1 Medical Staff Standards Focus: Performance Review Stephen M. Dorman, M.D.

Scoring and Accreditation Decision Model

3 Standard A statement that defines the performance expectations and/or structures or processes that must be in place in order for a healthcare organization to provide safe, high quality care, treatment, and services. An organization is either “compliant” or “ not compliant” with a standard.

4 Element of Performance The specific performance expectation and/or structure or process that must be in place in order for a healthcare organization to provide safe, high quality care, treatment, and services. The scoring of EP compliance determines an organization’s overall compliance with a standard.

Scoring/Accreditation Decision Model - Summary Elements of Performance (EP) will be categorized by common scoring characteristics (e.g., Category A-yes/no, Category C - multiple observations of non-compliance). The use of Category B EPs (qualitative and quantitative components) will be discontinued.

Scoring/Accreditation Decision Model - Summary The frequency of bulleted EPs will be reduced. Elements of Performance and other accreditation requirements will be tagged based on their “criticality” – immediacy of impact on quality of care and patient safety as the result of noncompliance.

Scoring/Accreditation Decision Model - Summary DIRECT impact INDIRECT impact

Scoring/Accreditation Decision Model - Summary All partially compliant and insufficiently compliant EPs must be addressed via the Evidence of Standards Compliance (ESC) submission process – No “Supplemental” findings. Potentially multiple submission deadlines based on the “immediacy” of risk. Direct Impact Requirements: ESC due within 45 days. Indirect Impact Requirements: ESC due within 60 days.

Scoring/Accreditation Decision Model - Summary If partial compliance or insufficient compliance is not resolved, a progressively more adverse accreditation decision may result: Provisional, Conditional, Preliminary Denial of Accreditation.

Scoring/Accreditation Decision Model - Summary Levels of Standards: Immediate threat to life: no a single standard, but condition Situational Decision Rule: immediate recommendation of Denial of Accreditation or Conditional accreditation alone. eg: unlicensed provider Onsite validation

Scoring/Accreditation Decision Model - Summary DIRECT impact standard: Sedation INDIRECT impact standard: Policies New labels on standards: (D): Documentation required (2): Situational Decision Rule (3): Direct Impact Requirements (blank): Indirect Impact Requirements

12 MS Chapter Outline I. Medical Staff Bylaws A. Bylaws (revised MS ) B. Unilateral Amendment (revised MS ) II. Structure and Role of Medical Staff Executive Committee (revised MS )

13 MS Chapter Outline III. Medical Staff Role in Oversight of Care, Treatment, and Services A. Oversight of Quality of Care (revised MS ) B. Management and Coordination of Care (revised MS )

14 MS Chapter Outline IV. Medical Staff Role in Graduate Education Programs (revised MS ) V. Medical Staff Role in Performance Improvement A. Role in Performance Improvement Activities (revised MS ) B. Participation in Performance Improvement Activities (revised MS )

15 MS Chapter Outline VI. Credentialing and Privileging A. Determining Resource Availability (revised MS ) B. Collecting Information (revised MS ) C. Decision Process (revised MS ) D. Reviewing Information (revised MS ) E. Communicating Decision (revised MS ) F. Expedited Process (revised MS ) G. Temporary Privileges (revised MS )

16 MS Chapter Outline VII. Appointment to Medical Staff A. Recommending Appointment (revised MS ) B. Peer Recommendations (revised MS )

17 MS Chapter Outline VIII. Evaluation of Practitioners A. Monitoring Performance (revised MS ) B. Use of Monitoring Information (revised MS )

18 MS Chapter Outline IX. Acting on Reported Concerns About a Practitioner (revised MS ) X. Fair Hearing and Appeal Process (revised MS ) XI. Licensed Independent Practitioner Health (revised MS )

19 MS Chapter Outline XII. Continuing Education for Practitioners (revised MS ) XIII. Medical Staff Role in Telemedicine A. Credentialing and Privileging of Licensed Independent Practitioners (revised MS ) B. Recommending Clinical Services to be Provided (revised MS )

20 MOVED STANDARDS MS > LD Standard LD The organization has a medical staff that is accountable to the governing body. The organization has a medical staff that is accountable to the governing body.

