Pulse check: Experts weigh in on last year s NPDB Guidebook updates

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1 P10 Quick Q&A: Employed physician credentialing 101 As MSPs and medical staff leaders adapt traditional governance and vetting processes to accommodate the growing ranks of employed physicians, many may wonder whether their existing credentialing approach fits the bill. William K. Cors, MD, MMM, CPE, FAAPL, provides some insight. P10 CRCJ coverage in action: Forevermore reference merits Inspired by a recent CRCJ story, reader Mary O'Donnell, CPCS, shares her forevermore implementation story and a sample form exclusively on the CRC website. Volume 25 Issue No. 8 AUGUST 2016 P11 The MSP's voice: Lessons from the road Sheri Patterson, CPCS, reveals how her time as an interim MSO director taught her lessons in leadership, teamwork, and process improvement and rid her of the travel bug to boot. Pulse check: Experts weigh in on last year s NPDB Guidebook updates Last April, the U.S. Department of Health and Human Services finalized the first substantive updates to the National Practitioner Data Bank (NPDB) Guidebook in more than a decade. Roughly one year after the rollout, experts say the broadened reporting expectations have weightier implications for big-picture peer review discussion and strategy than for routine administrative workflow. I don t know that there have been any changes in medical staff governance on a day-to-day basis, but I think there s been more attentiveness to the issue of whether an investigation has begun, says Harry Shulman, JD, partner in the San Francisco office of healthcare law firm Hooper, Lundy & Bookman, P.C. Even under the latest guidelines, which feature a sweeping interpretation of formal performance investigations, reportable events are thankfully few and far between at many healthcare organizations. Therefore, instead of applying the new parameters to one-off Data Bank filings, MSPs should focus on recalibrating the scales of collegiality and patient safety in performance evaluation. While every MSP that I know wants to do the right thing and protect patients, we have to be sensitive to the fact that once we make an NPDB report, that report follows the practitioner for the remainder of his or her career, says Barbara Warstler, MBA, CPMSM, director of medical staff services and credentialing at University Hospitals in Cleveland. Clinical Privilege White Papers We are constantly updating and expanding our library of Clinical Privilege White Papers. Here are a few of the latest updates and additions: Intravascular brachytherapy for coronary arteries Procedure 12 Vagus nerve stimulation for epilepsy Procedure 31 Pediatric pulmonology Practice area 460 Stereotactic radiosurgery Procedure 250 Harmonic scalpel tonsillectomy Procedure 58 Download the latest papers from resourcecenter.com.

2 Credentialing Resource Center Journal August 2016 Broader investigation bounds Experts see the NPDB s Guidebook revisions as an effort to jump-start sluggish reporting rates; prior to the update, only 45% of hospitals had ever submitted a report. Given this objective, the most significant change is the NPDB s expansive interpretation of an investigation. For Catherine M. Ballard, Esq., partner in the law firm of Bricker & Eckler based in Columbus, Ohio, and executive director of its affiliated consulting company, The Quality Management Consulting Group, aggressive may be a more befitting descriptor. The Healthcare Quality Improvement Act of 1986 (HCQIA), which formed the legislative impetus for the NPDB, specifies that organizations must report a physician s surrender of clinical privileges while the individual is under investigation for potential incompetence or improper conduct, or in return for not initiating such activity. In the updated Guidebook, however, the NPDB classifies a voluntary (and often temporary) agreement to limit privileges during an investigation as surrender a considerable overreach, Ballard contends. To me, surrender means giving up they re gone, you don t have them anymore. It doesn t mean that they re in some way restricted or limited. Semantics aside, the wider stance casts doubt on the sustainability of the so-called precautionary suspension, a measure that some medical staffs have deployed at the outset of investigations to protect patients and to simultaneously preserve a practitioner s standing until conclusive findings and long-term solutions emerge. The Data Bank has made it clear that you can call it a precautionary, you can call it anything you want if it s a suspension, it s a suspension, and if it meets the guideline regulations, you re going to have to report it, says Terry Wilson, BS, CPMSM, CPCS, director of medical staff services at Flagler Hospital in St. Augustine, Florida. In light of the broadened reporting expectations, Wilson advises MSPs to educate medical staff leaders and hospital administrators about the NPDB s revised view on investigations and to engage these stakeholders in reevaluating the merits of precautionary suspension. FPPE is stuck in the middle Beyond the implications for traditional peer review safeguards, experts say the more encompassing definition blurs the line between routine peer review processes and formal investigations. The NPDB uses broad strokes to distinguish the two activities in the This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission. EDITORIAL ADVISORY BOARD Adrienne Trivers Product Director Follow Us Follow and chat with us about all things medical staff and credentialing Delaney Rebernik Editor drebernik@hcpro.com Carol S. Cairns, CPMSM, CPCS Senior Consultant The Greeley Company Danvers, Massachusetts President PRO-CON Plainfield, Illinois Christina W. Giles, CPMSM, MS Independent Consultant, Medical Staff Administration Nashua, New Hampshire Kathy Matzka, CPMSM, CPCS Medical Staff Consultant Lebanon, Illinois Robert W. McCann, Esq. Partner Drinker Biddle & Reath, LLP Washington, D.C. Maggie Palmer, MSA, CPMSM, CPCS National Director of Credentialing Tenet Healthcare Dallas, Texas Sheri Patterson, CPCS Credentialing Specialist Yavapai Regional Medical Center Prescott, Arizona Sally J. Pelletier, CPMSM, CPCS Advisory Consultant, Chief Credentialing Officer The Greeley Company Danvers, Massachusetts Elizabeth Libby Snelson, JD Legal Counsel to the Medical Staff St. Paul, Minnesota Marna Sorensen, CPMSM Former Director, Medical Staff Services Portneuf Medical Center Pocatello, ID Fatema Zanzi, Esq. Associate Drinker Biddle & Reath, LLP Chicago, Illinois Credentialing Resource Center Journal (ISSN: [print]; [online]), the newsletter of the Credentialing Resource Center (CRC), is published monthly by HCPro, a division of BLR. CRC dues are $515/year for Basic members, $895/year for Platinum members, and $1,245/year for Platinum Plus members. Credentialing Resource Center Journal, 100 Winners Circle, Suite 300, Brentwood, TN Copyright 2016 HCPro, a division of BLR. All rights reserved. Printed in the USA. 