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MAMSS 2010 FALL EDUCATIONAL CONFERENCE
LOW-VOLUME/NO-VOLUME PRACTITIONERSWHAT’S THE SOLUTION FOR YOUR HOSPITAL?
Michael R. CallahanPartnerKatten Muchin [email protected]: 312.902.5634 60840358
Case 1: Low Volume/ No Volume Practitioners Tackling both Competency and Strategic Challenges
Jonathan H. Burroughs, MD, MBA, FACPE, CMSL and Michael Callahan, JD
Case Study: Dr. Competitor – Low volume at hospital – busy at ASC. How would you handle this today?
•
Dr. Competitor is an ENT on the medical staff at ABC Medical Center for 23 years and is considered the “expert”
in the community. In the past two years, she been primarily practicing in a freestanding ambulatory surgery center and has had a total of 3 admissions and 3 consultations at the hospital. The MS Bylaws require 15 patient contacts/year to maintain medical staff membership and Dr. Competitor would like her membership and privileges renewed.
Case Study: Dr. Fade-away – Primarily office based practice. How would you handle this today?
•
Dr. Fade-away is an experienced and beloved internal medicine practitioner who cares primarily for adults and has chosen to utilize the hospitalists to provide care for his patients at XYZ hospital. He has had 2 inpatient admissions over the past 2 years and received his reappointment application 120 days prior to the expiration of his current privileges. The hospital bylaws link membership and privileges and Dr. Fade-away would like his membership and privileges renewed.
Low and No Volume Practitioners:
Growing issue due to:
•
Changing financial incentives•
Increased performance expectations
•
Rapid growth of hospitalists•
Leap Frog recommendations
•
Increased liability•
Lifestyle preferences
•
Payer requirements
So, what’s the problem?
•
Matching privileges with demonstrated competency•
Risk management
•
Securing referrals and loyalty•
Poor policy compliance
•
Lack of support for hospital and medical staff strategic goals
•
Lack of alignment with non-hospital based practitioners
What are the legal risks here?
•
Negligent Credentialing–
Hospital liable if it gives privileges to unqualified physicians who then injure patients
•
Joint Commission─Accreditation Requirements regarding level of
information needed to appoint and reappoint physicians and to engage in ongoing monitoring –
OPPE/FPPE
There are two fundamental types of low volume/no volume practitioners
•
Adequate quality data elsewhere (another organization, free standing surgical/ambulatory center)
•
Inadequate quality data anywhere (Dr. Fade-away, reducing scope of practice, leave of absence or early retirement with desire for re-entry)
Step 1: Identify both Strategic and Competency Goals
•
What practitioners are important
strategically to the community, the medical staff and the organization?
•
What are the minimum threshold criteria (volume, qualitative, and quantitative data) to determine current competence to exercise clinical privileges?
Step 2: Create a Strategic Medical Staff Development Plan
•
Specialty by specialty analysis of demographic, strategic, leadership, call coverage, business, and quality
•
Semi-exclusive model (inclusivity vs. exclusivity)
•
Significant medical staff input to governance function
New strategic medical staff development planning: the “7 Rs”
•
Right number•
Right type of physicians
•
Right quality•
Right relationship to hospital
•
Right culture•
Right structure and processes
•
Right
leadership for helping the hospital fulfill its mission and strategic plan
Isn’t this economic credentialing? Is this legal?
•
If developed properly, using objective criteria and if reviewed and approved by management and the Board of Directors, the plan will be considered legal–
Need to be mindful of existing Medical Staffs and corporate bylaws and existing policies
What are the legal risks here? •
Open Medical Staff–
Is an IRS requirement. Can you limit access to Medical Staff?
•
Antitrust/Discrimination–
Is decision to limit access or deny appointment/reappointment based solely on anti-
competitive, discriminatory or other illegal motive?•
Medical Staff Development Plans–
Medical Staff can and should have input but cannot veto or make final plan decisions
What is the difference between medical staff membership and privileges?
Step 3: Separate medical staff membership from privileges•
Membership= political rights (vote, hold office, serve in leadership roles, recall an election, recall a decision, vote for amendments to bylaws, serve on committees, receive due process through fair hearing and board appellate review)
•
Privileges= what we are authorized to do (independent, co-management, dependent, refer and follow, none)
How many categories of membership do you have?•
Active?
