Medical Staff Briefing

Transcription

1 A training resource for medical staff leaders and professionals Medical Staff Briefing Volume 24 Issue No. 7 JULY 2014 P5 P7 P9 P11 Highlights of the MSP Salary Survey The 2014 results showed little movement in terms of income, but new questions shed some new light on MSPs responsibilities and chains of command. Drilling down into expirables Is a trip to the dentist preferable to the task of tracking expirables? Neither activity is enjoyable, but both are vital, write columnists Patricia A. Furci, RN, MA, Esq., and Samuel J. Furci, MPA. OPPE data and hospitalists The cofounder and past president for the Society of Hospital Medicine shares his views on how OPPE can be best utilized in the future. Disclosing medical errors Disclosing a medical error to a patient might not be required by law in your state, but there are compelling reasons to do so anyway, says William K. Cors, MD, MMM, FACPE. Regulatory issues CMS has reversed itself on unified medical staffs for multi-hospital systems. Now what? CMS final rule allowing multihospital systems to have a unified, integrated medical staff goes into effect this month. As with other Condition of Participation (CoP) modifications, changes won t happen overnight, and the long-term ramifications for medical staffs aren t clear. The rule could result in streamlined medical staff administration at sites that decide to adopt a unified model, but it will raise questions for a lot of organizations. Medical staff leadership as well as MSPs must be prepared for the unification question, according to several MSB sources. Under the final rule, which was announced in May, no hospital system can unilaterally impose a unified medical staff across the entire organization: Each hospital medical staff in the system must vote on the option, and the vote to unify must be a majority in order to take effect. This revision marks an about-face from CMS earlier position on unified medical staffs. Its previous interpretation of the Medical Staff CoP at was that each hospital must have its own independent medical staff, despite the arguable ambiguity of the regulatory language, CMS noted in the Federal Register regarding the final rule. The reversal is a step in the right direction, says Robert W. McCann, Esq., partner at Drinker Biddle and Reath, LLC, in Philadelphia. The unification of medical staffs makes sense as hospital systems evolve to handle the elements now under the umbrella of healthcare reform including population health management, clinical integration, and other things. I think you had to predict that this was going to happen, McCann says. But there s still obviously a lot of ambiguity there. I ll be curious how much flexibility surveyors give hospitals to implement these rules. For example, in order to have a unified medical staff, CMS requires hospital systems to have an appropriate means for all physicians in all facilities to have a voice

2 Medical Staff Briefing July 2014 in the medical staff. There are a lot of ways you can do that. It suggests to me that CMS may be looking for some representational form of governance to ensure that there s a seat for every facility, he says. That s not unreasonable, that s a way to create a representative governance structure, but it s probably not the only way. Even if facilities aren t immeidately effected by the CMS ruling, it should at least start a discussion among medical staff leadership about priorities and whether unification is worth pursuing, says William K. Cors, MD, MMM, FACPE, chief medical quality officer at Pocono Health System in East Stroudsburg, Pennsylvania. Just because CMS says you CAN do it, that doesn t mean you HAVE to. The discussion has to be, are we okay with the way things are, or do we need to look at change? And if we need to look at change, how are we going to evaluate our bylaws and our documents and our governance structure? says Cors. Getting a read on medical staff If I m an executive at a hospital who doesn t already have a read on what my medical staff might be thinking about a unified staff, I d start communicating with them to see if there s a feeling one way or the other, says Sandra DiVarco, BSN, RN, JD, partner at McDermott Will & Emery, LLP, in Chicago. Hospital systems that are interested in unification may want to query individual medical staffs to find out if there is support or opposition, and why. Internally, each organization will have to evaluate whether or not its goals and processes would support having a unified approach, and to some merging among operations, says DiVarco. Medical staff leadership must also explore any cultural issues when determining whether a unified approach is something that might work. And if there is an interest among the medical staff, hospitals must also determine whether they have the legal and administrative reources in place to make the transition happen, she says. Medical staff leadership must be involved in these discussions to have a voice in determining how unified and integrated the staff will be, Cors says. There will be questions: Do we put all [medical staff operations] together, or just pieces? For example, are 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 Product Manager, Digital Services Adrienne Trivers Follow Us Managing Editor Mary Stevens Follow and chat with us about all things healthcare compliance, management, and Alpesh