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3 Credentialing Resource Center Journal Face off: Addressing NPDB reporting criteria in governance documents Experts agree that compliance with the National Practitioner Data Bank s (NPDB) stepped-up reporting expectations lies in thorough practitioner education, a consistent approach to identifying investigations, and a deeper dive into reporting best practices. Their strategies on realizing these shared objectives, however, are sometimes at odds. Through interviews with medical staff attorneys, CRCJ discovered at least two schools of thought on how medical staffs should address formal investigations and other reporting considerations in their internal governance documents or whether they should do so at all. Catherine M. Ballard, Esq., partner in the law firm of Bricker & Eckler based in Columbus, Ohio, and executive director of its affiliated consulting company, The Quality Management Consulting Group, argues against defaulting to whatever the Guidebook says. Although vagueness may aid certain legal defenses, it can introduce needless confusion into everyday medical staff activities, Ballard contends. Instead, she advises medical staffs to establish a robust definition and timeline of an investigation for inclusion in bylaws, policies, and procedures (see the sidebar on p. 5 for Ballard s targeted advice on these activities). Harry Shulman, JD, partner in the San Francisco office of healthcare law firm Hooper, Lundy & Bookman, P.C., contends that attempting to codify the broader bounds and increasing complexity of the investigatory landscape in medical staff governance materials is an overly ambitious task that muddies the waters at best and poses legal ramifications at worst. Instead, he says medical staff leaders should look and point inquiring practitioners toward the NPDB Guidebook for such information. There s no upside behind incorporating all of that stuff (or even trying to) in your policies and procedures. The following are Ballard s and Shulman s counterpoints. Ballard: Develop internal definitions for key reporting considerations Establishing a clear position on the scope and distinguishing characteristics of a formal investigation is a basic professional courtesy, says Ballard. Your medical staff is entitled to know the parameters of what is going on, she explains, adding that providers who are confused about an organization s stance on investigations may be likelier to leave in the midst of one, inadvertently triggering an NPDB report. In addition, Ballard believes a clear definition of an investigation can help organizations establish reporting guidelines, better understand which peer review activities potentially qualify as investigations, and, in turn, recognize the importance of dealing with issues on an informal, remedial basis when possible. For example, if a practitioner who is struggling to master a new surgical technique proves receptive to a peer review committee s suggestion to pursue additional education, the event likely shouldn t be identified as an investigation, says Ballard. However, consider applying the descriptor when the practitioner s performance escalates to a Houston, we have a problem level that necessitates medical executive committee (MEC) involvement. In this way, clearly delineated investigatory bounds and grounds may give some teeth to a disputed reporting decision especially if a practitioner escalates his or her challenge to a fair hearing, says Ballard. Drawing the distinction between routine and potentially reportable activities is also critical to preserving the NPDB's integrity, says Ballard, who points to the fine line between robust data and information glut. If healthcare entities took the NP- DB s expanded reporting parameters at face value and flagged every performance inquiry as an investigation, the practice would generate so much stuff in the system that it would not be of value. Shulman: Defer to the Guidebook Establishing internal definitions surrounding NPDB reporting criteria made more sense in the late 90s and early 00s, when medical staff governance documents came under scrutiny and carried more clout in related court cases, says Shulman. He points specifically to Simpkins v. Shalala, a 1998 case in which Cuthbert Simpkins, MD, a former medical officer at the District of Columbia General Hospital (D.C. General), brought a suit challenging the hospital s submission of an adverse action report to the NPDB following Simpkins departure while under investigation for quality-of-care issues. One point of contention was whether Simpkins was truly under investigation at the time of his departure. In making its determination, the court granted considerable weight to the Healthcare 2016 HCPro, a division of BLR. 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 HCPRO.COM 3

