solutions, but how do you find them? Guest writer Patrick ... · But looking at the UMC as just a paper exercise is a mistake, says ... The 7C’s of leadership William K. Cors, MD,

november 2013Volume 23Issue No. 11

TrendspoTTing

Medical Staff Briefing

Did you know that, hidden away in the CMS Conditions of Participation (CoP), there is an often-overlooked requirement that is ideal for increasing medical staff involvement and improving practice evaluation?

The reason this requirement is so often missed is because, unlike all other CoPs, no accrediting body—The Joint Commission, DNV, the Healthcare Facilities Accreditation Program, or the Center for Improve-ment in Healthcare Quality—are allowed to survey for it as part of deemed status. The requirement, which states that hospitals must have a “utilization management committee,” can only be surveyed by CMS.

It turns out, though, that this committee can be an incredibly useful tool for the medical staff, according to Cary Gutbezahl, MD, CEO and president of Compass Clinical Consulting in Cincinnati.

“Most hospitals aren’t ever surveyed to see if they have a functioning utilization management committee, or UMC,” says Gutbezahl. “The reality is very few ever get surveyed to look at this condition. And most don’t have an active program—if they do, they go through the motions and don’t get a lot of benefit out of it.”

But looking at the UMC as just a paper exercise is a mistake, says Gutbezahl.

Does your organization have a utilization management committee?

Robots in the ER Read about how one organization’s use of telemedicine links led to statewide changes to credentialing and privileging.

Defining innovation Organizations often seek innovative solutions, but how do you find them? Guest writer Patrick Pianezza, MHA, takes a look at this concept inside.

FPPE and AHPsRegular contributors Patricia A. Furci, RN, MA, Esq., and Samuel J. Furci, MPA, discuss methods for handling the growing number of AHPs applying to your facility.

The 7C’s of leadershipWilliam K. Cors, MD, MMM, FACPE, continues his series of columns by discussing fundamental skills for leadership communication.

A training resource for medical staff leaders and professionals

P5

P9

P10

P12

$1.5 millionThe amount in transfer costs saved by Grande Ronde Hospital with its implementation of robot telemedicine links.

MS.08.01.01The standard in which The Joint Commission states the organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.

$28,000The approximate cost to transfer a patient from Grand Ronde saved by implementing telemedicine options.


2 hcpro.com © 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

November 2013

sTay connecTedMSB in Your Inbox Sign up for any of our 17 email newsletters, covering a variety of healthcare compliance, manage-ment, and reimbursement topics, at www.hcmarketplace.com.

Don’t miss your next issueIf it’s been more than six months since you purchased or renewed your subscription to Medical Staff Briefing, be sure to check your envelope for your renewal notice or call customer service at 800-650-6787. Renew your subscription early to lock in the current price.

Relocating? Taking a new job?If you’re relocating or taking a new job and would like to contin-ue receiving Medical Staff Brief-ing, you are eligible for a free trial subscription. Contact customer serv ice with your moving informa-tion at 800-650-6787. At the time of your call, please share with us the name of your replacement.

Follow UsFollow and chat with us about all things healthcare compliance, management, and reimbursement. @HCPro_Inc

Questions? Comments? Ideas?

Contact Contributing Editor Matt Phillion at [email protected].

“ A lot of healing comes from keeping someone local. It allows them to see loved ones more often, to see familiar faces. The nurses they are being treated by are faces they see in the community, rather than strangers.”

Doug Romer

Quick HitS

Medical Staff Briefing (ISSN: 1076-6022 [print]; 1937-7320 [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Dan-vers, MA 01923. Subscription rate: $389/year or $700/two years; back issues are available at $25 each. • MSB, P.O. Box 3049, Peabody, MA 01961-3049. • Copyright © 2013 HCPro, Inc. All rights reserved. Print-ed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription infor-mation, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of MSB. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

editorial advisory board

Alpesh N. Amin, MD, MBA, FACPExecutive DirectorHospitalist ProgramVice Chair for Clinical Affairs & Quality Dept. of Medicine University of California, Irvine

Michael Callahan, Esq.Katten Muchin Rosenman, LLP Chicago, Ill.

William K. Cors, MD, MMM, FACPE Chief Medical Quality OfficerPocono Health System East Stroudsburg, Pa.

Sandra Di VarcoMcDermott Will & Emery, LLP Chicago, Ill.

Roger A. Heroux, MHA, PhD, CHEFounding PartnerHospitalist Management Resources, LLC HMR ED Call Panel Solutions Pensacola Beach, Fla.

Jonathan Lovins, MD, SFHMHospitalist and Assistant Clinical Professor of Medicine Duke University Health System Durham, N.C.

Assoc. Editorial DirectorTodd Hutlock

Contributing EditorMatt [email protected]

Sally Pelletier, CPMSM, CPCSSenior Consultant and Director of Credentialing ServicesThe Greeley Company Danvers, Mass.

William H. Roach Jr., JDMcDermott Will & Emery Chicago, Ill.