N. Amin, MD, MBA, FACP Executive Director Hospitalist Program Vice Chair for Clinical Affairs & Quality Dept. of Medicine University of California, Irvine Michael Callahan, Esq. Katten Muchin Rosenman, LLP Chicago, Illinois William K. Cors, MD, MMM, FACPE Chief Medical Quality Officer Pocono Health System East Stroudsburg, Pennsylvania Jack Cox, MD, MMM Senior Vice President / Chief Quality Officer Hoag Hospital Newport Beach, California Sandra Di Varco, BSN, RN, JD McDermott Will & Emery, LLP Chicago, Illinois Roger A. Heroux, MHA, PhD, CHE Founding Partner Hospitalist Management Resources, LLC HMR ED Call Panel Solutions Pensacola Beach, Florida Jonathan Lovins, MD, SFHM Hospitalist and Assistant Clinical Professor of Medicine Duke University Health System Durham, North Carolina Sally J. Pelletier, CPMSM, CPCS Senior Consultant and Chief Credentialing Officer The Greeley Company Danvers, Massachusetts Richard E. Rohr, MD, MMM, FACP, FHM Director of Hospitalist Programs Guthrie Healthcare System Sayre, Pennsylvania Jodi A. Schirling, CPMSM Alfred I. dupont Institute Wilmington, Delaware Richard A. Sheff, MD Principal and Chief Medical Officer The Greeley Company Danvers, Massachusetts Raymond E. Sullivan, MD, FACS Waterbury Hospital Health Center Waterbury,Connecticut Medical Staff Briefing (ISSN: [print]; [online]) is published monthly by HCPro, 75 Sylvan St., Suite A-101, Danvers, MA Subscription rate: $389/year or $700/two years; back issues are available at $25 each. MSB, P.O. Box 3049, Peabody, MA Copyright 2014 HCPro, a division of BLR. All rights reserved. Printed 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 Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call or fax For renewal or subscription information, call customer service at , fax , or customerservice@hcpro.com. Visit our website at Occasionally, we make our subscriber list available to selected companies/vendors. 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3 July 2014 Medical Staff Briefing we going to continue to have an individual medical staff services department that is just going to do credentialing and privileging for one site, or does it makes sense to have one central corporate credentialing and privileging service that can do it for all the hospitals? he says. These are fundamental decisions that medical staffs needs to be involved in. More questions than answers Despite CMS earlier interpretations, some facilities were pushing the envelope and were already unifying some aspects of their medical staff, according to DiVarco. Now a lot will be more interested in it. There are some systems I can think of where having a unified staff would not work, but there are others that in the past have queried CMS to see if they could have something like that, she says. If some systems are ready to unify and integrate medical staff, others will no doubt take a wait-andsee approach, looking to the experiences of other organizations after the rule goes into effect. I think operationally it s going to be very interesting, says Libby Snelson, JD, Legal Counsel to the Medical Staff in St. Paul, Minnesota. She also sees more questions than answers. For example, if two medical staffs in a six-hospital system vote to unify and four don t, is the system better off with five different medical staffs instead of six? The other thing I leapt to immediately is, how does this work across state lines? says Snelson. Will the [unified, integrated] medical staff in Minnesota be recognized by the state of South Dakota, where the hospital system is licensed? It will be interesting to see what the state licensing [boards] sort out. McCann posed another possible scenario: If you have a unified structure now, do you have to go back and take a vote if you didn t actually do that before? You could fairly read the regulations to require that, he says. A tremendous step forward Despite the looming questions and issues, Cors says it s about time CMS allowed unified medical staffs across systems. The ability to standardize and use one credentialing and peer review process that can be best practice-based, centralized, and adopted locally for each hospital, to me, is a tremendous step forward, says Cors. And it s long overdue. Further, the regulations don t present an either-or situation. For example, even if a hospital system had a single, unified medical staff, credentialing and privileging could be handled by a central corporate office that could also be tailored to have a credentials committee in each hospital that would receive information and comment on physicians who are going to practice at that one hospital, Cors says. The final rule also prevents unilateral decisionmaking, says DiVarco. [If] a system elects to have it, then the medical staff would vote to do it or not to do it. In many ways, the ultimate decision may land with medical staff. At least there s the option for those systems that are looking toward or are in other ways very integrated and have a good amount of integration with their physicians. For these systems, an integrated medical staff is a logical next step and they probably already have the tools in place to manage that. However, hospitals must understand that unifying and integrating into a single medical staff will add an additional process layer, DiVarco says. Even with a unified medical staff among facilities, hospital systems must provide assurances that all medical staff