Competence Assessment: Low & No Volume Practitioners May 19, 2017 By: Carol Cairns, CPMSM, CPCS PRO-CON / The Greeley Company

COMPETENCY ASSESSMENT CHALLENGES Low-volume/no-volume practitioners: What’s the solution for your hospital?

Low-volume/no-volume practitioners Ongoing issue due to Rapid growth of hospitalist programs Outpatient settings offering better practitioner productivity with fewer hassles Physicians seeking enhanced revenues from provider-owned outpatient facilities Technological advances allowing minimally invasive procedures to be performed in the outpatient setting Active efforts to reduce or avoid ED call Groups asking for “just in case” coverage Crossover of practitioners in integrated systems Review and mention any that the audience did not come up with. 3 3

Low-volume/no-volume practitioners Et cetera, et cetera, et cetera Review and mention any that the audience did not come up with. 4 4

To develop a strategy that works for your organization Compile evidence to determine the extent of the issue ID the types of low-/no-volume practitioners Active inpatient practice elsewhere Active ambulatory practice Active outpatient practice Meet ongoing community needs (e.g., locum tenens/consultants) Not clinically active anywhere Consider membership without privileges

The best guiding principles Apply the Greeley Competency Equation and Competency Triangle Place the burden on the applicant

The Greeley Competency Equation Current competency = Evidence you’ve done it recently + Evidence that when you did it, you did it well # # 7

The Greeley Competency Triangle Privilege Delineation Structure: Def Ex Process Outcome Eligibility Criteria Peer Review Results # 8 8

Is this a 5 P’s moment? Our Policy is to follow our Policy. In the absence of a Policy, our Policy is to create a Policy.

Policy goals Protect patients Grant privileges only when there is evidence of demonstrated current competency Meet regulatory requirements Protect hospital’s reputation

Policy development: What should you consider? All practitioners are only granted privileges for which they have demonstrated current competence Build and maintain strategic relationships between the hospital and practitioners who rarely or never practice with the organization Interest in maintaining collegial relationships with a medical community that reduces their isolation in clinical practice. 11 11

Policy development: What should you consider? (cont.) Do not create new membership categories when it’s only privileges that are different Allow non-clinically active practitioners to be able to visit their patient, order outpatient tests, etc., and include this language in the appropriate MS category Separate membership from privileges #

Policy development: What should you consider? (cont.) Accurately delineate clinical privileges None Independent with limited scope (e.g., general surgeon who only first-assists) Co-management (Caution: May be problematic) “Refer and follow” Accurate delineation of privileges answers the question - What, if any, competencies are we obligated to assess? Leaving an easier approach to the next question - How can we assess competency efficiently? 13 13

Sample language for “refer and follow” privileges Order outpatient diagnostic tests and services Visit patient in hospital Review medical records for patients referred for admission/services Consult with attending physician Observe diagnostic or surgical procedures with the approval of the attending physician/surgeon

APPLICATION OF KNOWLEDGE: CASE STUDIES #1 - #5

Case study #1 – Lack of inpatient activity Dr. Favorite is a family medicine physician who recently became employed by Memorial Hospital’s affiliated medical group He’s been a member of Memorial Hospital’s medical staff for 17 years He has used the hospitalist program for the past two years and hasn’t provided clinical services to hospital patients in more than a year Dr. Favorite is up for reappointment

Case study #2 – “Just in case” coverage Hospital is in a small town in South Dakota (although this scenario could play out anywhere) Two cardiologists, Dr. Smith and Dr. Jones, cover for each other and informally agree not to be out of town at the same time. They are employed by a larger cardiology group, 100 miles away. The group wants all of its cardiologists to be privileged just in case they need to provide coverage during the rare occasions when Drs. Smith and Jones are both away

Case study #3 – Single specialty Rural Memorial contracts with a large academic medical center to provide oncology services. The community, patient, and hospital needs are met by having the oncologist onsite a couple of times a week. The remaining percentage of the oncologist’s practice is performed at the academic medical center

Case study #4 – No current clinical activity Dr. Mom took five years off to raise her young children and now wants to return to the practice of obstetrics. She recently took a one-week refresher course at a regional program. She wants to resume the same privileges she had before and has requested that she be allowed to do so

Case study #5 – The increasingly narrow practice At We Specialize Medical Center, the CEO, CMO, and medical staff president were becoming alarmed at the growing number of physicians significantly modifying their privileges and then saying they were no longer able to provide coverage for their specialty. This was occurring among breast surgeons, spine surgeons, plastic hand surgeons, and orthopedists who were limiting their practice to hip and knee replacements. As a result, a critical shortage of specialists who could provide call coverage was developing. Using the tools of credentialing & privileging, what can WSMC leaders do to more effectively address ED call?

Credentialing solutions for ED call are complicated Educate all medical staff leaders on the requirements of EMTALA Recognize that all practitioners are permitted emergency privileges, as outlined in medical staff governance documents (bylaws, P&Ps, rules/ regulations, privilege forms) Address ED call obligations and privileges separately 21

One simple step Add EMTALA-based language to privileging forms “Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services.” 22

In summary Strategically credential and privilege low- volume and no-volume practitioners Privileges granted based on evidence of current competency Win/win for hospital and practitioner – referrals and loyalty Mitigate risk Alignment with non-hospital based practitioners is achieved

The bottom line There is not one simple answer or solution to low-volume/no-volume practitioners Remember that one size does not fit all The development of a well thought out strategy applied to individual practitioners is key

How would you like a sample policy?

“All things should be made as simple as possible, but not more so “All things should be made as simple as possible, but not more so.” —Albert Einstein

Questions? #