4 Face off: Addressing NPDB reporting criteria in governance documents (cont.) Quality Improvement Act of 1986, the NPDB Guidebook s interpretation of the statute, and D.C. General s bylaws. The court is convinced that the Bylaws are an important indicator of whether D.C. General was conducting an investigation of plaintiff at the time of his resignation, District Judge Royce C. Lamberth wrote in a memorandum opinion. These Bylaws conclusively reveal that D.C. General was not conducting an investigation of plaintiff when he left the hospital. In this way, D.C. General s documented stance on investigations helped stakeholders navigate that question of what s an investigation and what s a reportable event in a given instance, says Shulman. However, legal opinion and the Guidebook s own attitude toward internal documents has evolved considerably since this decision, according to Shulman. This shift, he says, is apparent in Doe v. Leavitt, a 2009 appellate court case in which a physician contested an NPDB report triggered by his departure while under MEC review for alleged unprofessional conduct. In an administrative review decision, First Circuit Judge Bruce M. Selya nodded to the Simpkins v. Shalala rationale in his acknowledgment that a hospital s bylaws may shed light on whether the institution has initiated an investigation within the purview of the statute and, if so, whether that investigation is ongoing. However, he qualified that the federal judiciary and the agency to which the interpretive task has been entrusted have independent responsibilities for fashioning a global definition of an investigation that a hospital cannot frustrate through its bylaws. Judge Selya s sentiment reflects the NDPB s contemporary stance on defining an investigation, says Shulman. If anything, the courts are probably going to defer more to the Data Bank s interpretation of an investigation rather than a narrow definition that a medical staff might put in its bylaws, he adds. In this more nuanced environment, Shulman maintains that it s unwise for medical staffs to try to distill Guidebook principles in internal governance documents. It would be challenging to get it right, and I m not sure you really could. Although Shulman acknowledges that attempting this integration would likely carry minimal consequences for most organizations, in extreme cases, missing the mark could trigger adverse hearing outcomes. For example, Shulman points to the Guidebook s clarification that an investigation is generally a precursor to disciplinary action. Incorporating this legalistic and awkward phrase into internal governance documents may confuse the medical staff. What's more, it could dampen an institution s defense of an investigation as impartial and open-ended during a fair hearing. It has a bad ring to it, says Shulman. It makes it sound like the investigation was basically calculated to result in disciplinary action against the physician, and attorneys who represent physicians in these proceedings are going to seize on that. Given these risk areas, Shulman recommends deferring to the Guidebook s definitions when making reporting decisions, as that language will likely prevail over internal constructions during legal proceedings. updated Guidebook. It states, for example, that a routine, formal peer review process does not constitute an investigation when the health care entity evaluates, against clearly defined measures, the privilegespecific competence of all practitioners. However, a peer review activity that draws on a formal, targeted process to identify issues related to a specific practitioner s professional competence or conduct is considered an investigation. This distinction seems to cut across focused professional practice evaluation (FPPE) lines: Although FPPE is an integral element of routine peer review for many accredited institutions, it is also used to dig deeper into potential performance issues. If you look at the way they define investigation in the ultimately revised Guidebook, it certainly would include anything that one might characterize as an FPPE, says Shulman. However, Ballard sees the residual gray area the Guidebook stops short of explicitly referencing FPPE as an opportunity for organizations to make their own determinations about whether focused review constitutes an investigation. Because the NPDB establishes that it may look at a health care entity s bylaws and other documents for assistance in determining whether 4 HCPRO.COM 2016 HCPro, a division of BLR. 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

5 Credentialing Resource Center Journal Developing an internal position and process for formal investigations Given the contention over whether National Practitioner Data Bank (NPDB) reporting criteria should inform medical staffs' peer review processes (see the sidebar on p. 3), those who take this route should be methodical and precise in their approach. Catherine M. Ballard, Esq., partner in the law firm of Bricker & Eckler based in Columbus, Ohio, and executive director of its affiliated consulting company, The Quality Management Consulting Group, recommends the following steps. Define a formal investigation Historically, medical staff attorneys have reserved the formal investigation descriptor for performance inquiries prescribed and/or carried out by the medical executive committee (MEC) or the governing body, says Ballard. In other words, the classification has been applied narrowly to bodies that have the authority to take formal corrective action, and by extension, trigger a fair hearing process, she explains. Performance inquiries and interventions executed by peer review stakeholders without this power (e.g., department chair, credentials committee, or a peer review committee) are typically considered part of the informal peer review process and are less likely to trigger an NPDB report should a provider leave while in the midst of the activity, says Ballard. Depending on the institution, such activities may include case review, focused professional practice evaluation (FPPE), proctoring, and remediation. Distinguish routine review from formal investigation Peer review policies should position ongoing professional practice evaluation (OPPE), FPPE, and related activities as core elements of the routine peer review process, says Ballard. In particular, stress that FPPE is the standard approach for the given circumstances, rather than something specific to an individual doctor that could reasonably be construed as an investigation. Although the NPDB ultimately has the authority to determine whether an activity under dispute constitutes a reportable event, full-bodied internal positions and procedures can hold