members still have a local voice and local representation. Not all those processes are going to go away. I think any notion that having unified staff is going to make things easier on the hospital level [is a misconception]. You ll still need to ensure that local needs and local communities are addressed, she says. Unification does offer potential advantages, such as collaboration for things like peer review, DiVarco adds. If you re a hospital system that has two facilities in close proximity and physicians [who are privileged to work] at both, in some cases it makes sense to have a collaborative peer review process, she says. Unified, integrated medical staffs might therefore come to smaller systems first, according to DiVarco. Snelson agrees: I can see it being implemented most rapidly in those smaller, regional, and within one-state systems. But how many systems are in one state? The larger systems might look at doing something more regional rather than national, DiVarco says. Internally, each organization will have to evaluate whether its system s goals and processes would support 2014 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 Medical Staff Briefing July 2014 having a unified approach; and agree to some merging among operations. If and when the issue of unification arises in their organization, medical staff leadership and management must look at how unifying and integrating the medical staff would affect their facility s daily operations; what should stay at the local level, and what could be unified, say Cors and DiVarco. If the organization doesn t want to unify, then the medical staff leadership would need to figure out if unification is something it would want to lobby for, says DiVarco. It s all local Many systems will welcome the clarification because a lot of organizations have been looking to create some amount of greater unity within their medical staff structures, McCann says. The thing that most strikes me about all of this, and the reason I think recognizing the possibility of a unified medical staff is a good thing, is that this is all very local, the same way they say all politics is local, he says. This is kind of political. The culture and history of some organizations make it easy to have unified medical staff, and the culture and history in others will make it impossible to have. If the medical staff and hospitals have come up with a structure that they think is workable, and if there s some assurance that this is, in fact, a collaborative decision, that should be a good indicator that the needs of the physicians are being met, McCann adds. In the next go-round with some of our clients, we ll be talking to them about [options to ensure] they have something that will look good to a surveyor. It s always good to have another impetus to take a look at governance and make sure your processes are what you need and what you want, he says. Like a lot of CoPs that have shifts like this, the effects won t be understood until hospital systems start to implement unified medical staff models, and systems start to see how these models are received by CMS, DiVarco says. This is the sort of thing I can imagine [will engender] some interesting interpretive guidelines. I can also see this being one of those CoPs where it takes a while for CMS to get the interpretive guidelines out, she says. CMS has thought through a way for hospitals to adopt a unified medical staff that would involve both the system and the medical staff and included four provisions that must be taken into account (see sidebar, p. 4). But how surveyors are going to look at it, what Provisions for a unified medical staff CMS revised Conditions of Participation ( (b)) allowing a unified, integrated medical staff includes provisions that hold a hospital responsible for showing that it actively addresses use of a unified and integrated staff model. These provisions ensure: (1) All medical staff members who are privileged to practice at separately certified hospitals in a system vote, by majority and in accordance with medical staff bylaws, either to accept a unified medical staff structure according to provisions in the medical staff bylaws; or to opt out of such a structure and maintain a separate, distinct medical staff for their respective hospital. (2) The unified, integrated medical staff has bylaws, rules, and requirements that describe its processes for self-governance, appointment, credentialing, privileging, and oversight, as well as its peer review policies and due process rights guarantees, and which include a process for the members of the medical staff of each separately certified hospital to be advised of their rights to opt out of the unified, integrated medical staff structure after a majority vote by the members to maintain a separate and distinct medical staff. (3) The unified, integrated medical staff is established in a manner that takes into account each hospital s unique circumstances, and any significant differences in patient populations and services offered in each hospital. (4) The unified and integrated medical staff gives due consideration to the needs and concerns of members of the medical staff, regardless of practice or location, and the unified and integrated medical staff has mechanisms in place to ensure that issues localized to particular hospitals are duly considered and addressed. 