Richard E. Rohr, MD, MMM, FACP, FHMDirector of Hospitalist ProgramsGuthrie Healthcare System Sayre, Pa.

Jodi A. Schirling, CPMSMAlfred I. duPont Institute Wilmington, Del.

Richard A. Sheff, MDPrincipal and Chief Medical OfficerThe Greeley Company Danvers, Mass.

Raymond E. Sullivan, MD, FACSWaterbury Hospital Health Center Waterbury, Conn.

this document contains privileged, copyrighted infor-mation. if you have not purchased it or are not otherwise entitled to it by agreement with HcPro, any use, disclo-sure, forwarding, copying, or other communication of the contents is prohibited without permission.

Joint Commission calls for high reliability in hospitalsToo many hospitals and healthcare leaders currently experience serious safety failures as routine and inevitable parts of daily work, according to an article published last week in The Milbank Quarterly. Hospitals are urged to make the substantial changes necessary to achieve the ultimate goal of zero patient harm by adapting lessons from high-risk industries.

Source: Medical Staff Leader Insider (www.hcpro.com/MSL-296441-871/ Joint-Commission-leaders-call-for-high- reliability-in-hospitals.html)

N.Y. hospital staffs must get flu shot or wear maskIn an effort to limit the flu in the upcoming season, the New York Health Department is requiring thousands of medical staff and other personnel statewide to get vaccinated or wear masks when in close contact with patients. The rules, adopted in July, apply to more than 4,000 health-care organizations statewide.

Source: Medical Staff Leader Insider (www.hcpro.com/MSL-296442-871/NY-hospital-staffs-must-get-flu-shot-or-wear-mask.html)

From The Fieldonline


3hcpro.com© 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

November 2013

“A well-designed one gets a lot of attention from physicians,” he says. “A UMC can help change the way you utilize resources.”

The UMC provides an outlet to examine important utilization issues, such as length of stay, readmissions, and even the use of MRIs, CAT scans, and other rou-tinely ordered tests.

So how can your organization make use of this oft-overlooked CoP? Simple: physician involvement and physician ownership.

The key to making the UMC an effective committee is to make it a peer review medical staff committee, according to Gutbezahl. The UMC reports to the medi-cal executive committee (MEC), so it is predominantly composed of medical staff members. “Usually, the only non–med staff person … is the director of case management, as they provide a lot of the information necessary to review cases.”

And obviously, Gutbezahl notes, you will want to in-vite anyone whose department is identified in reviews as a recurring concern, such as radiologists or physical therapists, as ad hoc committee members.

Setting the committee apart

Focus is the key to an effective UMC, Gutbezahl explains.

“A lot of committees focus on high-level data analysis—what is our length of stay, etc.,” he says. “But a UMC is truly effective when you use it as a peer review committee. Look at specific cases and really discuss those cases. Assess utilization practices of the physician, and also within particular departments or specialty groups.”

The question to ask when examining a case is, “What can we learn from this and what do we not want to do again?”

If the UMC is used as a peer review committee, the physicians are much more likely to want to come to the meeting, says Gutbezahl.

In addition, the peer review concept allows for increased communication with members of the medi-cal staff. “Frequently, the UMC will send a letter to the physician stating they had reviewed their case, thought the length of stay was excessive, and felt on specific days the patient was not getting hospital-level services,” he says. “Medical staff members on the

committee really take the bull by the horns, assessing each other’s practices.”

As a committee, the UMC reports to the MEC and might make recommendations to the MEC, but its find-ings become incorporated into the med staff’s OPPE.

“Even though [OPPE] is Joint Commission–only, all hospitals have to have policies or procedures for ongoing review,” says Gutbezahl.

Interestingly, the UMC is not something that most physicians ask for on their own, but if they are intro-duced to it in the right way, Gutbezahl notes, they see the value in it and become engaged.

“They’re using their professional judgment as peers, and their efforts are having an impact on the way care is provided at the hospital,” he says.

For that to happen, however, the proper introduc-tion is key. “The problem with UMCs that are not working is that so much time is spent on high-level discussion,” says Gutbezahl. “An organization will note that a physician’s average length of stay is up, but there isn’t an answer to the question of what do we do now. But if you get your medical staff into a territory they are comfortable with—individual cases, observing the medical record—they know they are doing some-thing constructive.”

Most organizations miss this opportunity to actively involve the UMC. They know that the organization’s average length of stay is up, for example, but they do not use this type of resource to craft solutions.

Case management is great at identifying the prob-lems, and improvements in case management can be helpful, but this doesn’t address the issue of profes-sional practice, says Gutbezahl. “To improve physician practice you need a peer review committee. This is what their review is really all about—complications are being reviewed by a group of the physician’s peers.”

Active involvement

To get a UMC rolling in an organization that doesn’t have one, the best place to start is with a physician champion.

