1. Medical Staff Standards
CHRISTUS Health
Medical Staff Standards
New … Challenging
Presentation by Linda Van Winkle, CPMSM, CPCS,
Manager, Medical Staff Services
March 13, 2008

2. Medical Staff Standards New/Challenging
“Determining the competency of practitioners to provide high quality, safe patient care is one of the most important and difficult decisions an organization must make.”
(The Joint Commission)
March 13, 2008

3. … Determining competency is accomplished through the processes of
Medical Staff Standards New/Challenging
… Determining competency is accomplished through the processes of
Credentialing and
Privileging.
March 13, 2008

4. It’s not just about paperwork!
Medical Staff Standards New/Challenging
It’s not just about paperwork!
March 13, 2008

5. The Credentialing & Privileging processes
Medical Staff Standards New/Challenging
The Credentialing & Privileging processes
involve a series of activities designed to
COLLECT 
VERIFY
and EVALUATE
data
relevant to a practitioner’s
professional performance.
This is the foundation
for objective, evidence-based decisions
regarding
(a) membership and (b) privileges.
March 13, 2008

6. The Credentialing process …
Medical Staff Standards New/Challenging
The Credentialing process …
Involves (a) collecting, (b) verifying, & (c) assessing information regarding 3 critical parameters:
Current licensure
Verification informs the organization that applicant is appropriately licensed to practice as required by state &/or federal law. The license verification process is conducted at ALL of the following times: (a) prior to granting initial privileges, (b) prior to re-privileging, & (c) at time of license expiration.
Education and relevant training
Verification informs the organization of applicant’s clinical knowledge and skill set. Whenever feasible, verification should be obtained from original source of specific credential. When not possible, reliable secondary sources* may be used.
A reliable secondary source can be another hospital that has documented primary source verification.
Experience, ability, & current competence to perform the requested privileges.
Verified by peers knowledgeable of applicant’s professional performance. This process may include an assessment for proficiency in the 6 areas of “General Competencies”.
Why Verify?
To minimize possibility of granting privileges) based on fraudulent documents.
March 13, 2008

7. The Credentialing process …
Medical Staff Standards New/Challenging
The Credentialing process …
For those of you in Medical Staff Services … we’ve come a long way, haven’t we?
In 1988 the Joint Commission began to require Primary Source Verification (PSV) … which changed the credentials file from a skinny folder to a very fat folder. The reappointment application packet was one page, front and back. Now the reappointment packet is ½” to 1” thick depending on the practitioner.
HOWEVER … the good news in the last few years is the impact of the Internet, , faxing, credentialing software, and scanners!!!!
The PSV process in some aspects takes seconds as opposed to the days and even weeks it used to take. SCANNING technology saves filing time and space. And with TJC now permitting us to share PSV with other TJC-accredit4ed hospitals … this has also been a major time-saver.
While the credentialing process is becoming more and more streamlined, the same cannot be said of the privileging process … YET!!!
March 13, 2008

8. The Privileging process …
Medical Staff Standards New/Challenging
The Privileging process …
Typically entails …
Developing and approving a procedures list
Processing the application
Evaluating applicant-specific information
Submitting recommendations to governing body for applicant-specific delineated privileges
Notifying applicant, relevant personnel, and, as required by law, external entities re privileging decision
Monitoring the use of privileges and quality of care issues
Add to the above three (3) new TJC Medical Standards 
March 13, 2008

9. Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Let’s FOCUS …
… on these 3 newest concepts related to the Credentialing & Privileging processes
6 General Competencies
FPPE
OPPE
March 13, 2008

10. 1st NEW CONCEPT: 6 General Competencies*
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
1st NEW CONCEPT: 6 General Competencies*
NEW STANDARD (2007): The integration of the
6 General Competencies* into the Credentialing & Privileging processes.
The 6 areas:
*Developed by the Accreditation Council for Graduate Medical Education (ACGME)
and the American Board of Medical Specialties (ABMS) joint initiative.
Why?
To allow the organized medical staff to expand
to a more comprehensive evaluation of a practitioner’s professional practice.
Patient Care
Medical/Clinical Knowledge
Practice-based Learning & Improvement
Interpersonal & Communication Skills
Professionalism
Systems Based Practice
March 13, 2008

11. Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
6 General Competencies as defined by TJC - “Practitioners are expected to …”
Patient Care
… provide patient care that is compassionate, appropriate & effective for promotion of health, prevention of illness, treatment of disease, & care at end of life.
Medical/Clinical Knowledge
… demonstrate knowledge of established & evolving biomedical, clinical &social sciences, and the application of their knowledge to patient care and the education of others.
Practice-based Learning & Improvement
… be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices.
Interpersonal & Communication Skills
… demonstrate interpersonal & communication skills that enable them to establish & maintain professional relationships w/patients, families, & other members of health care teams.
Professionalism
… demonstrate behaviors that reflect commitment to continuous professional development, ethical practice, understanding and sensitivity to diversity, & responsible attitude toward their patients, their profession, & society.
Systems Based Practice
… demonstrate both an understanding of contexts & systems in which health care is provided, & ability to apply this knowledge to improve and optimize health care.
… but how to measure?
March 13, 2008

12. Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Getting started …
 Make an inventory of what you are already measuring.
Decide which of the 6 general competency(ies) the data satisfies.
 Can you pull that data into a profile format that can be generated periodically?
March 13, 2008

13. General Competency #1 - Patient Care For Measures, consider …
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
General Competency #1 -
Patient Care
For Measures, consider …
Core Measures (CHF, P, MI data)
SCIP Data
Results of cases referred to Peer Review Committee
Report of diagnoses treated & procedures performed
Mortality Rates
March 13, 2008

14. Medical/Clinical Knowledge
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
General Competency #2 –
Medical/Clinical Knowledge
For measures, consider …
 Continuing Medical Education (CME) activities attended
 Board certification
 Appropriateness of antibiobic usage
March 13, 2008

15. General Competency #3 – Practice-based Learning & Improvement
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
General Competency #3 – Practice-based Learning & Improvement
For Measures, consider …
Continuing Medical Education (CME) hours related to specialty
Post-graduate training, preceptorships
Board certification
Education regarding pathways, protocols, best practices … as a result of cases identified thru peer review cases.
March 13, 2008

16. General Competency #4 – Interpersonal & Communication Skills
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
General Competency #4 – Interpersonal & Communication Skills
For Measures, consider …
Patient/Family Satisfaction Survey comments (complaints + compliments)
Written complaints from peers and associates (e.g., case managers; ED staff)
Inappropriate comments in medical records about other physicians
Monitoring of handwriting legibility.
Use of unacceptable abbreviations.
Timeliness of H&Ps and operative notes.
March 13, 2008

17. General Competency #5 - Professionalism
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
General Competency #5 - Professionalism
For Measures, consider …
Written complaints from peers and associates
Inappropriate comments in medical records about other physicians
Timeliness of H&Ps and Operative Reports
Medical record suspensions/delinquency
MS meeting attendance
Responsiveness to ER Call obligations
Compliance with MS Bylaws & Rules & Regs
Participation on MS committees
March 13, 2008

18. General Competency #6 – Systems Based Practice
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
General Competency #6 – Systems Based Practice
For Measures, consider …
Avoidable Days
Average LOS
Utilization of Resources
Clinical Pathways
March 13, 2008

19. Why do we need to measure physician competence?
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Why do we need to measure physician competence?
Patient Safety
Quality of Care
To report to the physician for his/her own use …
(If a hospital provides a physician with reliable performance data, performance WILL CONTINUOUSLY IMPROVE!)
March 13, 2008

20. Once you have the 6 General Competency measurements defined …
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Once you have the 6 General Competency measurements defined …
you can incorporate them into the remaining 2 new processes:
OPPE and FPPE. 
Let’s look at them now.
March 13, 2008

21. 2nd NEW CONCEPT: Ongoing Professional Practice Evaluation (OPPE) 
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
2nd NEW CONCEPT:
Ongoing Professional Practice Evaluation (OPPE)
STANDARD MS.4.40: “OPPE information is factored into each decision to maintain existing privilege(s), revise existing privilege(s), or revoke existing privilege(s) prior to or at time of renewal.”
TRADITIONAL Credentialing & Privileging
Procedural and cyclical processes … practitioners evaluated
when privileges are initially granted and
every 24 months thereafter [i.e., reappointment]. 
NEW! OPPE
Continuous evaluation of practitioner’s performance. Requires medical staff to conduct ongoing evaluation of each practitioner’s performance. Allows ID of professional practice trends that impact quality of care & patient safety.
March 13, 2008

22. TJC: “OPPE CRITERIA may include:
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
TJC: “OPPE CRITERIA may include:
_ Review of operative & other clinical procedure(s)* performed and their outcomes
*Includes operative and other invasive & noninvasive procedures that place patient at risk. Focus is
on procedures & is not meant to include medications that place patient at risk.
_ Patterns of blood and pharmaceutical usage
_ Requests for tests & procedures
_ Length of stay patterns
_ Morbidity & mortality data
_ Practitioner’s use of consultants
_ Other relevant criteria as determined by Medical Staff”
The type of data to be collected is determined by individual departments and approved by the
organized medical staff.
March 13, 2008

23. Information used in OPPE may be acquired thru:
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Information used in OPPE may be acquired thru:
_ Periodic chart review
_ Direct observation (proctoring)
_ Monitoring of diagnostic and treatment techniques
_ Discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, nursing, and administrative personnel.
March 13, 2008