4 HCPRO.COM 2014 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 July 2014 Medical Staff Briefing they re going to look at, what indicia they re going to look at [remains to be seen], DiVarco adds. Cors acknowledges that some members of individual medical staffs and possibly hospitals as well may fear loss of local control or autonomy. Anytime you have change, somebody s going to be fearful that they re going to lose something in the process, he says. However, standardization is where things are heading, he adds. Frankly, I d like to spend my time managing the best practices for peer review for all five hospitals at once, rather than managing four or five different medical staffs under one corporate umbrella. H 2014 MSP Salary Survey More responses yield clearer pay picture The 2014 MSP Salary Survey included additional questions related to administration and management in our continuing bid to get a better understanding of today s MSSD and the organization in which it operates. The takeaway: Even as higher-level salaries seem to stay the course, the MSSD is performing far more than traditional credentialing and privileging tasks, although those are still front and center for most MSPs. For 2014, the upper salary choice was raised to more than $100,000, parsing the higher-paid MSPs somewhat from previous years. The new higher choice netted close to 7% of all respondents. (See Figure 1.) Although the 2014 survey had more respondents than the 2012 and 2013 editions, statistically, the 2014 salary responses remained very close to MSP Figure 1: What is your current salary range? > $100,000 $70,001 $100,000 $60,001 $70,000 $50,001 $60,000 $45,001 $50,000 $40,001 $45,000 $35,001 $40,000 $30,001 $35,000 < $30,000 Source: 2014 MSP Salary Survey 5% 10% 15% 20% 2014 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 Medical Staff Briefing July 2014 Salary Survey results from last year and The number of survey respondents who make less than $30,000 is inching downward, from approximately 5% in 2012 to 3% in 2014, while those making $30,001 $35,000 increased slightly during the same time period. Although we added options and questions to accommodate credentialing professionals in as many venues as we could, the vast majority of respondents work in hospitals. Nearly a third have experienced an expansion in their MSSD in the past three years. In addition to asking about respondents education level, we asked if they had a clinical background or degree. Just under 10% said they did, and nursing was the most-named clinical background. Supervisors Forty-eight percent of respondents said they supervise MSPs, credentialing specialists, or others. (See Figure 2.) Among those who supervise, 10% said they supervise 0.5 to one person (full-time equivalent); 21% supervise one person, 19% supervise two, and 22% supervise three to four people. Close to one-third of respondents oversee other departments or services, and 48% of these respondents said they oversee continuing medical education. Provider enrollment (21%) and graduate medical education (16%) rounded out the top three choices. Yet these choices were eclipsed by the Other category, which drew a 49% share. Services and departments mentioned most often in the Other column included medical library, institutional review board/irb, peer review, and administration. (Respondents could make multiple selections.) The chain of command If you re like 43% of all survey respondents, your department reports to the chief medical officer/vice president of medical affairs. (See Figure 3.) Another 28% report to the CEO/administration, and 12% said their department reports to the chief quality officer/ quality department. In the Other category for this question which took 17% of responses directors of human resources, nursing, and clinical and medical directors were Figure 2: Do you supervise others? 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Source: 2014 MSP Salary Survey Yes No N/A Figure 3: To whom does your department ultimately report? CMO/ VP Medical Affairs CEO/ Administration CQO/ Quality Dept. Other 10% 20% 30% 40% 50% Source: 2014 MSP Salary Survey 6 HCPRO.COM 2014 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 July 2014 Medical Staff Briefing mentioned. Chief of staff, chief operating officer, and chief financial officer were also mentioned multiple times. If MSPs titles vary, the titles of the office to which they report are also disparate. Accreditation The Joint Commission still reigns as the top accreditor by a wide margin and its dominance held steady from previous years. Nevertheless, the 2014 survey provided a sharper accreditation picture in The Joint Commission s shadow. Survey participants could make multiple selections, as in past years, but had a wider variety of possible choices in 2014, including CIHQ, CMS/state survey only, and CMS/state survey/voluntary. (See Figure 4.) The result was a smaller Other category in 2014: 6% versus 13% in 2013, and 11% in H EDITOR S NOTE The 2014 MSP Salary Survey was open for 30 days ending April 18, and received 803 complete responses. Values were rounded to the nearest whole number; values of 0.1 to 0.4 were rounded down; values of 0.5 or higher were rounded up. Figure 4: Which organization accredits your facility? 