“This could be your chief medical officer; it could be a physician advisor for utilization management; it could be a hospitalist or the chief hospitalist,” says Gutbezahl. “It could be any number of different



November 2013

“It’s nice to think we’re migrating toward a population health mentality, but the reality is that physicians focus on the patients on an individual basis,” says Gutbezahl. “They’re more comfortable dealing with individual assessments rather than looking at statistical numbers, which then raise more questions than answers.”

High-level data raises multiple questions, whereas individual cases give you the details you need to know to talk to the attending physician, he says.

“Case-by-case reviews provide much more information to reach a conclusion the medical staff can then act upon, where high-level data doesn’t provide much data for immediate problem solving,” says Gutbezahl.

Organizations will also want to loop in the appropriate metrics when creating or improving a UMC. These include length of stay and numbers of unnecessary hospital days, but at the granular level, your organization is also looking at changes in individual physician performance, changes in specific resource utilization, and changes in cost for specific diagnosis-related groups (DRG) or DRG clusters.

So with all that said: Will CMS ever cross your hos-pital’s front door and examine your UMC process?

“I can’t say no one will ever come in and look at it,” says Gutbezahl. “I always believe as long as the rules are on the books, CMS might come in and audit a hospital and look at what they’re doing. I think there’s some vulnerability if they don’t have an effective UMC that they might get dinged with something. It won’t give them an immediate jeopardy finding, but it will give them a condition level finding. This could increase as CMS conducts validation surveys, so you’ll want to put something on paper—it’s pretty straight-forward for what CMS requires.”

For the most part, though, the benefit of a UMC is not preparation for a CMS survey, but rather the focus the committee can provide to physician involvement and peer review.

“What CMS requires are some prescriptive de-tails on the minimum things you need to do, but [it] doesn’t provide a blueprint,” says Gutbezahl.

Hospitals have been proactive in creating and involving UMCs because “CMS hasn’t been badger-ing them about it. It used to be more important

people, but that person has to work in concert with the head of the case management program.”

The champion should know about the day-to-day problems among physicians, and should work with case management to pinpoint the cases that warrant review.

“Ultimately, the goal of the UMC is to reduce the use of services that cost money that really aren’t necessary to the care of the patient,” says Gutbezahl.

From the medical staff standpoint, physicians are increasingly aware of the changing world of healthcare, not just the aggregate costs of care but inpatient costs in particular.

“Medical staff physicians involved in patient care are going to be stepping up to the plate for these kinds of initiatives,” says Gutbezahl. “What we’re fundamentally talking about is eliminating waste. We’re talking about the extra days where better care and planning would have resulted in shorter hospitalization.”

In addition, hospitals aren’t the safest place for a patient to be, Gutbezahl notes.

“In another life, I worked in bone marrow trans-plants,” he says. “We wanted to get the patients quickly out of the hospital [because] hospital-acquired organisms are much harder to treat than community-based organisms.”

Patients don’t benefit from waiting from Friday to Monday for a stress test, for example. If a patient needs to be hospitalized while waiting for the test, that patient may be better served if the organiza-tion can find a way to conduct the stress test sooner, he says.

Determining effectiveness

When it comes to judging the UMC’s impact on the organization, the proof is in the pudding, Gutbezahl says.

“If the UMC is bending practice patterns, they’re probably doing okay,” he says. “Obviously, if you’re not getting a significant benefit, you should ask your-self what is not working. Look for outside help—some-one to come in and assess what you’re doing and give you ideas for better practices.”

It might sound counterintuitive, but the UMC should avoid the big picture.



November 2013

“I’ve seen cases where a physician has cut 1.8 days off his average length of stay based on feedback from the UMC,” says Gutbezahl. “He was then invited to be a part of the process, and his performance improved tremen-dously. The emphasis of this committee is that there is a huge opportunity for hospitals to reduce costs.” H

to CMS when they paid more for outlier days and outlier costs, but they’ve kind of let the utilization management condition become less of a focus,” says Gutbezahl.

The bottom line is that it’s not CMS that benefits from the UMC—it’s the hospital.

Medicine from afarHow one critical access hospital turned to telemedicine to better serve its community

Tucked away on the far side of mountain passes in northeast Oregon, the 25-bed critical access Grande Ronde Hospital in La Grande provides much- needed care for a populace that can be cut off from larger facili-ties by a single snowstorm. The hospital provides all that it can for the local population, but, as with every critical access facility, there are inherent limits to the services that can be provided on-site. Certain specialties and medical services simply do not have the demand to draw full-time physicians or other professionals to the area.

Grande Ronde has, however, found a high-tech solution to this issue—one that ensures its patient population can receive services locally rather than traveling hundreds of miles, as might have been necessary in the past.

“We were asked by Saint Alphonsus Hospital in Boise to take part in a grant program,” explains Doug Romer, the hospital’s executive director of patient care services. “Their outreach director got in touch with us and said, ‘I have these robots through a grant. Would you like to try providing telemedicine services?’ ”

At the time, Grande Ronde did not have a telemedi-cine program and was interested in taking part in the process. And so its robot, a nearly human-height, mobile machine with a monitor where the “face” would be, arrived at the facility.

