1. CEDAR RAPIDS Medical Executive Committee Orientation December 9, 2014

2. CEDAR RAPIDS Why Are You Here?

3. CEDAR RAPIDS The Medical Staff is responsible for monitoring and improving the quality of care provided at Mercy Medical Center; primarily the performance of individuals granted privileges (LIP)

4. CEDAR RAPIDS Medical Staff Organization Board of Trustees Medical Staff Management

5. CEDAR RAPIDS Medical Staff Organization Board of Trustees Medical Staff Executive Committee DepartmentsCommittees

6. CEDAR RAPIDS Medical Staff Departments Anesthesia CV Medicine Dental Emergency Medicine Family Medicine Internal Medicine OB/GYN Ophthalmology Orthopedics Pathology Pediatrics Podiatry Psychiatry Radiology Surgery Urology Committees Bylaws Credentials Nominating Physician Wellness Peer Review Medical Education Medication Management Blood Management Institutional Review Committee Trauma Allied Health Practitioners Board of Trustees Quality Committee Medical Director Council Cancer

7. CEDAR RAPIDS Medical Staff Organization Board of Trustees Medical Executive Committee Department Chairs Management VPMA Medical Directors

8. CEDAR RAPIDS So how do we go about ensuring the quality of care provided by the providers at Mercy?

9. CEDAR RAPIDS Quality Continuum © Greeley Company

10. CEDAR RAPIDS Poor Quality Continuum Corrective Action Credentialing

11. CEDAR RAPIDS Appoint Excellent Providers Credentialing and Privileging Appointment Reappointment Development of privileging criteria

12. CEDAR RAPIDS Appointment Application Primary Source Verification Review by Department Chair Credentials Committee MEC Board of Trustees

13. CEDAR RAPIDS Appointment Credentialing - Membership – Just being on the Staff –Same for all physicians, dentists, podiatrists –Categories of membership Associate, Active, Courtesy, Affiliate, Honorary Temporary, Locum Tenens, Disaster Privileges – What allowed to do Department Chair > Credentials Committee > MEC > Board

14. CEDAR RAPIDS Appointment Credentialing –Education: professional school/residency/fellowship –License, drug certificates, liability insurance –References –History at other institutions –Background check –Other factors: malpractice, NPDB, gaps in history, frequent movement, exclusion from federal payment programs Any other information you need? Interview?

15. CEDAR RAPIDS Appointment Privileging –Training and experience –Case logs –References –“Universal” criteria when privileges overlap between specialties –Main focus for Department Chairs

16. CEDAR RAPIDS Reappointment “Current competence” for privileges requested Provider profile – OPPE/FPPE Peer Reviews License, drug certificates, CME, liability insurance Dept Chair>Credentials>MEC>Board

17. CEDAR RAPIDS Other Credentialing Issues Core privileges vs. Laundry lists Competency clusters Current competency Turf battles Low volume/No volume providers Telemedicine Burden is on the applicant

18. CEDAR RAPIDS Process at Mercy Applications sent out by and returned to MSO Applications reviewed by MSO for completeness Compile all verifications, references, case logs For reappointments: OPPE/FPPE, PR, complaints, procedure volumes, CME Generally flag any “bumps” Department Chair called to review applications Chair makes recommendations to Credentials

19. CEDAR RAPIDS Ultimate Question Would I feel comfortable having my parent/spouse/child seen by this physician?

20. CEDAR RAPIDS Criteria Development What is the training, experience, competency necessary to adequately perform a new procedure? Formal or informal training? Hands-on labs? Proctoring? Maintenance criteria-CME, numbers?

21. CEDAR RAPIDS Quality Continuum © Greeley Company

22. CEDAR RAPIDS Set Expectations Medical Staff Bylaws Policies and Procedures Standardized order sets Quality of care Quality of service Specialty society guidelines External benchmarks

23. CEDAR RAPIDS Provide Feedback Ongoing Physician Practice Evaluations (OPPE) –Metrics developed for each Department to provide members with feedback on their performance –Sent out to members semi-annually Focused Physicians Practice Evaluations (FPPE) –For new members/privileges or to follow up identified concerns Meetings with physicians

24. CEDAR RAPIDS Why Have Feedback? To set expectations To recognize good performance To identify opportunities for improvement To allow physicians to self correct To initiate dialog on potential poor performance (Why are you different?)

25. CEDAR RAPIDS Quality Continuum © Greeley Company

26. CEDAR RAPIDS Manage Poor Performance Chart Reviews – Universal and Department-specific triggers Peer Review Medical Staff Wellness Committee (Article XI) Personal Conduct (Article VI)

27. CEDAR RAPIDS Peer Review Process Case referred for evaluation 1 Department Chair Rank 1 2 Rank 2 3 Rank 3 4 Peer Review Committee 5 MEC 6 BOT 7

28. CEDAR RAPIDS Corrective Action Article VII of the Medical Staff Bylaws

29. CEDAR RAPIDS Health Law

30. CEDAR RAPIDS General Duties Attendance at MEC and Department meetings – agenda planning Review of Credentials files for new applicants and reappointments Chart reviews Staff resource for clinical questions Resource for Department members Resource for development of new policies/procedures Assistance with performance issues

31. CEDAR RAPIDS Typical MEC Meeting 1 st Tues of month, 5:30, Neuhaus Board Room Agenda –Approve prior minutes –Review Department minutes –Administrative report –Committee reports-i.e. Credentials, Bylaws –Quality, Safety, Clinical Outcomes –Old Business –New Business

32. CEDAR RAPIDS Physician website https://p.mercycare.org (same user name and password as with Epic) –News updates –Agendas –Minutes –Bylaws/Policies –Send comments –References –Links

33. CEDAR RAPIDS Issues for 2015 Refinement of OPPE/FPPE Development of Department metrics Rules and Regulations/Bylaws update The Joint Commission – due for survey late 2015 or early 2016 Medical Staff leadership training ICD-10 training Continued progression towards P4P and population health management

34. CEDAR RAPIDS Questions ?