80% 70% 60% 50% 40% 30% 20% 10% 0 AAAHC CIHQ DNV-NIAHO HFAP The Joint Commission NCQA URAC CMS/state survey only CMS/state survey/voluntary Other Source: 2014 MSP Salary Survey Credentialing A closer look at the management of expirables By Patricia A. Furci, RN, MA, Esq., and Samuel J. Furci, MPA Trying to get MSPs excited about their role in managing and traking expirables is like trying to make a trip to the dentist sound like it will be fun. Actually, a trip to the dentist might be more exciting but let us not digress. Credentialing documents that are considered expirables include: Licenses to practice Board certification Drug Enforcement Agency (DEA) certificates Controlled dangerous substance certificates when required by state law Professional liability insurance Other certificates required by the organization or by state law The work required to manage expirables can be considered mundane, but it s also absolutely necessary. There are, however, some options regarding what documents an organization should consider to be an expirable for the purposes of the credentialing process. Organizations should also consider the details of documents that they 2014 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 Medical Staff Briefing July 2014 determine to be expirable. In this article we discuss some of the important aspects of expirable documents. We ll also explore how effectively managing these documents may benefit an organization by improving the overall credentialing process. So, as the dentist says, Now, sit back and relax. This won t hurt a bit. What to require and what to track Most organizations do not allow practitioners to continue to provide care when their license has lapsed. They might not be as stringent about other requirements. Too often a practitioner is allowed to continue to practice when his or her DEA, insurance, and/or board certification (if required by the organization) has expired, Sally J. Pelletier, CPMSM, CPCS, wrote in Credentialing Resource Center Insider, May 31, Regardless of whether or not a practitioner has an expired DEA or controlled dangerous substance registration/certificate, if both are required by state law or by the medical staff bylaws in order for practitioners to have a complete application, then practitioners should not be allowed to practice until all the lapsed credentials are renewed. Organizations may provide a caveat that allows practitioners who have lapsed DEA or controlled dangerous substance registration/certificates to remain on staff (via a voluntary leave), but allowing a practitioner to continue to practice without ordering any medications (or controlled substances) is not an option if you are Joint Commission certified (see The Joint Commission Medical Staff standard ). Furthermore, DEA and controlled substance registration/certificates must be from the state in which the practitioner practices. If a practitioner practices in more than one state, he or she needs a DEA certificate for each state. If a controlled dangerous substance certificate/registration is also required by the state, that documentation also should be state-specific and include the same address for the practitioner as the DEA certificate, according to the DEA Office of Diversion Control. Check state laws to be sure. With regard to licensure, we recommend, as a best practice, that primary source verifications be done on all licenses when a practitioner is licensed to practice in more than one state. In the case of a nurse practitioner (NP), both the RN and the NP licenses should be tracked and primary source verified. Although actual copies of licenses may no longer be required in most states, it is important to check state law because there may be exceptions. Proof of professional liability insurance coverage can be provided by a copy of the policy face sheet. This document contains the name of the insured, the term of the policy, and the policy limits (per occurrence and aggregate). It is also important that the face sheet include a description of practice locations or reflect the name of a system as opposed to one facility. This is especially important in multicampus systems. Board certification Verifying board certification might seem to be a straightforward process, but on occasion, an issue may arise that can present a more complex credentialing issue. One such issue is when an organization requires practitioners to be board-certified if a practitioner has more than one board certification, credentialing decisions can become less clear-cut. For example, if a cardiologist was board-certified in both internal medicine and cardiology, but his or her cardiology board certification had lapsed and the scope of his or her practice was primarily cardiology, it could be viewed as negligence if the practitioner is allowed to continue to have cardiology privileges. If such requirements are not noted in the bylaws, the practitioner could argue that he or she meets the requirements of board certification. Another example is the situation when a practitioner changes scope of practice such as when an NP who specialized in geriatrics changes his or her scope of practice to orthopedics. Even if there is no recognized pathway for such a change, the organization s allied health policy (AHP) or medical staff bylaws should require the practitioner to declare the change in scope in advance and to follow an approved pathway by the organization. It is important, therefore, for medical staff bylaws or AHP policy to specify that practitioners maintain board certification within a specialty that reflects the scope of their practice. Anything less can create a host of credentialing problems. 