sway, says Ballard. That s why, to me, even if [the NPDB s] position might be, We think this was a formal investigation, I want to be very clear in our documents that, in fact, we believed this to be our routine peer review process that we apply to every single practitioner whenever certain types of circumstances arise. Establish an investigation timeline Organizations are required to submit an NPDB report whenever a physician or dentist under investigation surrenders privileges regardless of whether the practitioner was aware of the investigation. For this reason, Ballard recommends establishing signposts for when an investigation begins and concludes. For example, an investigation may begin when the practitioner is informed of the activity, or at the outset of a MEC meeting, whichever occurs first. After setting these parameters, build specific guidance into the bylaws to increase awareness among practitioners. The following sample bylaws language, courtesy of Ballard and The Quality Management Consulting Group, illustrates these principles: Upon receipt of the request for corrective action, the Medical Executive Committee shall act on the request. (a) A matter shall be deemed to be under formal investigation upon the following event, whichever occurs first: (1) The Appointee/Member is notified (either verbally or upon proof of receipt of Special Notice) that a request for corrective action has been submitted to the Medical Executive Committee. (2) The start of the Medical Executive Committee meeting at which a request for corrective action is to be presented. In such event, Special Notice shall be provided to the Appointee/Member immediately following the meeting. (b) Once a matter is under formal investigation, the matter shall remain under formal investigation until such time as the Medical Executive Committee rejects the request for corrective action, closes the investigation, or a final decision is rendered by the governing body. Set reasonable parameters Although establishing a definition for routine peer review can help medical staffs make and defend reporting decisions, resist the temptation to apply this classification to all performancerelated activities. If you re going to be greedy, you re going to get in trouble, says Ballard. When it comes to developing investigation policies, she advocates tightly defined, reasonable, and consistent language HCPro, a division of BLR. 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 HCPRO.COM 5

6 Steps to NPDB reporting success To achieve long-term compliance with the National Practitioner Data Bank s (NPDB) expanded reporting parameters, experts recommend a mixed bag of targeted approaches and old standbys. Develop a methodical investigation process The specific vocabulary organizations apply to investigations is often less important than the delineation of a comprehensive and well-reasoned process that aligns with applicable accreditation and regulatory standards, says Terry Wilson, BS, CPMSM, CPCS, director of medical staff services at Flagler Hospital in St. Augustine, Florida. The Joint Commission makes it clear that we don t care what you call it; it s, if you re doing these things, then we consider it an investigation, she explains. The NPDB echoes this stance in its latest Guidebook, stating, An action must be reported to the NPDB based on whether it satisfies NPDB reporting requirements and not based on the name affixed to the action. Wilson recommends outlining a step-by-step methodology in bylaws for initiating a formal investigation, as well as for articulating specific triggers, involved parties, review criteria, and potential actions. I think [that] will give the hospitals and the medical staff a little better ground to stand on should there ever be a challenge to whether or not something should have been reported. Be deliberate A reporting decision has major implications for patients, practitioners, and the healthcare organization at large, so don t wing it, says Harry Shulman, JD, partner in the San Francisco office of healthcare law firm Hooper, Lundy & Bookman, P.C. When, after careful consideration, an organization decides to move forward with reporting, take the time to craft a meaningful submission. Be as factual and concise as possible, advises Barbara Warstler, MBA, CPMSM, director of medical staff services and credentialing at University Hospitals in Cleveland. Give as much detail in the NPDB report that you write as you d like to receive. Answer the question, Will this make sense in five years when someone reads this? Make tough calls as a community Obtaining multiple perspectives is important, Warstler says. We are very lucky in our health system to have more than 30 medical staff professionals on our team. We can share thoughts and ideas and ask each other questions when these difficult situations arise. For smaller facilities, or those seeking to further diversify input, draw from other disciplines. Viable advisors include legal counsel, medical executives, and medical staff leaders. For example, University Hospitals medical staff services department collaborates with the health system s law department, chief medical officer, and relevant medical staff leaders to determine whether a given issue is administrative or clinical in nature and, in turn, whether to address it through HR or medical staff channels. Brush up on the basics When adapting existing approaches to accommodate new reporting expectations, don t lose sight of long-standing best practices or downplay the role of good old common sense in achieving compliance, says Terry Wilson, BS, CPMSM, CPCS, director of medical staff services at Flagler Hospital in St. Augustine, Florida. I m not a clinician, but when the physicians involved are all saying, you know what, we ve got a problem here, our antennas have to be raised. Conversely, MSPs should also recognize when a flagged incident seems more attributable to medical staff politics or a system limitation. When in doubt, let the Guidebook steer I keep a copy of the Guidebook handy and refer to it often, says Warstler. To keep tabs on all relevant requirements, crossreference NPDB directives with state licensing laws, Shulman adds. Keep medical staff and hospital leaders in the know The NPDB s elevated reporting expectations demand heightened emphasis on meaningful reporting strategy. In particular, MSPs should ensure medical staff leaders and quality personnel can distinguish between routine peer review and an activity that really smells like formal corrective action, says Catherine M. Ballard, Esq., partner in the law firm of Bricker & Eckler based in Columbus, Ohio, and executive director of its affiliated consulting company, The Quality Management Consulting Group. These players should also recognize what events indicate the start and conclusion of an investigation. 6 HCPRO.COM 2016 HCPro, a division of BLR. 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