21 LD : Single organized medical staff 2: Self-governing 3: Conforms to guiding principles 4: Governing body approves structure 5: Medical staff oversees quality care provided by individuals with clinical privileges 6: Accountable to governing body

22 MS MS.1.20 (controversial) All elements RETAINED (at least for now). No new concepts pending rewriting this standard

23 MS Medical staff oversees quality of care, treatments, or services provided by practitioners privileged through the medical staff process 1: LIPs designated to perform oversight ! 2: Practitioners practices within scope of privileges 3: LIPs perform oversight

24 MS : Leadership in patient safety 5: Oversight of process of analyzing and improving patient satisfaction D 6: Minimal content of H&Ps defined 7: MS monitors quality of H&Ps 8: Privileged provider performs H&Ps 9: Others as allowed by laws may perform H&Ps, under a specified physician

25 MS D 10: Define when H&P must be validated or countersigned D 11: Defines scope of H&P when required for non-inpatient services

26 MS The management and coordination of each patient’s care, treatment, or services is the responsibility of a practitioner with appropriate privileges 1: LIP with privileges manage and coordinate patient’s care, treatment and services 2: Hospital educates all LIPs on assessing and managing pain (NEW)

27 MS : Patient’s general medical condition managed by a physician. 4: Circumstances warranting consultation 5: Consultations obtained when warranted 6: Coordination of care among practitioners

28 MS The organized medical staff has a leadership role in organization performance improvement activities to improve quality of care, treatment, and services and [patient] safety. Practitioner specific performance data.

29 MS : 1: The organized medical staff provides leadership for measuring, assessing, and improving processes that primarily depend on the activities of one or more licensed independent practitioners, and other practitioners credentialed and privileged through the medical staff process.

30 MS : 2: Medical assessment and treatment of patients 3: Use of information about adverse privileging decisions for any practitioner privileged through the medical staff process 4: Use of medications

31 MS : 5: Use of blood and blood components 6: Operative and other procedure(s) 7: Appropriateness of clinical practice patterns 8: Significant departures from established patterns of clinical practice 9: The use of developed criteria for autopsies.

32 MS : 10: Sentinel event data 11: Patient safety data

33 MS Practitioner specific data: citizenship 1: 1: Education of patients and families 2: Coordination of care, treatment, and services with other practitioners and hospital personnel, as relevant to the care, treatment, and services of an individual patient.

34 MS : 3: Accurate, timely, and legible completion of patient’s medical records 4: Review of findings of the assessment process that are relevant to an individual’s performance. The organized medical staff is responsible for determining the use of this information in the ongoing evaluations of a practitioner’s competence.

35 MS : 5: Communication of findings, conclusions, recommendations, and actions to improve performance to appropriate staff members and the governing body.

36 MS Prior to granting a privilege, the resources necessary to support the requested privilege are determined to be currently available, or available within a specified time frame.

37 MS : Process to determine sufficient: space, equipment, staffing, and financial resources are in place or time frame defined to support requested privilege 2: The hospital consistently determines the resources needed for each requested privilege.

38 MS The [organization] collects information regarding each practitioner’s current license status, training, experience, competence, and ability to perform the requested privilege.

39 MS : Clearly defined process 2: Process based on recommendations by medical staff 3: Process approved by governing body D 4: Outlined in bylaws 5: Verify identify: hospital ID card, government issued ID (TO BE CHANGED)

40 MS D 6: Primary Source verification of: – –The applicant’s current licensure at time of initial granting, renewal, and revision of privileges, and at the time of license expiration. – –The applicant’s relevant training. – –The applicant’s current competence.

41 MS The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidenced- based process.

42 MS ! 1: ! 1: All licensed independent practitioners that provide care possess a current license, certification, or registration, as required by law and regulation. (SITUATIONAL DECISION)

43 MS D 2: Criteria based privileges include: – –Current licensure and/or certification, as appropriate, verified with the primary source. – –The applicant’s specific relevant training, verified with the primary source. – –Evidence of physical ability to perform the requested privilege. – –Data from professional practice review by an organization(s) that currently privileges the applicant (if available). – –Peer and/or faculty recommendation. – –When renewing privileges, review of the practitioner’s performance within the hospital.

44 MS : 3: All of the criteria used are consistently evaluated for all practitioners holding that privilege D 4: Process defined for granting, renewing, revising privileges 5: Process is approved by medical staff

45 MS D 6: Applicant submits health statement. 7: Hospital queries NPDB at initial privileges, renewal of privileges, and when new privileges requested.

46 MS D 8: Peer Recommendation includes: – –Medical/Clinical knowledge. – –Technical and clinical skills. – –Clinical judgment. – –Interpersonal skills. – –Communication skills. – –Professionalism.

