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

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

3. 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

4. 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

5. 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

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

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

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

9. 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.

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

11. 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

12. 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 #

13. 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

14. 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

15. APPLICATION OF KNOWLEDGE: CASE STUDIES #1 - #5

16. 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

17. 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

18. 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

19. 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

20. 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?

21. 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

22. 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

23. 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

24. 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

25. How would you like a
sample policy?

26. “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

27. Questions? #