8 HCPRO.COM 2014 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 July 2014 Medical Staff Briefing While many organizations track the expirables noted above through their MSSD, consistency varies when it comes to tracking expirables considered to be in the other category. Examples of those that might fall under the other category include: Mantoux tuberculosis test results or attestation (i.e., purified protein skin test) Individual health status (via a physical exam or attestation) Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS), Advanced Trauma Life Support (ATLS), and Pediatric Advanced Life Support (PALS) We have found the tracking of practitioners for annual Mantoux tests or attestations for those with a positive history are not uncommon, while individual health status updates are often limited to the reappointment process every two years. Some organizations require annual reappointments for senior practitioners; however, this is not a common practice. If your organization does not require senior practitioners to be reappointed annually, initiating a requirement for an annual physical exam for senior practitioners is worthy of consideration. We have found active certifications for BLS, ACLS, ATLS, and PALS are sometimes not included as expirables. However, when required by an organization or state law to fulfill specific privileges (such as moderate sedation), they should be included as an expirable and tracked accordingly. Bylaws and AHP policy statements should provide clarity and guidance for MSPs and practitioners to ensure uniformity in the requirements for maintaining current credentialing documents. This may also include placing the onus on the practitioner. In the end, however, the MSPs involvement is both unavoidable and crucial. Much like that periodic trip to the dentist. H EDITOR S NOTE The authors are principals at Furci Associates, LLC, in West Orange, New Jersey, specializing in management and personnel assistance in medical staff offices in vari ous settings. Furci Associates provides an array of management consulting services to healthcare organizations addressing complex regulatory compliance issues, including plans of correction to multiple state and federal agencies as well as The Joint Commis sion, AAAHC, CMS, OCR, OSHA, NCQA, and URAC. They can be reached at info@furciassociates.com. The impact of OPPE on hospitalists and team-based care The cofounder and past president for the Society of Hospital Medicine shares his views on how OPPE can be best used in the future It s been six years since The Joint Commission released requirements regarding OPPE and FPPE, which serve as a mechanism for hospitals to regularly evaluate the competency of physicians that hold hospital credentials or privileges. The two peer review requirements are credited with altering the landscape of physician evaluations. Instead of simply reviewing a physician s performance every two years upon recredentialing, hospitals are required to look at physician quality data on an ongoing basis, which allows the medical staff to take immediate steps to identify quality concerns with physicians and improve performance measures. OPPE can also lead a hospital to initiate its FPPE process, which takes a deeper dive into the quality issues linked with a certain physician and explores ways to eliminate those problems. Although both OPPE and FPPE have become commonplace in every hospital across the country, many are still trying to figure out how to effectively use them. In fact, some experts have argued that OPPE may be used ineffectively, particularly when a physician s privileges are on the line. In an article published in the January issue of The 2014 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 Medical Staff Briefing July 2014 Hospitalist, Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners located in Darien, Connecticut, assistant professor of medicine at the University of Massachusetts Medical School, and cofounder and past president of the Society of Hospital Medicine, argued that OPPE is directional at best for most hospital physicians, and particularly hospitalists. The problem, he notes, is that OPPE data is not always credible because it can t always be linked to one specific physician. This is especially the case for hospitalists, who are rarely assigned to a single patient for that patient s entire hospital stay. As healthcare moves toward a team-based care approach, it s becoming more difficult to link physicians to specific quality care measures, Whitcomb says. Currently, nurses, therapists, pharmacists, and many other medical specialists all play an important role in the care of the patient and contribute to the quality metrics that are frequently measured by the hospital. If you re an individual physician, outcome measures associated with your patient, such as readmissions mortality, and even other outcome measures like infections, falls, or pressure ulcers, it s not a perfect science because you re attributing an outcome to a single member of a very large healthcare team, Whitcomb says. If you looked at the number of healthcare professionals that are involved in a patient outcome whether that s a good or bad outcome, or a mixed outcome it would literally be in the hundreds. Although Whitcomb says he agrees with the idea of measuring physicians in a