47 MS : 9: Before recommending privileges, the organized medical staff also evaluates the following: – –Challenges to any licensure or registration. – –Voluntary and involuntary relinquishment of any license or registration. – –Voluntary and involuntary termination of medical staff membership. – –Voluntary and involuntary limitation, reduction, or loss of clinical privileges. – –Any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant. – –Documentation as to the applicant’s health status. – –Relevant practitioner-specific data as compared to aggregate data, when available. – –Morbidity and mortality data, when available.

48 MS : 10: The hospital has a process to determine whether there is sufficient clinical performance information to make a decision to grant, limit, or deny the requested privilege. (CMS) C 11: Completed applications for privileges are acted on within the time period specified in the medical staff bylaws.

49 MS : 12: Information regarding each practitioner’s scope of privileges is updated as changes in clinical privileges for each practitioner are made.

50 MS The organized medical staff reviews and analyzes all relevant information regarding each requesting practitioner’s current licensure status, training, experience, current competence, and ability to perform the requested privilege.

51 MS : 1: The information review and analysis process is clearly defined. D 2: D 2: The hospital, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a requested privilege.

52 MS C 3: C 3: The hospital completes the credentialing and privileging decision process in a timely manner. 4: 4: The hospital’s privilege granting /denial criteria are consistently applied for each requesting practitioner. 5: 5: Decisions on membership and granting of privileges include criteria that are directly related to the quality of health care, treatment, and services.

53 MS : 6: If privileging criteria are used that are unrelated to quality of care, treatment, and services or professional competence, evidence exists that the impact of resulting decisions on the quality of care, treatment, and services is evaluated.

54 MS : 7: The governing body or delegated governing body committee has final authority for granting, renewing, or denying privileges. 8: 8: Privileges are granted for a period not to exceed two years.

55 MS The decision to grant, limit, or deny an initially requested privilege or an existing privilege petitioned for renewal is communicated to the requesting practitioner within the time frame specified in the medical staff bylaws.

56 MS : 1: Requesting practitioners are notified regarding the granting decision. 2: 2: In the case of privilege denial, the applicant is informed of the reason for denial. 3: 3: The decision to grant, deny, revise, or revoke privilege(s) is disseminated and made available to all appropriate internal and external persons or entities, as defined by the hospital and applicable law.

57 MS D 4: D 4: The process to disseminate all granting, modification, or restriction decisions is approved by the organized medical staff. 5: 5: The hospital makes the practitioner aware of available due process or, when applicable, the option to implement the Fair Hearing and Appeal Process for Adverse Privileging Decisions.

58 MS An expedited governing body approval process may be used for initial appointment and reappointment to the medical staff and for granting privileges when criteria for that process are met.

59 MS D 1: D 1: The organized medical staff develops criteria for an expedited process for granting privileges. (two voting members) 2: The criteria provide that an applicant for privileges is ineligible for the expedited process if any of the following has occurred: - The applicant submits an incomplete application. - The medical staff executive committee makes a final recommendation that is adverse or has limitations.

60 MS Ineligible if: 3: 3: There is a current challenge or a previously successful challenge to licensure or registration. 4: The following situations are evaluated on a case-by-case basis and usually result in ineligibility for the expedited process: The applicant has received an involuntary termination of medical staff membership at another hospital.

61 MS Ineligible if: 5: 5: The applicant has received involuntary limitation, reduction, denial, or loss of clinical privileges. 6: The hospital determines that there has been either an unusual pattern of, or an excessive number of, professional liability actions resulting in a final judgment against the applicant.

62 MS : 7: The organized medical staff uses the criteria developed for the expedited process when recommending privileges.

63 MS Under certain circumstances, temporary clinical privileges may be granted for a limited period of time. 1: 1: Temporary privileges are granted to meet an important patient care need for the time period defined in the medical staff bylaws.

64 MS : 2: When temporary privileges are granted to meet an important care need, the organized medical staff verifies current licensure and current competence.

65 MS : 3: Temporary privileges for new applicants may be granted while awaiting review and approval by the organized medical staff upon verification of the following: – –Current licensure. – –Relevant training or experience. – –Current competence.

66 MS Verification (cont): – –Ability to perform the privileges requested. – –Other criteria required by the organized medical staff bylaws. – –A query and evaluation of the National Practitioner Data Bank (NPDB) information. – –A complete application. – –No current or previously successful challenge to licensure or registration. – –No subjection to involuntary termination of medical staff membership at another organization. – –No subjection to involuntary limitation, reduction, denial, or loss of clinical privileges.

67 MS : 4: All temporary privileges are granted by the chief executive officer or authorized designee. 5: 5: All temporary privileges are granted on the recommendation of the medical staff president or authorized designee. 6: 6: Temporary privileges for new applicants are granted for no more than 120 days.