24. March 13, 2008

25. There must be a CLEARLY DEFINED OPPE PROCESS!
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
There must be a CLEARLY DEFINED OPPE PROCESS!
Relevant information obtained from OPPE is integrated into PI activities.
PI activities adhere to policies/procedures intended to preserve confidentiality or legal privilege of information established by applicable law.
If there is uncertainty regarding a practitioner’s professional performance, the Medical Staff should follow course of action defined in the MS Bylaws for further evaluation of a practitioner.
NOTE: Privileged practitioners have access to the medical staff fair hearing and appeal process should the
intervention result in corrective action.
March 13, 2008

26. Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
STANDARD MS.4.45
“The organized medical staff evaluates and acts upon reported concerns regarding a privileged practitioner’s clinical practice and/or competence.”
March 13, 2008

27. Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
RATIONALE: A well-structured internal reporting process supports OPPE and enhances the quality of care & patient safety.
Effective OPPE =
Systematic Measurement +
Systematic Evaluation +
Systematic Follow-through
Based on this equation … creating a systematic and timely physician competency report* will be the key to successful OPPE.
*See 26.1 for Sample Physician Competency Report. SOURCE: The Greeley Company.
How often will reports be generated?
Can we modify the CURE report to follow the 6 General Competencies format and be our OPPE tool?
March 13, 2008

28. What happens when OPPE identifies a problem?
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
What happens when OPPE identifies a problem?
March 13, 2008

29. This bring us to the 3rd New Concept:
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
This bring us to the 3rd New Concept:
Focused Professional Practice Evaluation (FPPE)
Standard MS.4.30 – effective 1/1/08
FPPE is a process used by the organization in 2 circumstances.
Evaluation of privilege-specific competence of a practitioner who does not have documented evidence of competently performing the requested privilege(s) at the organization.
AND
2. May be used when a question arises regarding a currently privileged practitioner’s ability to provide safe, high quality patient care.
March 13, 2008

30. In FPPE the organized Medical Staff does the following:
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Focused Professional Practice Evaluation (FPPE)
Standard MS.4.30 – effective 1/1/08
In FPPE the organized Medical Staff does the following:
Evaluates practitioners without current performance documentation at the organization
Evaluates practitioners in response to concerns regarding the provision of safe, high quality patient care
Develops criteria for extending the evaluation period
Communicates to the appropriate parties the evaluation results and recommendations based on results
Implements changes to improve performance
March 13, 2008

31. The FPPE process is defined by the organized Medical Staff.
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Focused Professional Practice Evaluation (FPPE)
Standard MS.4.30 – effective 1/1/08
The FPPE process is defined by the organized Medical Staff.
The time period of the evaluation can be extended … and/or a different type of evaluation process assigned.
March 13, 2008

32. Although this standard went into effect 1/1/08,
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Although this standard went into effect 1/1/08,
approximately 75% of hospitals do not have a defined FPPE process in place yet.
Why?
What is required?
March 13, 2008

33. When questions arise in the OPPE process related to competency.
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
It’s a BIG process!!!
TJC requires use of an FPPE process to confirm competency for ALL initially granted privileges.
AND
When questions arise in the OPPE process related to competency.
“Triggers” that indicate the need for performance monitoring must be defined.
TJC is looking for CONSISTENT implementation.
March 13, 2008

34. Information for FPPE may include:
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Information for FPPE may include:
 Chart Review
 Monitoring clinical practice patterns
 Simulation
 Proctoring - Prospective, Concurrent, and/or Retrospective*
*Excellent Resource: “Proctoring & FPPE” - The Greeley Company. Recently used
by our new MS President to design a proctoring process when questions arose about a practitioner’s competency..
 External Peer Review
 Discussion with other individuals involved in the care of each patient (e.g., consulting physicians, assistants at surgery, nursing, or administrative personnel).
COLLABORATION
among hospital depts (including hospitalists)
and the Medical Staff is KEY.
March 13, 2008

35. Elements of Performance:
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Elements of Performance:
EP-1 - A period of focused professional practice evaluation is implemented for all initially requested privileges.
EP-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.
March 13, 2008

36. Elements of Performance:
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Elements of Performance:
EP-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.
March 13, 2008

37. Elements of Performance:
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Elements of Performance:
EP-4 – FPPE is consistently implemented in accordance with the criteria and requirements defined by the organized medical staff.
EP-5 – The triggers* that indicate the need for performance monitoring are clearly defined.
“Triggers” can be single incidents or evidence of a clinical practice trend.
March 13, 2008

38. Elements of Performance:
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Elements of Performance:
EP-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.*
*Other existing privileges in good standing should not be affected by this decision.
March 13, 2008