rigorous way to improve quality care, translating the OPPE program into actual practice has proven difficult. In his article in The Hospitalist, Whitcomb shared some of the data from his most recent OPPE report card, including readmissions, resource utilization, and mortality. The statistical feedback was helpful in making small adjustments to his practice, but he also recognized that he was just one part of a team of healthcare practitioners involved in the care of each patient. My mortality rate may be high, but how much of that can I really control myself? he says. My readmission rates are low, but how much of that did I play a role in and how much of that did all the other members of the team play a role in? And that s the bigger challenge we face as we move to more teambased care. We re not looking at physicians as lone rangers or solo agents working with patients. Using OPPE data for hospitalists Whitcomb argues that hospitalists are particularly vulnerable to this variability in OPPE data because they rarely follow a patient during his or her entire hospitalization. Instead, a patient will often receive care from multiple hospitalists throughout the course of his or her stay. That said, any specialist is most likely going to be sharing responsibility for hospitalized patients with their partners, he notes. It s not just hospitalists, but intensivists, cardiologists, pulmonologists, and surgeons. That s why we run into this problem of attribution and attributing an outcome to an individual physician. The problem arises when hospitals make credentialing and privileging decisions based on data that can t be directly attributed to a physician, Whitcomb says. For that reason, hospitals need to be able to fall back on other data sources that are more closely tied to that physician in order to justify any adverse credentialing or privileging decisions. In the case of surgical site infections, you could say that if a surgeon has been observed not complying with hand hygiene practices repeatedly, that would be an example of a situation where you have additional information, he says. Developing a fair FPPE process In some instances, physician quality data collected through the OPPE process triggers FPPE for a more investigative look at potential patient safety issues. This can lead to corrective action or physician monitoring when necessary, or suspension or denial of medical staff privileges in more drastic cases. Although The Joint Commission offers basic requirements for FPPE, each hospital varies in how it conducts physician evaluations. But what many hospitals and physician leaders are still trying to work out, even six years after OPPE and FPPE came into play, is how to make the FPPE process truly fair, says Whitcomb. 10 HCPRO.COM 2014 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 July 2014 Medical Staff Briefing I think for FPPE to be fair, you need to be able to draw a line between processes of care that the physician in question is engaged in and outcomes of care that the physician is responsible for, he says. The best example is not complying with hand hygiene, because we know that s the single best way to prevent healthcare-associated infections, including surgical site infections, but there are plenty of others. I would go on to say that FPPE has to give the physician a reasonable opportunity to respond to remedial treatment. Mixing process and outcome measures There is some general concern within the hospitalist community about how OPPE and FPPE data will be used going forward, Whitcomb says. Although information derived from the OPPE process is helpful in getting to the root of quality issues, those outcome measures should be balanced with process measures that are easier to attribute to one individual. Going forward, Whitcomb believes hospitals should combine process, outcome, and patient experience measures to develop a more comprehensive form of OPPE. In general, if you think of what makes a really good physician, OPPE will need to evolve into domains such as diagnostic skill and accuracy, judicious utilization of resources in general, he says. H Disclosing medical errors, Part 1: Some practical tips by William K. Cors, MD, MMM, FACPE, chief medical quality officer at Pocono Health System in East Stroudsburg, Pennsylvania. This month we continue with a series of practical tips to help medical staff leaders deal with a host of challenges that they may encounter in their roles. The challenges and solutions will be excerpted from the Medical Staff Leader s Survival Guide, a new book to be published by HCPro, a division of BLR, in Danvers, Massachusetts, in September. The material is designed to offer medical staff leaders a quick snapshot of a challenge and solutions that can be implemented to address these challenges. Many organizations, physicians, and insurance companies advocate candid disclosure because it helps providers learn from their mistakes and empowers patients to make decisions based on complete information. When a hospital decides to set a disclosure policy, it must guide its staff on how to inform patients about errors. To address the challenge of having medical staff leaders buy in to such a policy and help their peers do what can be a painful disclosure, we offer a practical, step-by-step process. Ideas will also be offered about what to say during a disclosure conversation based in part on discussion scripts