Policy Must Be Consistent With Community Needs and Standard of

Cared d l ff l l d l l l– Consider Separating Medical Staff Non‐Clinical and Clinical Privileges

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Proctoring

• Medical staffs requiring proctoring for new staff members or those granted new privileges• Difficulty finding qualified proctors willing to perform the service• While not specifically mandated, should start with first case• While not specifically mandated, should include direct observation• Cognitive practitioners should include some concurrent review• Cognitive practitioners – should include some concurrent review• Bylaws description – may wish to focus on first number of cases rather than time period• Bylaws provision for advancement to active staff category while proctoring still required• Proctoring form should clearly indicate date, diagnosis, procedure, direct vs retrospective g y g p p

review, technical skills, interpersonal skills• ADVANCEMENT FROM PROVISIONAL TO ACTIVE – Must not be a casually performed function

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OPPE vs FPPE

• Ongoing Professional Practice Evaluation– Clearly defined process – optimal period is every 6 months– Looks at whatever data is available– Looks for practice trends impacting quality of care

C b h t i di t b ti i t f th i di id l– Can be chart review, direct observation, input from other individuals– Conclusion of review should be documented– Goal is Determination of Incompetence

• Reappointment – Goal is Determination of CompetenceReappointment Goal is Determination of Competence• Focused Professional Practice Evaluation

– Evaluation of new members or members granted new privileges– Evaluation (not investigation) when question arises regarding providing quality care( g ) q g g p g q y– Nondisciplinary review process and not reportable to Medical Board or NPDB– Communication to appropriate parties evaluation results and recommendations– Circumstances (triggers) must be defined by the medical staff

• Is FPPE taking the place of corrective action?

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Reappointment

• Must be performed within 2 year cycle• Application must be received early enough to complete process in timeApplication must be received early enough to complete process in time• Primary source verification:

– Peer references– NPDB query– Sanction checks– Licensure, DEA– Malpractice claims history

• Includes review of clinical privileges requested– Evidence that privilege criteria have been met– Performance data, peer review reports

• Burden is Great – Confirming current competence for all privileges requested– Not the same as OPPE X 4– What to do with the senior physician who has not exercised certain of his/her

i il ?privileges?

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Ongoing Monitoring thru NPDB

• NPDB Continuous Query Disclosure service– Automatic and immediate notification of:

• Licensure actions• Malpractice actionsMalpractice actions• OIG sanctions

• ?? Future Licensing Boards Automatic Notification Service

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Negligent Credentialing

• Imposter physicians• Dangerous physicians• Court cases

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Imposter PhysicianImposter Physician• Dennis Roark

claimed to have graduated from Rush University Medical College in Chicagocompleted post‐doctoral research at Wayne State Universityworked as clinical assistant at hospitals in Ohio and Detroitused fake credentials, applied for and received Michigan licenseaccepted into 3 different surgical residency programs in Ohio and Michiganaccepted into 3 different surgical residency programs in Ohio and Michigan

was asked to leave or left each onepracticed as physician in Michigan from 1994 to 1998treated more than 1,000 patients – operated on 300

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Dangerous PhysicianDangerous PhysicianBlind Eye Effect

Michael Swango (Doctor Death)high school valedictorianhonorable discharge from Marine Corpssumma cum laude in collegeSouthern Illinois University medical schoolSouthern Illinois University medical schoolfaked H&Ps in OB/GYN rotationseveral patients who he worked up died (association discovered later)graduated 1 year late – escaped unanimous vote required to dismiss studentdespite poor deans letter, entered Ohio State University surgical residencyseveral healthy patients died mysteriously – he had been the internnurse reported him injecting “medicine” into patient who became sickerd i i l d d ff i f “ i ”administrators concluded nurses were suffering from “paranoia”

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Frigo vs Silver Cross HospitalFrigo vs Silver Cross Hospital• Illinois case• Podiatrist operated with ulcerated foot which ultimately had to be p y

amputated• Podiatrist failed to meet established criteria for Level II surgical procedures

– Postgraduate training board certification and performance of certainPostgraduate training, board certification and performance of certain number of bunionectomies

• Podiatrist may have been “grandfathered” prior to change in requirementsDetermined that podiatrist appointed AFTER change in requirements– Determined that podiatrist appointed AFTER change in requirements

• While grandfathering did not play a role in this case, medical staff burden when using grandfathering is to assure current competence since the current criteria are waivedcurrent criteria are waived

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