IAMSS NEWSLETTER. President s Corner by Lisa Goodwin. Thinking about going paperless? Inside this Issue. Presidents Corner 1.

Transcription

1 IAMSS NEWSLETTER April 2014 President s Corner by Lisa Goodwin I want to thank all of those that were able to join us at the IAMSS conference in Boise. We had a great conference with Kathy Matzka as our main speaker and Claire Brennan, Supervisory Diversion Investigator from the DEA Portland office. Inside this Issue Presidents Corner 1 Resource Tool 2 Being Appreciated 3 Evidence-Based Program 2-3 NAMSS Report 3-4 Problems at Work??? 4-5 Cord of Credibility 6 If you have not had an opportunity to renew your IAMSS membership the membership forms are attached. If you do not renew your membership by May 15 th, I am sorry to tell you that your name will be removed from the membership distribution list and you will no longer receive the newsletter or other important information related to networking. So I urge you to renew or join as soon as possible. As we at Kootenai are midway through our journey towards paperless credentialing and enjoyed this article from the HCPro website, I thought others might as well. Thinking about going paperless? Over the years here at Children s Medical Center in Dallas, we have worked to streamline our credentialing processes as much as possible. Most of this is done through utilizing technology. We have implemented online physician orientation modules at initial and reappointment. WE have electronic OPPE data profiles that the division chiefs can log in and review electronically as well as drill down on quality indicators to get more specific data. FPPE is also electronic; it is linked to our electronic medical record system so proctors are notified electronically that there are cases for them to review and they can they complete the chart audit electronically. Through the use of laptops, we ve had paperless medical staff meetings for many years. We recently started the transition from using our old laptops in all of our medical staff meetings to incorporating ipad tablets. I asked our director of medical staff services, Kenneth Enad to give me a quick summary from his perspective on this new initiative. His words are worth sharing with others debating whether to go paperless: Preparing the packet for the credentials committee meeting has come a long way over the past few years. The entire team used to spend more than a full day gathering material for the packets and literally running around making copies to the point where it was an approved sneaker day. The environment would be such high stress, and I can t even begin to count the number of times the copy machine would break! I would say our transition from killing so many trees depended on two major steps. First, we developed an organized process to collect

2 the material for the packet. We structured our shared network drive with a folder created for each major category (new applicants, additional privileges, reappointments, etc). Firm deadlines for each coordinator for getting the information into the folders gave the parameters necessary to allow all five MSPs to contribute to the packet without creating chaos. Secondly, using the Adobe software and laptops, we found a viable technological solution to gather, merge, bookmark, and display the electronic packets. The committees found these very easy to navigate. We re now transitioning to the use of ipads for our meetings. We have found that these are far more cost effective than laptops, and a lot faster to boot up before a meeting. So far, the committee members have been very receptive to them. If they ve never used an ipad or the ibooks app before, I give them a 30-second tutorial, and soon enough I see a smile on their face as they impressively tap, pinch, and swipe through the pages of the packet! Resource Evaluation Tool Several years ago I created a resource evaluation form to demonstrate just how significant and varied the job of a Medical Staff professional is. The form outlines each responsibility with the estimated number of hours to achieve each task, and is helpful when you are proposing additional staffing or defending the staffing you currently have. If you d like a copy of the form, just let me know. - Marna IMPLEMENT A CONSISTENT, EVIDENCE-BASED EVALUATION PROGRAM Chris Hinton Liability claim experience demonstrates that haphazard collection of performance data and lax implementation of privileging policies are major sources of risk. Yet, a report from the Joint Commission indicates that most organizations lack an objective process to grant, deny or renew medical staff privileges. The Joint Commission expects organizations to conduct an evidence-based performance evaluation prior to the granting of specific clinical privileges. Decision-makers should review a broad range of practitioner-specific data, including but not limited to: Morbidity and mortality data Comparative practice patterns Patient complaints Adverse occurrence trends Case review results Peer review recommendations