The program is what is known as a hub-and-spoke model—the tertiary hospital, in this case Saint Alphonsus, is the hub, and the rural facilities are the spokes. This model has evolved for Grande Ronde and is now known as a remote presence healthcare network. The network connects Grande Ronde with four states and five cities for specialty healthcare. For example, patients in the Grande Ronde ICU receive telemedicine services from St. Louis.

“The physicians log in, can see our electronic medical records, review images, review labs, review vital signs, and they will come in and visit patients face-to-face [via the robot’s camera and monitor],” explains Romer. “They are able to assist and direct the care of patients through-out the day and through the night when our nurses have questions. They will call ICU doctors in St. Louis and they will make decisions or change therapies as needed.”

Perhaps the most immediate benefit Grande Ronde saw following the start of the program was a reduc-tion in patient transfers. In the first 52 months of the program, the hospital was able to keep 57 patients in-house who otherwise would have been transferred because Grande Ronde didn’t have the necessary on-location intensivist coverage.

The benefits of keeping those patients in-house are multiple. For starters, the hospital averted almost $1.5 million in transfer costs. Because of the location of the hospital, every patient transfer carries roughly $28,000 in travel costs. Thanks to the telemedicine pro-gram, the patients did not have to travel and were able to receive care locally—and Grande Ronde was able to keep a significant amount of healthcare dollars in the commu-nity that would otherwise have gone to other hospitals.

“That $1.5 million is savings to the system,” explains Romer. “Sometimes it’s private insurance, sometimes it’s people with no insurance who have to mortgage their house to pay for a helicopter ride [to the next facility].”

In addition, there is a benefit associated with keep-ing a patient local during the healing process, one that’s difficult to define, he says.

“A lot of healing comes from keeping someone local,” says Romer. “It allows them to see loved ones more often, to see familiar faces. The nurses they are



November 2013

In fact, Romer has an interesting story along these lines. “I get a note every time the robot fires up,” he says. (The In Touch technology sends an alert to the appropriate parties when the robot becomes active.) “I wanted to see how things were going. We had a patient who didn’t want to be in the ICU, and [when I went to observe] he was trying to negotiate with the intensivist on the robot. This boy wanted to leave. He’d already tried negotiating with the primary care-giver in our community and with his nurses.”

It was at this point a remarkable moment happened right in front of Romer’s eyes.

“I heard the physician on the robot say, ‘Sir, the reason you are in my ICU is because you have very bad pneumonia,’ ” says Romer.

Not the ICU, he notes. My ICU.“He wasn’t being arrogant by saying it was his ICU,”

Romer explains. “He had treated so many patients in our ICU that he felt like a part of it, that it was his own ICU.” In other words, the technology had provided so clear a personal and professional connection that a physician who was hundreds of miles away felt empowered and involved with an ICU he had never set foot in.

Romer shares another anecdote involving an out-patient cardiology patient. The ICU nurse had taken some pulses, and otherwise was acting as the hands of the cardiologist, who was seeing the patient from afar.

“The doctor then said, ‘Okay, you can sit up now,’ ” says Romer. “The man sits up on the side of the bed, kicks his legs over, and starts having a conversation about alter-nate forms of lowering his cholesterol with the physician. They were looking each other in the eye and having a high-quality conversation about his health.”

This was a level of connectivity that, Romer says, a simple phone conversation cannot provide. “He did see that doctor in person.”

Scope and range

Grande Ronde Hospital will perform more than 500 consults this year with the help of its robotic telemedicine link. The services provided are wide-ranging, including:• Dermatology• Endocrinology• Neurology

being treated by are faces they see in the community, rather than strangers.”

Finally, staying local means that family members who would otherwise not be able to make the trip out of the valley to offer support are able to see their loved ones in person.

All of this being said, Romer notes that simply having access to telemedicine services is not sufficient to ensure quality care. In addition, a hospital abso-lutely must have top-notch nursing and support staff as well as top-of-the-line equipment to make sure the on-site care matches the quality of the consult.

“You need that bench. You need those resources,” he says.

The technology

The telemedicine robot was created by In Touch Health. (Note: Video footage of the robot in use can be viewed both at www.intouchhealth.com and on Grande Ronde Hospital’s website, www.grh.org, under the telemedicine link.) At first glance, the robot might not seem not too different from the sort of telemedicine technology hospi-tals have encountered before—for example, many orga-nizations use wheeled carts with monitors and cameras that allow the physician and patient to see each other. The robot used at Grande Ronde, however, allows the physician to take control remotely by using a joystick (or other technology—it is even possible to use an iPad®) to move through the hallways and navigate to the patient’s room. Once at the destination, those same controls allow the physician to control the robot’s camera and look around the room, such as from the patient to the EKG.

The robot isn’t just a viewport, either; it also offers more complex interactivity. The physician can, through the robot, use an electronic stethoscope to listen to the patient’s breathing or chest sounds. Here, again, is where the importance of skilled nursing staff comes into play. A nurse is in the room at the same time and listens to the patient through a stethoscope; this is done as a precaution to confirm what the physician may detect on the other end of the line.