7 Credentialing Resource Center Journal Steps to NPDB reporting success (cont.) Such education should also extend to hospital administrators, says Wilson, who encourages organizations to take a hard line on characterizing and carrying out investigations. If you actually have initiated a formal process of some sort, you can no longer hedge and say, Well, we just didn t call that an investigation. In terms of specific educational tactics, Wilson favors short, sweet, and straight to the source. Brief the credentials committee, medical executive committee, and governing board on the salient Guidebook developments during their respective meetings. I think that s the best way to educate getting to the groups that are making the decisions, says Wilson. Prepare five-minute presentations that highlight the revised NPDB reporting expectations, related risk areas, and key takeaways for current credentialing, privileging, and peer review activities. The specific talking points are less significant than drawing attention to the updated requirements and promoting thoughtful reporting practices, says Wilson. Plant the seed in everybody s mind even if all they walk away with is, you know what, there s been changes, and they re telling us to be a little more cautious. Maybe we better stop and think before we act, and let s find out the right way to do this. an investigation has started or is ongoing, Ballard recommends distinguishing routine peer review activities (including FPPE) from formal investigations that have NPDB implications in medical staff bylaws and policies. Shulman takes a different view, advocating fairly strongly against amending the medical staff bylaws to try to incorporate principles from the Guidebook. Although the NPDB s expanded interpretation of an investigation is probably the single most important development in the Guidebook, Shulman says its dayto-day application is somewhat limited. The definition of an investigation and when it begins is only of significance when privileges are relinquished or voluntarily restricted while under or to avoid an investigation, he explains. In other words, avoid placing undue emphasis on such considerations, which likely won t affect the majority of peer review activity. For more on Ballard s and Shulman s opposing strategies for addressing the NPDB s expanded definition of investigations, see the sidebar on p. 3. Proctoring also assumes middle ground In addition to reporting a physician s surrender of clinical privileges in the midst of an investigation, healthcare organizations must report corrective action that adversely affects or restricts privileges for a period of more than 30 days. Although this obligation has long been in play, medical staffs have historically struggled to determine whether certain performance monitoring or improvement activities qualify as reportable action. This question often arises surrounding proctoring, given the practice s broad definition and frequent use in peer review. The new Guidebook clarifies that proctoring is reportable when (1) the activity lasts for more than 30 days and (2) a physician is not permitted to perform certain procedures without the proctor s approval and/or presence and observation. Proctoring should not trigger reporting, however, when the proctor is assigned for reasons other than approving or directly observing practice, such as to conduct a retrospective case review a circumstance that the NPDB doesn t deem a restriction of clinical privileges. In this way, the latest Guidebook resolves, from a reporting perspective, some overlap between observation and reporting, terms that are used often in connection with the same types of measures, says Shulman. However, calling attention to which proctoring activities have reporting implications could have a legal downside, says Ballard. When a peer review decision has the potential to trigger an NPDB report, the affected physician should have an avenue for challenging the event namely, a fair hearing. Typically, however, hearing rights are restricted to actions taken or recommended by the medical executive committee (MEC) or governing board, while proctoring can be prescribed by a lower-level peer review committee. Given this disparity, a physician may claim mistreatment by the hospital if he or she is subjected to prolonged proctoring that culminates in an NPDB report and isn t given the 2016 HCPro, a division of BLR. 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 HCPRO.COM 7

8 opportunity to challenge the action in a fair hearing, says Ballard, adding that the hospital wouldn't be able to obtain HCQIA immunity from damages in this situation. Reporting across platforms Although preliminary suspensions, FPPE, and proctoring have been at the forefront of reporting discussions since the NPDB first announced the Guidebook updates, another striking implication of the broadened investigation definition has come to light since the finalized version s debut: The divide between state and federal reporting requirements may have deepened in some jurisdictions, increasing the potential for confusion come submission time, says Shulman. In many states, medical board reporting requirements historically have resembled (but not mirrored) NPDB reporting requirements. As a result, most (but not all) reportable events have called for a submission to the NPDB and another to the state medical board in accordance with each entity s respective reporting