suggested by the American Society for Healthcare Risk Management (ASHRM) for apologizing to patients and sharing information about remedial measures taken in response to errors. Step 1: Why disclose? If you live in a state where disclosure is mandated, the answer is obvious. But what if you don t? Why would you even think of disclosing a serious incident or medical error? There are several things to consider: The idea that physicians should disclose medical errors to patients has grown in importance with the patient safety movement initiated by the seminal 1999 Institute of Medicine (IOM) report, To Err Is Human. The report specified that one of the main goals of disclosure was to enhance patient safety. Physicians have an ethical commitment of honesty to their patients. As fiduciaries for their patients, 2014 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 Medical Staff Briefing July 2014 this involves a commitment to do the right thing for the right reasons for each and every patient. When an error occurs, there is an ethical responsibility to disclose. Interestingly, with properly done disclosure, there was a reduction in professional liability actions for an unexpected outcome. Disclosure also recognizes that there are at least two victims of every medical error: the patient and the provider. Appropriately done, disclosure can be a healing experience for both. Finally, it s really about doing unto others as you would have them do unto you. Step 2: Decide who should participate in meetings Because disclosing medical errors is a sensitive area with potential legal consequences, your organization should carefully consider who should be involved in the conversation. To promote consistency within your organization and to hone communication and interpersonal skills, it s imperative to train staff members who will disclose errors. In addition, your risk manager should always meet with disclosers ahead of time to ensure that they re comfortable with topics such as apologies, requests for money, and remedial actions, without implying or promising more than is appropriate at the time. Step 3: Choose appropriate disclosers Experts agree that the attending physician should participate in disclosure. According to the ASHRM, the attending physician is in the best position to communicate on behalf of the hospital because his or her relationship with the patient is the strongest. Also, physicians can best explain how the error will affect the patient s treatment plan. A physician may handle the disclosure alone or use a team approach. A team approach is helpful if the physician has weak communication or interpersonal skills. To avoid overwhelming patients, the team should consist of the physician and, preferably, just one other person, usually a nurse. This serves two purposes. First, the nurse witnesses the conversation, which may be helpful if a lawsuit ensues. Second, nurses are available at hospitals more often than physicians for follow-up conversations with patients and family members and for discussions about the case with other hospital personnel. Another option is to have a facility medical director, patient services representative, hospital chaplain, physician who consulted on or participated in the patient s care, or another individual involved in the patient s care (such as a pharmacist) accompany the attending physician. The initial disclosure conversation should never include a hospital attorney. Likewise, a risk manager usually shouldn t be involved in the initial conversation. It gives the wrong signal to the patient to involve a risk manager up-front. The point is to express empathy and discuss the impact of the error on the patient s health. A risk manager s presence may give the impression that the hospital is mostly concerned about its liability. An exception to this is the rare occasion when a grievous error has occurred and the hospital is clearly at fault; in such cases, it s appropriate for a risk manager to participate in the initial conversation and broach the subject of settlement. Step 4: Determine who should be present Sometimes it s appropriate to disclose an error to the patient alone. But other times, family members should be present, such as when the patient is not mentally capable of making decisions about his or her care. Because disclosure is such a difficult task, you want to make sure that all the family members with a need to know are present. All the family members should hear the same explanation to avoid misunderstanding. But remember that the patient must give permission for family members to be involved in the discussions. It s also important to determine whether the patient and family members understand the explanation. The shock of hearing about an error in addition to the stress of the illness may make it difficult for them to process the information. Disclosers should gauge from the reactions and demeanor of the patient and family members whether they understand the explanation. If they don t seem to understand, disclosers must decide whether additional family members should be involved or whether to postpone the discussion until a later date. In next month s column, we ll discuss additional steps on disclosing medical errors as we continue this series on practical tips for medical staff leaders. Until then, be the best that you can be. H 12 HCPRO.COM 2014 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