•
Courtesy?•
Consulting?
•
Affiliate?•
Tele-radiology?
•
Locum Tenens?•
Non-member staff (AHP)?
•
Temporary?•
Community?
Membership Categories:
Membership Political Scope of PrivilegesCategory Rights__________________________________________1. Active Full Varies2. Associate Partial Varies3. Affiliate Partial Refer and Follow or none 4. Honorary Partial Refer and Follow or none
How many gradations of privileges do you have?
Step 4: Create gradations in privilege delineations
•
Independent•
Co-management until precepting/proctoring demonstrates competence
•
Co-management (unlikely to generate necessary quality data)
•
Dependent•
Refer and Follow
•
None
References•
How many do you require?
•
Who gets to decide who the references are?•
Are the references open ended or responses to specific questions?
•
If someone won’t respond or answer your questions, what do you do?
•
If you receive a “form letter”
as a reference, what do you do?
•
Do you call all references or some?
Step 5: Improve quality of information from references•
Policy driven references for each clinical specialty
•
Address broad quality framework (technical, service, professionalism etc.)
•
Open and closed ended content•
Validated through physician to physician dialogue
•
Place the burden on the applicant for incomplete information (form letters, refusal to speak etc.)
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Reinforced indemnification if necessary•
Evergreen references for former practitioners
Step 6: Create an effective OPPE and FPPE program/policy
•
OPPE= Routine evaluation and measurement of all practitioners granted privileges through the medical staff process (peer review, performance feedback q 6-8 months)
•
FPPE= Timely confirmation of competence when quality data is adequate and competency is likely (new privileges and potential issues identified by OPPE)
OPPE and FPPE:
•
What is the intent of The Joint Commission in creating these requirements?
•
What is the intent of OPPE?•
What is the intent of FPPE?
Types of physician care
•
Cognitive
•
Procedural
Methods of on-site proctoring
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Prospective: Describe what you plan to do
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Concurrent: Direct observation
•
Retrospective: Case reviews for processes or outcomes
Methods of off-site proctoring
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Reciprocal: Utilize concurrent work completed at another institution
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Preemptive: Proctoring completed at original institution prior to arrival of physician
New technology in proctoring
•
Tele-proctoring: May help increase the efficiency and availability of concurrent proctors
•
Procedure recording: Can allow later review of procedure by a proctor without a time constraint
•
Simulation: Increasing sophistication in these techniques may allow proctoring to be completed before patients are affected
FPPE:
•
How do you know you’re done?•
Who gets to decide?
•
Can you be flexible for experienced v. inexperienced practitioners?
•
Who oversees FPPE?
Step 7: Create a strategic approach to competency for each type of practitioner
•
Clinically active with sufficient quality data•
Clinically active with sufficient quality data elsewhere
•
Clinically active with ambulatory quality data•
Clinically active non-members who provide necessary clinical services (tele-radiologists, LTs, consultants etc.)
Step 7: continued•
Clinically less active members who are reducing their inpatient practice (older physicians who are reducing their scope of practice)
•
Clinically inactive members who have taken time off to pursue other interests or priorities and who offer a strategic advantage for alignment
•
Clinically inactive members who offer no strategic advantage for alignment
Case Study: Dr. Competitor – Low volume at hospital – busy at ASC. How would you handle this tomorrow?
•
Dr. Competitor is an ENT on the medical staff at ABC Medical Center for 23 years and is considered the “expert”
in the community. In the past two years, she been primarily practicing in a freestanding ambulatory surgery center and has had a total of 3 admissions and 3 consultations at the hospital. The MS Bylaws require 15 patient contacts/year to maintain medical staff membership and Dr. Competitor would like her membership and privileges renewed.
Case Study: Dr. Fade-away –Primarily office based practice-How would you handle this tomorrow?
•
Dr. Fade-away is an internal medicine practitioner who cares primarily for adults and has chosen to utilize the hospitalists to provide care for his patients at XYZ hospital. He has had 2 inpatient admissions over the past 2 years and received his reappointment application 120 days prior to the expiration of his current privileges. The hospital bylaws link membership and privileges and Dr. Fade-away would like his membership and privileges renewed.
The bottom line:
Balance Strategy and
Safety to create a vigorous healthcare network made up of aligned hospital based and non-hospital based practitioners who support the mission of the medical staff, the hospital, and the community.