guidelines. In addition to these separate filings, the HCQIA stipulates that, whenever an organization submits a report to the NPDB, it must supply a copy to the relevant state medical board. Given these requirements, most reportable events will trigger three reports: 1. The NPDB receives a report in accordance with its specific requirements 2. The state medical board receives a copy of the NPDB report 3. The state medical board receives a separate report in accordance with its specific requirements Although this is the norm, certain circumstances may warrant submission of a report to the NPDB without a complementary submission to the state. Even fewer may trigger submission to the state but not to the NPDB. Of the three possible scenarios, the second in which the NPDB requires a report but the state does not is riskiest, and given the NPDB s expanded interpretation of reportable investigations, the likeliest to increase in prevalence, says Shulman. In cases where the NPDB requires a report and the state does not, an organization will submit only two reports: an original report to the NPDB and a copy of that report to the state. If the institution fails to specify why it's submitting fewer than the typical number of reports to the state medical board, the board may perceive the move as an error and initiate further investigation and/ or enforcement action. To head off unwarranted scrutiny, Shulman advises MSPs and medical staff leaders to include a cover letter explaining why the state medical board is only receiving a single report. State reporting requirements may also come into play with the Guidebook s clarification on whether application withdrawals necessitate reporting, says Shulman. When submitting an initial application for privileges, a practitioner may typically withdraw at any time prior to a final governing body decision without triggering an NPDB report, says Ballard, noting that the potential for reporting arises during a credentialing period related to reappointment or regranting of privileges. When the credentialing process dredges up red flags that demand additional information, practitioners may opt to withdraw their application to avoid supplying requested information that could hurt their chances of approval, says Shulman. Sometimes, an application may make it all the way to the MEC before the practitioner pulls it. Per the updated Guidebook, such withdrawals are not reportable unless the medical staff has adopted bylaws language that characterizes the credentialing process as an investigation, which Shulman says is a highly unlikely move. The NPDB clarifies that an applicant may withdraw an application at any time prior to the governing body s official denial of appointment without incurring an NPDB report. However, Shulman recommends cross-checking this provision against state statutes. In California, for example, depending on the facts, this could be one of those rare cases where you d file a state report but not a Data Bank report. Querying clarification Although the NPDB s Guidebook revisions focus primarily on adverse action reporting, they include an important and surprising clarification on the querying front. The updated Guidebook specifies that organizations must query the NPDB every two years and additionally each time a physician submits a request that would alter his or her standing in the organization including cases where the physician seeks medical staff appointment without clinical privileges (e.g., admission to the honorary medical staff). Many people thought you only had to query when you were granting clinical 8 HCPRO.COM 2016 HCPro, a division of BLR. 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

9 Credentialing Resource Center Journal privileges, and not when you were just granting appointments, so that has been a substantial change for a lot of medical staff offices, says Ballard. Given the per-document cost of querying the NPDB, stepped-up querying related to the clarification may have a modest financial impact. Is it out of control? Absolutely not, Ballard assures. Variable discussion Although the updated Guidebook has universal implications for peer review, it has garnered variable attention from implicated disciplines. The expanded reporting criteria have piqued the interest of and prompted action from Shulman s and Ballard s clients. There s a greater tendency to report things for relinquishments of privileges, or resignations that probably in the past would not have been reported, Shulman says. I think medical staffs are being more conservative about that in light of the definition of investigation, which is broader than it was. Although Ballard can t point to hard evidence that reporting rates have risen in the past year, she says the latest Guidebook s debut has generated additional discussion and renewed focus on best reporting practices. What I am seeing is a heightened awareness by the hospitals and their medical staffs that perhaps they should be reporting things that they have not reported previously, she explains. However, the reaction in the MSP community has been considerably more muted, according to Warstler and Wilson. I would have thought that there would have been more buzz about these changes, especially considering that they impact all of us, says Warstler. I think more needs to be done to educate medical staff leaders about the changes. (See the sidebar on p. 6 for educational approaches and other reporting strategies.) Wilson attributes the scanty discussion to the update s limited implications for the regular workflow. I think it was a good thing for [the NPDB] to do, but I just don t think it impacts that much on the day-to-day basis. Looking past the tweaked wording and the moderate adjustments in reporting latitude, the latest Guidebook embodies classic tenets of reporting. You have to know when there s something right and there s something wrong, even when you can t sometimes put it down on paper, Wilson says. And I don t think that element has changed, and so I don t think that there s been a big uproar among our profession. But while the Guidebook update may have minimal implications for daily workflow, Ballard anticipates