This teamwork has led to an interesting development—the physicians from remote locations develop working relationships with the nurses, and vice versa, in much the same way medical professionals working together in person would.



November 2013

Grande Ronde’s size enables it to do this sort of thing impartially, in comparison to the competition factor that might be present at larger facilities. “We’re small. We don’t have a dog in the fight,” says Romer. “In a big city, it’s unlikely the hospital would allow you to visit your loved one by telemedicine link. We’re like Switzerland in this matter.”

And these links are not just used for the beginning of life. A local woman’s grandfather was very ill at another facility, too far away for her to get to his bedside. That other facility was part of Grande Ronde’s remote presence healthcare network. The woman approached Grande Ronde and made an appointment, and both facilities agreed to help. The remote location brought its robot to the grandfather’s bedside, and the woman sat in Romer’s office to talk with her grandfather.

“I left them for a little while to give them some privacy, did some work down the hall,” says Romer. Both facilities let the conversation go on longer than initially expected. When they were wrapping up the call, the woman told her grandfather she loved

• Rheumatology• Cardiology• Sign language translation• Foreign language translation• Grand rounds• Oncology• Pacemaker clinic consults• Teaching and counseling

The pacemaker clinic, in fact, uses the robot for a

teaching process—it allows a nurse practitioner to beam in and teach patients prior to discharge. The same practitioner does a series of lectures for the community on diet, medication, and signs to watch for involving congestive heart failure. It’s the sort of education a small community might not otherwise have the resources to provide.

The robot enables consultation for other services, too. “Genetic counseling is another big one,” says Romer. “We have an oncologist here who has done outreach oncology for us. Part of having a full-fledged oncology program is needing to have a full-time genetic counseling service. We can’t afford to have one on staff full-time, but we are able to do that through a telemedicine link. That counseling is paid per click rather than kept on staff full-time.”

Neonatology is another area that has seen signifi-cant benefits. “These are situations where the baby is ill—they might have been premature or had respira-tory challenges, and the pediatrician has had to get consults from neonatologists,” says Romer. “Some-times they call for an immediate transfer.”

More often than not these incidents happen following a cesarean section, and so when the mother wakes up, the baby has already been transferred. Because of the tele-medicine technology, in these situations the organization is now able to set up a link and beam in a real-time visit.

“We’re able to beam over to St. Alphonsus with the neonatologist on the other end, who goes through the whole visit with her, explaining the treatment, and the mom can see her husband there with the baby” on the other side of the link, says Romer. “This pre-pares the mom for when she gets discharged so she already knows her doctor on the other end and is able to visit with her baby remotely. We’ve used these tele-visits in conjunction with five different hospitals” so far.

Writing books and speaking on audio conferences and at

seminars are great ways to share your industry knowledge

with peers. With the guidance of a solid publishing company,

you’ll see your thoughts and tips become beacons to others

in your field.

We’re always looking for new authors, speakers, and

reviewers, and we offer competitive compensation. For more

than 20 years, HCPro has been a leading provider of inte-

grated healthcare information, education, training, and con-

sulting products. Among HCPro’s need-to-know information

products are a vast array of books, newsletters, websites,

and annual broadcast and live events.

Contact me at [email protected] and let me know

your areas of expertise and interests in publishing or training.

Please do not send unpublished manuscripts or specific

proposals for future works.

—Matt Phillion

Senior Managing Editor

We’re seeking experts for books, audio conferences, and seminars



November 2013

know which ones want to drive the robot, which ones want the [ picture archiving and communication system] images up already, which ones won’t log into the electronic medical record but rather talk through it with the nurse directly,” says Romer. “It’s been nothing short of spectacular.”

Financially, use of the telemedicine link is a net win for the hospital as well. It pays the consultants, but is able to retain patients who might otherwise be sent else-where for treatment. Patients, in turn, avoid large trans-port costs, repeated tests, and traveling to new facilities. Telemedicine has furthered Grande Ronde’s commit-ment to providing access to high-quality healthcare.

Telemedicine and credentialing

Anyone who has been in healthcare during the advent of telemedicine knows that credentialing and privileging remote physicians has been a learning process for the industry. In the case of Grande Ronde Hospital and Oregon, specifically, this was a unique chance to change the process for the entire state.

When the telemedicine link was first established, the hospital went through all the hoops to get 17 remote physicians fully credentialed at its facility. They were fingerprinted and had complete back-ground checks—everything was shipshape. But when Grande Ronde filed this information with the state, the physician licenses came back as inactive. It turned out Oregon had a law prohibiting the practice of medi-cine unless a physician first conducts a face-to-face visit with the patient.

“This may have been a way to prevent online prescribing of drugs, but we don’t know for certain,” says Romer.

So Grande Ronde went to the state medical board and pleaded its case. The hospital did a complete demonstration of the process with a volunteer patient, and showcased how the service would provide care and options that were otherwise unavailable in its geographic region.

