Documenting Provider Competencyfor Low and No- Volume Practitioners. What is competence? DOCUMENTING COMPETENCY FOR LOW- AND NO-VOLUME PRACTITIONERS

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1 Documenting Provider Competencyfor Low and No- Volume Practitioners Presented by Kathy Matzka, CPMSM, CPCS 1 What is competence? Ability to do a particular activity to a prescribed standard or a desirable outcome Based on knowledge, traits, skills, and abilities 2 Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) Core Competencies Interpersonal and Communication Skills Practice-based Learning and Improvement Medical Knowledge Core Competencies Professionalism Patient Care and Procedural Skills Systems-Based Practice 3 (c) Kathy Matzka, CPMSM, CPCS, LLC 1

2 Verification of Competency Training program Affiliations Peers 4 Provisional Appointment Clinical work is subject to review and evaluation for a period of time May include proctorship, chart review Need adequate volume 5 Intent of Performance Improvement Monitor patient care -appropriateness and timeliness Provide a mechanism for responding to and reporting issues Identify and address impediments to improving patient care Enhance patient outcomes 6 (c) Kathy Matzka, CPMSM, CPCS, LLC 2

3 Joint Commission Focused Professional Practice Evaluation (FPPE) All initially requested privileges When issues affecting the provision of safe, high quality patient care are identified Consistently implemented 7 Components of FPPE The issue Start date Means of identifying and documenting the issue Periodic reporting as the review progresses Interventions taken during the review to correct problematic issues Completion date or endpoints of the review Final analysis Mechanism for reporting results See FPPE Plan Pg 1 8 Joint Commission-Ongoing Professional Practice Evaluation (OPPE) Used in decision to maintain/revise/revoke privileges: Clearly defined process that facilitates evaluation of each practitioner s professional practice Type of data to be collected is determined by individual departments and approved by the MS Information is used to determine whether to continue, limit, or revoke any existing privilege 9 (c) Kathy Matzka, CPMSM, CPCS, LLC 3

4 Potential Aspects of OPPE/FPPE: Periodic chart review Direct observation/proctorship Monitoring of diagnostic and treatment techniques Discussion with other individuals involved in the care of each patient See sample proctorship forms pages 2 and 3 10 Low-No Volume Practitioners Practice mostly or all at another facility Voluntary limiting practice Practice all or primarily office-based Took time off (medical, family, retired and came back to work, etc.) 11 Low- or No-Volume Practitioner Options Get data from another organization/office Use peer recommendations Ask them why they want to be on staff Consider admit and follow privileges or refer and follow category Consider using temporary privileges rather than staff appointment May need new Bylaws language 12 (c) Kathy Matzka, CPMSM, CPCS, LLC 4

5 Get Data From Another Organization/Office Need policy and appropriate consent/release Will not replace OPPE, but can use to supplement Office data Kinds of patients Procedures performed Keep in mind -may not be relevant to hospital privileges See sample letter pages 4 and 5 13 Peer Recommendations Use per TJC when insufficient practitionerspecific data available See sample letter pages Ask Why they Want to be on Staff Practices change over time Office assistants complete forms Managed care may require admitting privileges See sample letter and survey pages 9 and (c) Kathy Matzka, CPMSM, CPCS, LLC 5

6 Consider Admit And Follow Privileges or Refer And Follow Category Great if referring to hospitalist No privileges = No FPPE/OPPE Admitting privileges would require evaluation of appropriateness of admission See sample forms pages 11 and Consider Using Temporary Privileges Rather Than Staff Appointment TP allowed by accreditors Good for occasional covering practitioners Pros and Cons 17 Check Bylaws May need new language Further define staff categories Redefine prerogatives Do you really want them to not be able to participate in committees, etc.? Thresholds for categories Ambulatory or Office-Based Category Define complete application to include data from other facilities for low/no volume Add/Increase reapplication fees 18 (c) Kathy Matzka, CPMSM, CPCS, LLC 6

7 Documenting Recommendations Use standardized forms FPPE/OPPE Appointment/Privileges Document in minutes See sample form and language pps Questions 20 (c) Kathy Matzka, CPMSM, CPCS, LLC 7