that conversation will spike when medical staffs encounter their first reporting quandaries under the revised guidance. You definitely have to deal with it every time one of these situations comes up. Preserve collegiality In attempting to grow reporting rates, the NPDB may have exacerbated a long-standing sticking point with quality reporting: upholding collegiality in the peer review process. Reporting requirements do have a chilling effect on properly conducted peer review in many instances, says Shulman. If you expand the reporting obligations, or the new definition of terms like investigations, you broaden the scope of the reporting laws and make it harder to do collegial peer review. Although he says this unintended consequence doesn t invalidate reporting, it does disrupt an approach that has long been used to increase practitioners receptiveness to performance improvement and, by extension, to promote quality care and patient safety. But while medical staffs may not be able to completely compensate for regulation-driven declines in collegiality, they can make some headway by adopting a thoughtful approach to imposing temporary restrictions, suspensions, and other measures that could have reporting implications, says Shulman. Whenever possible and appropriate, seek alternative means to realize performance improvement goals, but at the same time, never nix an effective course of action for fear of triggering reporting requirements. Although we all recognize that everybody cares about whether a matter is a reportable event or not, their peer review decisions and credentialing decisions should not be driven by whether a matter is going to have to be reported to the medical board or the Data Bank, says Shulman. They should be driven by basic care considerations and doing that which is reasonable and warranted to establish and enforce appropriate professional standards and performance and to protect patients. H 2016 HCPro, a division of BLR. 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 HCPRO.COM 9

10 Credentialing Resource Center Journal August 2016 Quick Q&A Employed physician credentialing 101 Q Must employed physicians be credentialed and privileged? AThe simple answer is yes, they must be credentialed and privileged if their employment requires them either to hold membership on a hospital medical staff or to be granted privileges by the hospital. One possible exception is this three-part consideration: (1) the physician is 100% in an ambulatory setting, (2) the practice site is a health system corporation with its own unique (non-hospital) CMS billing number, (3) the physician does not require any hospital-based privileges. That said, it is still best practice and the most efficient use of hospital resources to have a single, unified process to handle all employed physicians. Q Are employed physicians subject to a special set of criteria? A No. An employed physician must meet the same standards that everyone else must meet. H EDITOR S NOTE This Q&A was adapted from The Medical Staff s Guide to Employed Physicians by William K. Cors, MD, MMM, CPE, FAAPL, chief medical officer of Pocono Health System. For more information or to order the book, visit CRCJ coverage in action Forevermore references save time and brain power Editor s note: After reading the lead story in the June issue of CRCJ, Long live the reference, Mary O Donnell, CPCS, medical staff coordinator at Lakeview Medical Center in Rice Lake, Wisconsin, was inspired to share her initial challenges and ultimate triumphs with implementing forevermore references, also called forever or evergreen references, in her small community hospital. About four years ago, we (and when I say we, I mean me, as I am a one-woman office) instituted evergreen letters. The evergreen serves as a verification of privileges and as a clinical reference. On our evergreen form, the department chair completes the evaluation section, and I complete a general information section. Share your story Has recent CRCJ coverage resonated with you? Whether you ve debuted a new policy, soothed a chronic pain point, or reinvigorated a stagnant process, we want to hear about it. stories, strategies, and sample tools to Editor Delaney Rebernik at drebernik@hcpro.com, and you could see your contributions featured in an upcoming issue. Once the evergreen form is completed, I run a query of the given practitioner s activity for the previous 24 months or for the time period he or she was on staff (whichever is shorter) and store that information with the evergreen along with the most current privilege form. At first, the chairs questioned why they should do this, but they embraced the idea after I explained that not having to answer multiple reference requests would save them time in the long run and that they (or the future department chair) would not have to try to recall years from now how the practitioner in question performed. Not only does an evergreen save the department chairperson time and brain power, but it benefits me, as well. Reference requests are returned by fax in a matter of minutes a big improvement over sending a paper request to a department chair and waiting for its return. H Sample forevermore form Access a copy of Lakeview Medical Center s evergreen reference template in the Credentialing Resource Center s Resources Library ( policies-and-procedures). 10 HCPRO.COM 2016 HCPro, a division of BLR. 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