3 Two areas of particular concern within the physician evaluation and credentialing process are grandfathering provisions and core privileging. Grandfathering provisions in the bylaws must reflect the collective judgment of organizational leadership and the medical staff that an exception to the adopted criteria is warranted. The rationale supporting the decision should be documented, with supporting data summarized in the practitioner s credential file. These data may include surgical logs, statements from department chairs at other facilities, records of the number of procedures performed and proof of continuing medical education. The *Frigo case demonstrates the potential issues that may arise when grandfathering provisions are not clearly documented in medical staff bylaws and not applied sedulously in practice. Core privileging refers to evaluation of applicants based upon a preselected group of procedures or treatments relevant to the medical specialty. While the practice is generally permitted, core privileges must be defined by the medical staff and tailored to the organization s needs and capabilities. Skills should be evaluated independently, even if they are often grouped together e.g., special qualifications for laser surgery should be expressly articulated within the larger privilege of endoscopic and open procedures. * Frigo v. Silver Cross Hospital and Medical Center An Illinois appellate court upheld a $7.7 million jury verdict in this negligent credentialing case. The claim involved a podiatric physician who operated despite the presence of an infected ulceration on the patient s foot, which ultimately had to be amputated. The plaintiff sued the defendant hospital based upon its appointment of a podiatrist to the medical staff who failed to meet the hospital s established criteria for receiving Level II surgical privileges, which included postgraduate training, board certification and performance of a requisite number of bunionectomies. At issue in the credentialing claim was whether the podiatric physician had been grand-fathered in i.e., had obtained hospital staff privileges prior to a change in the prerequisites and was not required to satisfy new requirements under the organization s bylaws due to experience and clinical record. In affirming the Cook County jury verdict, the Illinois appellate court found that the hospital s medical staff bylaws were silent on the concept of grandfathering. The court also determined that the podiatric physician had failed to meet the standards set out in the medical staff bylaws for Level II surgical privileges upon initial appointment, and so could not have been grandfathered in under any circumstances. The Frigo decision represented the first time that a negligent credentialing claim was recognized by an Illinois appellate court. Even more important, the decision signified that the state peer review statute does not protect a hospital from these claims, even if the credentialing materials are generated by a peer review committee and therefore considered inadmissible in medical liability litigation.

4 NAMSS Leadership Conference Report Chris Hinton January 30 th 31 st, 2014, Charleston, South Carolina Following an adventurous travel plan from Twin Falls to Charleston, I attended the 2014 Leadership Conference in Charleston, South Carolina. Mark Thorsby, CAE, Vice President, Consulting Services at Smith Bucklin Corporation presented useful information on Leadership Development. We were asked to write three things down to change within their Associations as a result of the session, address the list, and share with another attendee. The original responses will be mailed back to the participants on May 1, like a short-term goals time capsule. Connie Riedel announced that NAMSS is offering a NAMSS PASS Cooperative Outreach Program to all the State Associations. The goal is to create a program whereby the State Associations can benefit from their efforts to encourage their members to participate in NAMSS PASS. Participation is easy and all that is require is for your association to provide NAMSS with a listing of its members (for the purposes of tracking participation only) and to distribute NAMSS PASS s and promotional information, as provided by the NAMSS headquarters, on a monthly basis. By participating in the program, your State Association has the opportunity to take advantage of several incentives and/or benefits. The more participation from your state, the greater the benefits for the State Association and its members. Most incentives are only being offered through the Promotional Period (June 30, 2014), so it is imperative that you start as soon as you return from this leadership meeting to gain the most benefits! Profession Risa Mish, Cornell University provided the Keynote Presentation - The Critical Thinking Advantage. Her presentation included guidance on Information Sorting, Communication, and Steps to Strategic Problem Solving. This presentation proved to be the best education I have received in quite some time and will forever impact my Strategic Thinking Process. Other presentations included the following: o Needs Assessment & Industry Gap Analysis o NAMSS Leadership How To Get Involved o Membership Recruitment and Retention Update o Conference Committee Update Dates to Remember o October 4-8, NAMSS 38 th Education Conference & Exhibition in New Orleans, LA o January 14-16, 2015 Leadership Conference in Tucson, Arizona o October 3-17, NAMSS 39 th Education Conference & Exhibition in Seattle, WA If you have questions about any of the information presented above, please do not hesitate in contacting me at