The perseverance paid off. The next day Grande Ronde received a call from the state medical board saying that a temporary rule would be put in place to allow the hospital to begin its program, and that during the following year a change would be forthcoming to allow telemedicine credentialing permanently. H

him; unable to speak because of a tracheotomy, he responded by mouthing that he loved her back.

“Following that display, I got an email from the other organization,” said Romer. His counterpart there was amazed. “He said that was the most spectac-ular event he’d ever seen, and that even his hardened ICU nurse was in tears afterward.”

Time and distance

It isn’t just the emotional or human side of telemedi-cine that makes it such a boon for Grande Ronde. Due to the hospital’s remote location, its patients have, in the past, had to travel vast distances for services that were not available locally. Take endocrinology, for example. The nearest endocrinologist is 86 miles away. This physician had a good working relationship with the hospital, but also had a high no-show rate. With a three-hour drive there and back, minimum, the chances of a patient and his or her family deciding to cancel an appointment last minute, whether due to health issues, weather, or other unforeseen circumstances, were very high. “People are not going to drive over snow in a situation that is not life or death,” says Romer.

Now, the endocrinologist holds a remote clinic one afternoon a week through the telemedicine link to see the patients rather than asking them to make the 86-mile drive.

“Because of this, people are getting the preventative care they need,” says Romer.

As mentioned earlier, the interactions between on-site and remote staff have built a solid foundation and repertoire for these teams. Though some have never met face-to-face or shared the same building, they are as much colleagues as they would be if they worked in the same office.

Of course, that level of familiarity wasn’t achieved overnight. “It’s all about communication. There haven’t been any big challenges, but it did take a little time to get used to,” says Romer.

The medical staff struggled a bit with the technology at first, but after they had a couple of wins—a few situ-ations that really demonstrated the power of the tele-medicine link—they became fully invested in the system.

The nurses have even developed a knowledge of the peculiarities of the remote doctors, the way they would with their own in-house physicians. “They



November 2013

by Patrick Pianezza, MHA

Innovation is a favorite buzzword in healthcare. There are any number of vendors and consultants lining up to sell you a toolkit, seminar, or some other widget to make your organization more “innovative.”

However, innovation isn’t just another word for the latest and greatest technology, and it doesn’t have to be obscenely expensive either. The reality is that your organization can make meaningful, sustainable changes internally, for a low cost, without paying for outside council.

The first and most important concept to understand is that innovation is a process and must be treated as such. There must be a methodical and meaningful way to approach newly formed ideas that is robust, but not overly lengthy.

Having too many gatekeepers stifles innovation; having too few, on the other hand, leads to frivolous pursuits. In addition, innovation has to become an organizational priority in order to be successful. That means it must be funded and viewed as an investment in the organization.

For the process of innovation to work, it must start with a free flow of ideas and a repository where they can reside. This can easily be accomplished through the use of a dedicated email address or a suggestion box placed in a central location. It’s worth repeat-ing: Innovation must be an organizational priority, and the ideas that are submitted must be reviewed frequently and responded to by leadership so staff will continue to submit them. Every idea—whether it’s absolutely amazing or completely crazy—must get a reply. The simple act of thanking people for com-ing up with ideas and letting them know whether the organization moves forward is the single greatest motivating factor.

Next, assemble an innovation council. This group of people should be made up of 80% frontline staff—not just clinicians, but also including representation from ancillary and support services, operations, and ad-ministrative roles (such as human resources). Leader-ship should be represented on the committee as well,

specifically for their administrative oversight and project management skills.

Leadership also plays a key role in getting buy-in at the executive level. These individuals should have enough authority to act on an idea that has made it to the pilot project stage. More importantly, the leadership person should not be in charge of the meeting, nor should he or she be so intimi-dating that the meeting becomes solely about a personal agenda.

Ideally, the committee would meet on a monthly basis and suggest funding for pilot projects to the executive team quarterly. The committee should come up with criteria for strategically screening the ideas that cross its desk. These criteria should include consideration of the mission of the orga-nization, the idea’s financial feasibility, its return on investment, and its impact on daily operations. Most importantly, just like any other goal-setting that occurs at your organization, there should be meaningful, objective targets that these ideas are intended to improve, ones that can have their prog-ress monitored.

Finally, reward and recognize the staff member who came up with the initial idea, regardless of whether the idea was successful. Thank him or her publicly in a meaningful way so coworkers can see that the organi-zation is listening to its people and actively working on improving their ability to accomplish their work of helping others.

For ideas that are beneficial and have monetary implications, consider giving a cost savings percent-age to the employee as a bonus for discovering a cost savings.

Implementing a process for innovation in your organization can increase employee engagement and drive positive change, leading to exciting results. H

EDitoR’s NotEPianezza is a consultant who specializes in patient experience and employee en-gagement. He has worked in healthcare for more than a dozen years both as a clinician and in administrative roles. Pianezza has worked with the Studer Group and Johns Hopkins Hospital. in his most recent role, his work drove organizational performance in the Hospital consumer Assessment of Healthcare Providers and Systems to the 90th percentile—an all-time hospital best. He can be reached at [email protected].