68 MS The organized medical staff provides oversight for the quality of care, treatment, and services by recommending members for appointment to the medical staff.

69 MS D 1: D 1: The organized medical staff develops criteria for medical staff membership. 2: 2: The professional criteria are designed to assure the medical staff and governing body that patients will receive quality care, treatment, and services.

70 MS : 3: The organized medical staff uses the criteria in appointing members to the medical staff and appointment does not exceed a period of two years. 4: Membership is recommended by the medical staff and granted by the governing body.

71 MS Deliberations by the medical staff in developing recommendations for appointment to or termination from the medical staff and for the initial granting, revision, or revocation of clinical privileges include information provided by peer(s) of the applicant.

72 MS : 1: Recommendations from peers are obtained and evaluated for all new applicants for privileges. 2: 2: Upon renewal of privileges, when insufficient practitioner-specific data are available, the medical staff obtains and evaluates peer recommendations.

73 MS : 3: Peer recommendations include the following information: - Medical/Clinical knowledge. - Technical and clinical skills. - Clinical judgment. - Interpersonal skills. - Communication skills. - Professionalism.

74 MS : Peer recommendations are obtained from a practitioner in the same professional discipline as the applicant with personal knowledge of the applicant’s ability to practice.

75 MS The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.

76 MS : 1: A period of focused professional practice evaluation is implemented for all initially requested privileges. D 2: D 2: The organized medical staff develops criteria to be used for evaluating the performance of practitioners when issues affecting the provision of safe, high quality patient care are identified.

77 MS : 3: The performance monitoring process is clearly defined and includes each of the following elements: - Criteria for conducting performance monitoring. - Method for establishing a monitoring plan specific to the requested privilege. - Method for determining the duration of performance monitoring. - Circumstances under which monitoring by an external source is required.

78 MS : 4: Focused professional practice evaluation is consistently implemented in accordance with the criteria and requirements defined by the organized medical staff.

79 MS : 5: The triggers that indicate the need for performance monitoring are clearly defined. Note: Triggers can be single incidents or evidence of a clinical practice trend.

80 MS : 6: The decision to assign a period of performance monitoring to further assess current competence is based on the evaluation of a practitioner’s current clinical competence, practice behavior, and ability to perform the requested privilege. Note: Other existing privileges in good standing should not be affected by this decision.

81 MS D 7: D 7: Criteria are developed that determine the type of monitoring to be conducted. D 8: D 8: The measures employed to resolve performance issues are clearly defined. 9: 9: The measures employed to resolve performance issues are consistently implemented.

82 MS Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.

83 MS D 1: D 1: The process for the ongoing professional practice evaluation includes the following: There is a clearly defined process in place that facilitates the evaluation of each practitioner’s professional practice.

84 MS : 2: The type of data to be collected is determined by individual departments and approved by the organized medical staff. 3: Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege(s).

85 MS The organized medical staff, pursuant to the medical staff bylaws, evaluates and acts upon reported concerns regarding a privileged practitioner’s clinical practice and/or competence.

86 MS D 1: D 1: The hospital, based on recommendations by the organized medical staff and approval by the governing body, has a clearly defined process for collecting, investigating, and addressing clinical practice concerns.

87 MS : 2: Reported concerns regarding a privileged practitioner’s professional practice are uniformly investigated and addressed, as defined by the hospital and applicable law.

88 MS The medical staff implements a process to identify and manage matters of individual health for licensed independent practitioners which is separate from actions taken for disciplinary purposes.

89 MS : 1: Process design addresses the following issues: Education of licensed independent practitioners and other organization staff about illness and impairment recognition issues specific to licensed independent practitioners (at-risk criteria).

90 MS : 2: Self referral by a licensed independent practitioner. 3: 3: Referral by others and maintaining informant confidentiality. 4: 4: Referral of the licensed independent practitioner to appropriate professional internal or external resources for evaluation, diagnosis, and treatment of the condition or concern.

91 MS : 5: Maintenance of confidentiality of the licensed independent practitioner seeking referral or referred for assistance, except as limited by applicable law, ethical obligation, or when the health and safety of a patient is threatened.

92 MS : Evaluation of the credibility of a complaint, allegation, or concern. 7: Monitoring the licensed independent practitioner and the safety of patients until the rehabilitation is complete and periodically thereafter, if required.

93 MS : Reporting to the organized medical staff leadership instances in which a licensed independent practitioner is providing unsafe treatment. 9: Initiating appropriate actions when a licensed independent practitioner fails to complete the required rehabilitation program.