5 From the Editor: I just finished reading the definition of narcissism (with some tiny shocks of self recognition) when I saw this article on Workers who don't do their fair share. Knowing this doesn t apply to anyone in our field, I thought the tips might be helpful. It s not just The Peter Principle, it s enabling incompetence. If you d like to check out this website: I m going to summarize their comments below. A recent survey by the corporate training firm VitalSmarts found that the work slouch typically cost the rest of us an extra one to three hours a week at the office. Covering for a deadbeat doesn't just get you home late for dinner, either, it can cause your own performance to suffer. Unfortunately, slouches tend to respond poorly to feedback from peers. "They actively resent it," says Cambridge, Mass., executive coach Steven Robbins. So while you'll want to try confronting the slacker first, you'll probably have to talk to your boss to get real results. Before Going to the Boss, make your expectations known. Set team deadlines in a meeting or group so that everyone knows what everyone else is responsible for and by when, says Robbins. When someone doesn't deliver, try working it out with them by summarizing the facts neutrally and Problems at Work? No, not us! asking for clarification. ("Can we talk about how this project went? I never received the data from you. Can you help me understand why not?") It's possible your colleague had a good reason. When You're Face to Face With the Boss, put the problem in the context of the hospital as a whole, not your personal gripe. For example, "I'd like to speak with you about an apparent performanceissue on the team that could affect patient care." Putting the problem in the context of business results will elicit more buy-in from the boss than gripes about personality clashes. Define the issue with specific information. For example, "I'm hesitant to bring this up, but I haven't received the data I need from Bob to write the report Medical Executive Committee needs by next Monday. I ve talked with him a few times and even offered to help, but he says he's busy and can t get to it. Demonstrate that you've made every effort to get what you need before going up the ladder so you don t look like a whiner. And while you re at it, suggest solutions. Maybe there s another resource for the information you need.

6 The Four Cords of Credibility Chris Hinton CPCS, CMPSM Be professional, but do stand up for yourself. Ask your boss what you should reprioritize if you have to do Bob s work for him. You need to set boundaries once you ve done all you could to assist the other person. #1 Are You Congruent? Integrity is deep honesty and truthfulness. It is who we really are. It includes congruence, humility, and courage. Congruence: To live in harmony with your deepest values and beliefs. You walk your talk. Humility: To stand firmly for principles, especially in the face of opposition. You are more concerned with what is right than with being right. Courage: To act according to principles. You do the right thing-especially when it s hard to do. Increasing Your Integrity: 1) Make and keep commitments to yourself. Treat commitments to yourself as you would treat commitments to other important people in your life. Make, keep, repeat. 2) Stand for something. Write a mission statement or personal credo-an expression of what you stand for. Then live by it. 3) Be open. Exercise humility. Challenge the way you see the world: Are your own viewpoints totally accurate and complete? Do you seriously consider other viewpoints? Sue Salyer is now a member of the Catholic Health East-Trinity Health Credentials Standards Committee. This group represents several different disciplines from across the system, and has been charged with envisioning an easier, more streamlined approach to credentialing. This will be done by eliminating variances in credentialing standards like a clinical pathway for credentialing. This enormous but valuable goal must be accomplished while assuring compliance with regulatory standards and developing best practices. We know Sue will contribute a great deal to this project. We are proud of you Sue! Cabbage Stew 2 pounds Ground beef 1 medium Onion, chopped 4 cloves Garlic, minced 4 ribs Celery, sliced She promised, and here they are two of Tawna Miles favorite recipes, tested and approved by her staff!

7 1/2 teaspoon Chili powder oz cans Mexican stewed tomatoes 2 cups Beef broth 2 Tablespoons Beef bouillon 1 15 oz. can Kidney beans, drained and rinsed 1 15 oz. can Tomato sauce 1 teaspoon Salt 1/2 teaspoon Black pepper 1 teaspoon Parsley 1/2 head Cabbage, chopped Brown Ground beef add garlic and onion and saute until onion is tender. Drain well. Add remaining ingredients (except cabbage) and cook 8 hours on low. Add cabbage 2 hours before serving. Honey Beer Bread 3 cups all-purpose flour 2 Tbsp. sugar 1 Tbsp. baking powder 1 tsp. salt 2 Tbsp. honey or agave nectar 1 bottle (12 ounces) beer 4 Tbsp. (half stick) butter, melted Preheat the oven to 350 degrees F. Grease a 9x 5x 3-inch loaf pan. In a medium bowl, whisk together the flour, sugar, baking powder and salt. Using a wooden spoon, stir the beer and honey into the dry ingredients until just mixed. Pour half the melted butter into the loaf pan. Then spoon the batter into the pan, and pour the rest of the butter on top of the batter. Bake for 50 to 60 minutes, until top is golden brown and a toothpick/knife inserted in the middle comes out clean. Serve immediately.