39. Elements of Performance:
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Elements of Performance:
EP-7 – Criteria are developed that determine the type of monitoring to be conducted.
EP-8 – The measures employed to resolve performance issues are clearly defined.
EP-9 – The measures employed to resolve performance issues are consistently implemented.
March 13, 2008

40. The FPPE clock starts ticking
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
The FPPE clock starts ticking
when an applicant is approved for privileges by the Board.
There must be a mechanism for tracking physicians and AHPs undergoing FPPE and ensuring that there is an evaluation and action taken at the end of the FPPE period.
March 13, 2008

41. Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
FPPE - Where to Begin?
Assign an ad hoc task force of medical staff members and hospital associates.
Build on the strengths of existing processes. Use your OPPE Physician Competency Reporting process, your Peer Review Committee …
Establish accountabilities.
Assure all participants understand their roles & accountabilities.
Document the process in a policy & procedure.
Sample FPPE Policy. Source: The Greeley Company.
Implement.
March 13, 2008

42. Remember who owns FPPE … Who are the Key Individuals/Groups?
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Remember who owns FPPE …
… the Organized Medical Staff!
Who are the Key Individuals/Groups?
for Design of FPPE:
Medical Staff Organization leaders
Dept Chairs/Section Chiefs
Credentials Committee
PI Committee/Peer Review Committee
MEC
for Support of FPPE:
Medical Staff Services Department
Quality Management Department
March 13, 2008

43. Medical Staff Services Department Quality Management Department
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
FPPE – What are Typical Roles of Key Individuals/Groups?
Medical Staff Services Department
Communicating requirements to involved practitioners and staff
Tracking
Reporting (status reports)
Notifying (practitioners, dept chairs, etc.)
Summarizing and presenting results
Documentation of the review process, ensuring follow-through.
Quality Management Department
Supporting the peer review-like processes
Screening cases
Facility of review processes (participation in committees and with individuals)
Collecting any required aggregate data
Forwarding results of review to MSSD
March 13, 2008

44. Each Clinical Specialty
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
FPPE – What are Typical Roles of Key Individuals/Groups?
Each Clinical Specialty
Examines current methods & systems for confirming competency for new applicants/new privileges.
Evaluates current privilege forms to determine scope of services for which competency
needs to be confirmed.
Identifies what new methods for confirmation of competency need to be developed.
Develops specialty-specific written plan/guidelines.
Submits guidelines to Credentials Committee.
Department Chairs
Tailor guidelines to new applicants
(depending on privileges requested, knowledge of applicant’s current competency, etc.).
Make written recommendation related to FPPE
(along with recommendation related to granting of privileges)
March 13, 2008

45. Credentials Committee Medical Executive Committee
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
FPPE – … more typical Roles of Key Individuals/Groups …
Credentials Committee
Develops overall policy/procedure for FPPE
Evaluates recommendations/plans made by department chairs.
Medical Executive Committee
Final recommending authority for FPPE.
Board of Directors
Final approval/denial authority for FPPE.
March 13, 2008

46. FPPE Process - What will it take?
Medical Staff Standards New/Challenging - _________________________________________________________________________________________________________
FPPE Process - What will it take?
Education of Elected Medical Staff Leaders and hospital associates who support the FPPE process.
 Selection of MS leaders willing to take on the challenge & spend the time it will take.
March 13, 2008

47. to determine competency
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Developing &
maintaining
credible processes
to determine competency
requires
diligent
data collection …
&
data evaluation.
March 13, 2008

48. Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
 … And Collaboration!!!!
COLLABORATION among hospital depts (including hospitalists) and the Medical Staff is KEY.
Don’t work in a vacuum.
Access to a shared tool (i.e., software) to maintain information about status/tracking of FPPE – this provides the “glue” to assist in communication.
March 13, 2008

49. Collaboration!!!! (cont’d)
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Collaboration!!!! (cont’d)
Understand each department/area’s specific accountabilities.
Identify required outputs/inputs.
Flow diagram.
Imbed utilization of IT.
March 13, 2008

50. Get the right information to the right people at the right time!
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Get the right information to the right people at the right time!
Peer Review Committee
Department Chairs
Credentials Committee
March 13, 2008

51. to Competent Practitioners providing Quality, Safe Patient Care!!!
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Ensure Analysis
and Evaluation …
… And Follow-Through,
to Competent Practitioners
providing
Quality, Safe Patient Care!!!
March 13, 2008

52. Some last-minute FPPE Lessons Learned
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Some last-minute FPPE Lessons Learned
Develop overall policy before
developing individual FPPE criteria.
Make guidelines reasonable & attainable.
Do not overuse labor-intensive FPPE methods such as concurrent proctoring.
Build in ability to shorten or lengthen
FPPE process as situation requires.
March 13, 2008

53. Let’s work together to get the processes in place!
Medical Staff Standards New/Challenging _________________________________________________________________________________________________________
Let’s work together to get the processes in place!
March 13, 2008