94 MS : 10: The medical staff implements its process to identify and manage matters of individual health for licensed independent practitioners.

95 MS All licensed independent practitioners and other practitioners privileged through the medical staff process participate in continuing education.

96

97 Physician Performance Components of a compliant process

98 CMS CMS requires that physician performance plans be defined in writing. This is scored as part of quality and not credentialing or privileging.

99 Basics Indicators must be established that are appropriate to each physician. Generally this is specialty based. Components to be included are delineated in MS and MS

100 Indicator Development Must originate at the department level Must be approved by department chairman Must be approved by MEC Must be approved by Governing body

101 Indicator Development Many appropriate indicators are already being measured within the hospital: –Core measures (internal medicine) –SCIP measures (procedural specialties) –Traditional review (LOS, denials) –Medical records

102 Indicator Development Some measures have been part of generic screens: –Returns to the operating room –Returns to the emergency room –Surgical site wound infections –Critical events

103 Indicator Development Some indicators are antiquated: –C-Section rate –Appropriateness of Appendectomies

104 Indicator Development Commonly used indicators: –ASA Indicator set: Prolonged recovery for anesthesia Prolonged recovery for anesthesia Failed regional anesthesia Failed regional anesthesia Hypotension Hypotension Hypoxia Hypoxia Difficult intubation Difficult intubation

105 Indicator Development Obstetrics: –Fetal age at C-Section delivery –3 rd and 4 th degree lacerations for delivery (morbidity) –Appropriate management of labor (as defined) –Use of analgesia

106 Indicator Development Radiology: –“Over-reads” for diagnostic imaging –Appropriateness and outcomes from invasive radiology procedures

107 Indicator Development Surgical Specialties: –Appropriateness of selected procedures (high risk, problem-prone) –Outcomes: Surgical site wound infection Other post-operative morbidity Mortality

108 Indicator Development Psychiatry: –Multi-drug therapy –Restraint need –Recidivism rate –Appropriateness of evaluations

109 Data Use The periodicity of data collection must be defined, and the method of collecting data defined: –Retrospective review –Concurrent review

110 Data Use Once the indicators are established and methodology developed for collection of the data then the task of analysis must occur. Data analysis: Conversion of all raw numbers to rate based performance. Incumbent on having good denominator data.

111 Data Use Some data may be available on an aggregate basis, but not at a practitioner specific level: –Core Measure data –SCIP data –Other PI data

112 Data Use Once the rate based data is collected on an individual basis, it must be compared to “peer” or departmental performance. The comparison must be analytical, and indicate if sub-par performance is a simple data variant, or truly statistically significant. Tools will be required for this analysis.

113 Data Use Once the organization has the ability to define, collect, and analyze the data, then the periodicity of review must be determined. Ongoing performance monitoring has been stated by TJC to be at an interval not greater than every 6 months.

114 Data Use Who will be charged with the data review? Will it be the department chairmen? Will be it a medical staff quality function? How will you demonstrate that this ongoing review function is being done?

115 Data Use What happens now? What will happen to variant performance issues? –FOCUSED REVIEW The next review period should reveal improvement. If not what will happen? CLOSE LOOPS

116 Data Use Now that data collection and analysis is ongoing, it should be easy to establish a comprehensive physician based reappointment profile for reappointment. Performance data must then go to the board for their consideration when reappointments are being granted.

117 Data Use What will go to board? –Normal data? –Variant data? –Who will present this to board with credentials file?

For 2009, a focused review plan, including the following will be required for all initial appointments: (provisional) –How performance will be measured –What indicators will be used –Will the focused review be conducted as direct observation, chart review?

What determines “pass” or “fail”? How will further evaluation be conducted? What will happen if the physician performance in a sub-optimal? How long will you wait to take action.

120 Indicators Some events should not be “rated based” such as sentinel or critical events. Even one is too many, such as “intra-operative anesthesia death.” These types of cases should be defined as requiring immediate “focused review.”

121 Plan Define indicators Obtain department and leadership approval Formulate a “data inventory” and specify methodology for data collection Establish reporting chain of command Write the plan Define focused review

122 Plan Define ongoing review Establish a methodology to write focused review plans for all new appointments to the medical staff as of Establish methodology for statistical analysis.

123 Challenges Most data collection is manual. Extra staff will probably be required. Data collection and analysis is not a job that is normally undertaken by the medical staff office, but usually originates from the performance measurement department (quality). Expertise must be acquired for analysis.

124 Questions?