11 Credentialing Resource Center Journal The MSP s voice by Sheri Patterson, CPCS Lessons from the road: Taking the reins and inspiring change as an interim MSO director I was sitting in my office one day, thinking about how little of this fine country I ve seen and wondering what it would be like to travel the interim staffing train. You know, see the United States, network with my fellow MSPs, be the rider on the white horse who saves the day. The picture in my mind was colored with excitement, possibilities, challenges, and, yes, hard work. But even with this balanced outlook, things didn t pan out quite as I anticipated when I finally took the leap and joined the interim workforce. During my first medical staff office (MSO) interim director assignment and every one thereafter I learned the following unexpected, albeit critical, lessons about leadership, teamwork, and process improvement. Venture outside of your comfort zone Walking into an MSO as either an interim or permanent director presents many challenges that we often (incorrectly) assume we must tackle alone. After all, people are counting on us to know how, why, and when to act. This expectation often drives us to dig into our bag of experiences, skills, and education, and pull out what is familiar to us without really thinking through what may be comfortable or palatable to our new team and to the medical staff. This was my initial impulse, and although I was feeling comfy, my staff was squirming. For example, prior to my first interim director assignment, I had organized a file the same way for years, arranging the materials in the order that medical staff leaders would read them during application review. In contrast, my new team organized the file according to the input flow of their software. Although I was not happy, the MSPs and their medical staff leaders were used to this format, so I left my comfort zone and way of thinking to learn their method. In this business, there are different roads one can take to reach the same destination. Keeping an open mind and being willing to compromise may be the best way to improve satisfaction, collaboration, and productivity. Hold a staff meeting to learn more about your team After our disparate approaches to file organization came to light, I scheduled a meeting with my new team to learn more about their current dynamic and processes. During the meeting, I posed the following questions: How long have you been together as a team? Who has the most tenure and experience, and who has the least? What aspects of the medical staff services profession do you particularly enjoy? What are your strengths and weaknesses? What do you hope to accomplish in your career? What are your ideas for improvement and/or change in the office? The meeting was very productive: I found out that some of the staff were assigned to tasks that they did not enjoy and that they felt weren t using their talents to full effect. We looked at the workload together and came up with a temporary rotating schedule that served two purposes: 1. Allow staff to test an array of functions and discover the roles best suited to their interests and expertise. 2. Support the MSO s long-term sustainability. I am a strong believer in cross-training to cultivate a team whose members have diverse knowledge and, should the need arise, the ability to take over any number of processes HCPro, a division of BLR. 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 HCPRO.COM 11

12 Credentialing Resource Center Journal August 2016 The MSP s voice by Sheri Patterson, CPCS (continued) Once everyone became familiar with each aspect of the office, we settled into roles that best fit each staff member s experience, talent, skill, and fun factor. Introduce yourself to key departments Shortly after joining a new team, I reached out to those in hospital administration, quality/risk, human resources, health information management, provider enrollment, and clerical roles. Because MSOs in many organizations collaborate closely with these departments and professionals, it s critical for new directors and managers to build good working relationships as soon as possible. Try to make this happen within the first couple weeks of your arrival. Take a notepad and jot down names and extensions. Ask some important questions like: What projects and/or goals are you working on that involve the MSO? What contributions do you see my team making? Are there resources and/or tasks that the MSO can share to lighten our load and budget? What challenges do current MSO processes present? How can the MSO better collaborate with your department? What changes would you like to see moving forward? Although you may not like the answers to some of these questions, the feedback will provide wonderful insight into strengths and opportunities for your staff. Creative thinking and teamwork can make everyone s life easier, and understanding current challenges and frustrations is the first step in developing more effective, efficient processes. Make the time to meet and greet medical staff leaders Ensure this interaction fits into their schedule. Because medical staff leaders are always on the move, demonstrate respect for their time and appreciation for their contributions. With this in mind, I met with leaders in their (limited) off time and in a place that was convenient for them typically their office, clinic, or lounge. Reaching out in this way allowed me to engage the leaders in my team s work, to emphasize that I valued their time and what they had to offer, and to ask some important questions: Is the medical staff currently dealing with any issues that require prompt action? If so, how do you see us proceeding? Do you have any frustrations with the MSO that we can work together to alleviate or improve? Are there any changes you would like to see occur in the MSO? How can the MSO better collaborate with and serve the medical staff? Take small, purposeful steps to achieve longterm results When we walk into an office for the first time as a director, a staff member, an auditor, or an educator, the initial steps toward making meaningful change are often listening, gathering information, and, if necessary, stepping out of our comfort zone to make others feel at ease. Similarly, fostering harmony and driving progress in the MSO are often the culmination of several simple, albeit strategic activities: Seeking the contributions of your team, administrative departments, and medical staff leadership Respecting colleagues schedules by producing timely, organized presentations Taking moments out of your day to patiently educate and explain issues that are unclear Saying those two little words, Thank you, with a smile H EDITOR S NOTE Patterson is a credentialing specialist at Yavapai Regional Medical Center in Prescott, Arizona. 12 HCPRO.COM 2016 HCPro, a division of BLR. 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