Meaningful innovation: Moving past the buzzword



November 2013

by Patricia A. Furci, RN, MA, Esq., and Samuel J. Furci, MPA, principals at Furci Associates, LLC, in West Or-ange, N.J.

The aging of both the current healthcare workforce and the population in general, coupled with the dramatic healthcare reform facing the country, has increased the demand for many healthcare professionals and expanded the roles and skill sets for existing profession-als. These growth areas are especially seen among allied health professionals (AHP). The healthcare sector con-tinues to maintain a large and rapidly expanding work-force, with national gains of some 23,000 per month, according to the April 2013 Bureau of Labor Statistics Employment Situation Summary. In fact, healthcare was the only sector that experienced growth during the most recent economic downturn.

The intent of this article is to provide guidance for establishing the essential framework for AHP FPPE.

FPPE criteria and the AHP

The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance (MS.08.01.01). FPPE, as you know, is conducted to assist the medical staff in assess-ing current clinical competence of medical staff mem-bers and AHPs (certified registered nurse anesthetists, advanced practice nurses, physician assistants, certified nurse-midwives, etc.) under the following circumstances:1. Initially requested privileges for all new AHPs2. Current AHPs seeking additional privileges 3. Identification of questions regarding an AHP’s pro-

fessional performance that may affect the provi-sion of safe, high-quality patient care

A time period for the FPPE needs to be established

for all AHPs initially requesting privileges or seeking additional privileges. The Joint Commission standard MS.08.01.01 indicates that the time period of the evalua-tion can be extended, and/or a different type of evaluation process can be assigned. This as well as other FPPE crite-ria are to be approved by the organized medical staff.

The performance monitoring process also must be clearly defined and include each of the following elements (MS.08.01.01):• Criteria for conducting performance monitoring• Method for establishing a monitoring plan • Method for determining the duration of perfor-

mance monitoring• Circumstances under which monitoring by an

external source is required

Medical staff oversightWhether your facility has a separate allied health

credentials committee or a combined credentials committee, it is this committee that drives the imple-mentation and monitoring of the FPPE processes.

The chair of the department to which an AHP has been assigned should have the primary responsibility for ensuring that the AHP’s clinical competency and conduct is evaluated. The department chair should ap-point one or more physicians or AHPs to monitor the new appointee. It is very important that the selection of the monitoring practitioners be based on each prac-titioner’s leadership position in the new AHP’s area of practice and/or the likelihood that the practice pattern of the monitoring practitioners will overlap with that of the new AHP to allow for personal interaction, real-time observation of care, and/or shared care of patients.

FPPE monitoring process

FPPE should be submitted to the department chair and medical staff office at the end of the specified time period. In preparing this report for the department chair, the monitoring practitioners’ review may include information from:1. Chart review2. Monitoring clinical practice patterns3. Simulation4. Proctoring5. External peer review6. Discussion with other individuals involved in the care

of each patient (e.g., consulting physicians, assistants at surgery, nursing, or administrative personnel)

Does your FPPE process address the growing numbers of AHPs applying to your facility?



November 2013

new AHP’s competency.It should be within the discretion of the department

chair to determine whether the observation at the local facility meets the facility’s requirements. The department chair’s recommendation and evaluation will need to be forwarded through the medical staff committee structure, usually including the credentials committee and MEC.

If, at any time during the evaluation period, the monitoring practitioner has concerns about the new AHP’s qualifications, behavior, or clinical competence to perform specific privileges or cases, your FPPE policy should indicate that the practitioner may notify either the department chair or the credentials com-mittee chair. Any sentinel event would also cause an immediate report to the credentials committee. Such concerns may be addressed through the appropriate facility mechanism depending upon the issue raised.

Failure to meet FPPE requirement

In the event the AHP fails to meet the FPPE requirements, he or she should be notified in writing via a certified letter that his or her evaluation is incom-plete. The practitioner should be given an opportunity to request (within a specific time frame, such as 30 days) a meeting with the department chair and credentials com-mittee. At that meeting, the AHP should be given the opportunity to explain or discuss extenuating circum-stances involving his or her failure to provide sufficient clinical experience for a satisfactory evaluation.

At the conclusion of the meeting, the credentials com-mittee should make a recommendation to the MEC. After reviewing the credentials committee’s recommendation, the MEC can adopt that recommendation as its own, send the matter back to the credentials committee with specific concerns or questions, or make a differing rec-ommendation that outlines the MEC’s specific reasons for disagreement. The MEC’s recommendation is then forwarded to the board of directors. The decision of the board is final.

Conclusion

With the increased demand for many AHPs in health-care and the growing numbers of AHPs applying to practice in various settings, it is important to have a solid FPPE process, used consistently for all AHPs, to ensure the provision of safe, high-quality patient care. H

The monitoring and evaluation form used by the monitoring practitioners also needs to be approved by the medical staff and then given to the monitoring practitioners to complete. Once the form is completed, the monitoring practitioners must send the form to the department chair and medical staff office and pre-pare it for submission to the credentials committee.

While not a regulatory requirement, the credentials committee often assists in determining whether the AHP’s evaluation has been completed satisfactorily and the AHP is competent to perform requested privileges. The committee also can request continued focused review or forward a recommendation to the medical executive committee (MEC) supporting termination of the AHP’s appointment and/or clinical privileges due to questions concerning qualifications, behavior, or clinical competence. If the MEC upholds the rec-ommendation of the credentials committee regarding termination of membership and/or privileges, proce-dures that are outlined in the medical staff bylaws and/or AHP policy will need to be followed in terms of the procedural rights for AHPs. The report should become a part of the practitioner’s credentials file, although that does not mean it cannot be maintained in a sepa-rate confidential location.

Parameters of FPPE performance monitoring

The monitoring period for FPPE is to follow the specified time noted by policy to ensure uniformity in its implementation and should clearly define the “trig-gers” that indicate the need for performance monitor-ing. Policies often empower the credentials commit-tee as a “gatekeeper” for altering the time frame for individual circumstances deemed to require further evaluation. One example of altering the FPPE time frame is a low-/no-activity AHP within the hospital for (as an arbitrary number) 180 days following appoint-ment or granting of additional new privilege(s). He or she should submit the name of a peer who has directly observed and/or reviewed his or her clinical activity or specific procedure requested at another location during the defined time period; the AHP should also sign a new release form allowing the hospital to obtain the requested information. The designated peer will be asked to complete and return a low-/no-volume proctoring form to the medical staff office to assess the



November 2013

by William K. Cors, MD, MMM, FACPE, chief medi-cal quality officer at Pocono Health System in East Stroudsburg, Pa.

Editor’s note: This column explores the seven lead-

ership competencies—the “7 C’s”. This month we will continue to explore the third competency, increasing communication. For a complete list of the 7 C’s, see the August issue.

Last month in our series, we explored the funda-mentals of increasing communication. This month we will explore the crucial conversations that are essential to achieving that increase.

Stakes are high, opinions are divided, and emo-tions are charged. You are under pressure, possibly stumped, full of adrenaline. Welcome to the world of deeply human conversations as outlined in the semi-nal work Crucial Conversations, by Kerry Patterson, Joseph Grenny, Ron McMillan, and Al Switzler. Last month I addressed the fundamental competencies of managerial communication. This month all of those skills and then some will be put to the test as the waters of everyday conversations are navigated.

Crucial Conversations offers a step-by-step approach for handling an impending crucial conver-sation or examining one that has already occurred. These steps include:• Start with heart. You know what you believe in,

what you are passionate about. This step addresses your knowledge of self, your own starting point. The focus is on what you do and do not want.

• Learn to look. As with previous competencies, a self-assessment of your innate style is a useful starting point. This step offers a specific “style under stress” tool that explores how you typical-ly respond in the middle of a crucial conversation. Six styles are identified— masking, avoiding, with-drawing, controlling, labeling, and attacking–and placed under two broader headings: degrees of “silence” or “violence.” As in any self-assessment,

there are no right or wrong answers. The key is to gain self-knowledge and be able to apply it when the stakes get high.

• Make it safe. This is where you look for mutu-al purpose. It is a tough step that requires you to “CRIB”: Commit to seek mutual purpose, Recognize the purpose behind the strategy, Invent a mutual purpose, and Brainstorm new strategies.

Think of the multiple daily challenges in the re-lationship between physicians and hospitals. How much better might it work if you start with the proposition, “There is a mutual interest in provid-ing ever-better and expanding clinical care and programs to our patients and our communities.” Working from that mutual core value might take you down different paths.

• Master your story. Stories—yours or others’—explain what’s going on and offer an interpreta-tion of the facts. The intent of this step is to get to the infamous radio announcer Paul Harvey’s comment, “And now the rest of the story.”

• “STATE” your path. Here you Share your facts, Tell your story, Ask for other’s paths, Talk tentatively, and Encourage testing. My view? Your view? A new view?

• Explore other’s paths. Now you are able to Ask-Mirror-Paraphrase and Prime the pump to actively explore the views of others.

• Move to action. This is the step where you decide how you will decide; how decisions will be documented; and who will follow up and how.

The intensely charged atmosphere of contemporary

healthcare will inevitably cause sparks. These sparks can set off a fire—or, with trained leaders, they can cre-ate an opportunity to turn a crisis into a well-managed communication process: one that begins to seek mu-tual ground, discover alternate solutions, and imple-ment, one step at a time, a positive change in culture.

Next month, we will explore handling competi-tion. Until then, be the best that you can be. H

Leadership equation: 7C + 1 = successPart 3b: Increasing communication

Documents

solutions, but how do you find them? Guest writer Patrick ... · But looking at the UMC as just a paper exercise is a mistake, says ... The 7C’s of leadership William K. Cors, MD,