This is What We Live For: Effectively Dealing with Our Most Complex Applicants and Re-Applicants Session Code: MN08 Time: 12:45 p.m. 2:15 p.m. Total CE Credits: 1.5 Presented by: Hugh Greeley
This is what we live for Protect the Patient Facilitate Clinical Practice Support organizational goals Qualified, competent professional staff. (MD, DO, PA, DPM, DDS, APRN) No surprises No Denials No Litigation (at least no losses) No accreditation surprises Great business support for organization Constant improvement in structure and process Qualified and Competent Staff If not qualified, can t be seriously considered. Qualified is a function of the law and bylaws: It is primarily managements job following MS/board rules) Example: A completed and verified application (expand) Licensed Residency trained (off shore) Certified or Admissible (by whom) In a open specialty (kettle of fish) Not economically or otherwise conflicted?? Not bared from Federal programs 1
And Perhaps Not a current or recent felon With an Unrestricted License Willing to support medical staff and hospital mission With an active DEA permit (but not necessary for all) Free of illegal active drug addiction/use?? If not Qualified Deflect at management level No clinical review needed No credentials committee review No MEC review No Denial ( Just let them know they do not qualify to have application reviewed until. Report on these to MEC as demonstration that system is working well. Competent-different than qualified If qualified, competence is determined from References that must be privilege specific Rule of thumb is for at least three (multidiscipline) Define number and type of references for each specialty. (i.e.: if an anesthesiologist we need references from an anesthesiologist, a surgeon, the OR supervisor, an OBGYN) The optional interview, occasionally critical but not mandatory 2
It takes two to TANGO Constantly push the competency equation Performance + Evidence of acceptable quality permits a decision concerning competency. One without the other is unacceptable! Competency equation Performance= patient activity that is identical to or clinical similar to requested privileges. ( If someone has not done bypasses for two years but has good letters of reference the competency equation is not solved. If someone has done lots of bypasses but has poor or no letters of reference the competency equitation is not solved. No Surprises Management must prepare a complete report concerning every applicant for privileges (regardless of profession.) Physician leaders should never identify a significant issue after being presented with an application to review. What, no one told us that this applicant had gone to three residency programs over an 11 year period? or 3
No surprises Had we known that this applicant had been in jail we would have questioned him further. Had we known that she had lost two jobs over the last 13 months that would have raised a flag. Had we known that his board was a self designated certification he wouldn't t have gotten a positive recommendation. Had we known that she had been in a substance abuse program it would have made a difference. No Surprises It would have been nice if we had know about the problems this doctor had had with nurses in his past hospitals. Hey, the OR staff just told us that the new doc had no experience doing complex back surgery, it is a mess now. Wow, had we known that he was among the highest billing Docs in America we might have looked closer at his work and asked for more references. And why didn t we know about his addiction when he applied? No Surprises Well, he had great references and he is a great doc, he had only two settlements but we would have documented our review more carefully if we had known that he had 22 suits in the past three years. This is really bad, his references didn t comment on the fact that she has had no acute care experience in the last three years but she is really not up to speed with acute care practice, we should have known more. 4
No Denials You all know the drill Not qualified, no review and no denial. ( Sorry, your license is restricted and we require an unrestricted license, come back later) (You must not have read our bylaws, we do not accept self declared Boards. When you are certified or admissible by an ABMS, AOA or AAPS board we will be glad to take another look at your application. (exception for certain international boards)) (Unless we are sent references from reputable individuals who are wiling and able to comment on your past performance we can not review your file.) No Denials You qualify for appointment and core privileges but we can not review your request for complex back surgery due to either lack of a fellowship, insufficient experience, or no comments on this area from your references. The kicker: What, you won t review my application. That is simply another way of denying me, I ll sue you!!! Response from the MSP or VPMA--- Take a number, that s why I am paid the big bucks. No litigation No antitrust suits, no corporate negligence suits, no tortious interference in advantageous business arrangements. Well, maybe not no suits but none that go to court and no losses!! 5
No litigation Dot all I s and cross all T s. Involve applicant at the right time and level Use legal council judiciously Example: Multiple residencies-you knew about them, got references from each, documented that this was unusual but that you had considered it carefully, obtained more information, and made a reasoned decision. (remember, you are not required to make the right decision you are required to follow the right process. Example: Lack of recent impatient experience but good references Very tailored collaborative privileges in the beginning, followed by well documented FPPE and a well documented decision to move to OPPE due to excellent performance. (documentation is key or else you will be forced to prove in court that you acted reasonably 5 years ago, you have now retired, the chair of cred is gone, your department chair says, who me, I was elected while absent, or hummm, the paper work has no dates, signatures, rational for the decision, etc. 6
No Litigation I ll sue your Medical Staff for not letting me practice here.. Humm, good luck, the staff had nothing to do with this issue, you didn't t complete a recognized residency, are not boarded, have incomplete references and have not practiced in the OR for five years. Your application was not reviewed by the MS and the last letter you got specified that we would be glad to present your application for review once you furnished A-M as specified on the attached. We have received nothing from you in response to that letter. KNOCK YOURSELF OUT. No Accreditation surprises This is the easiest. Standards are easy to comply with. Have good documents Follow good policies Have trained and committed leaders Dot all I s Recognize that credentialing is a well defined activity. Try hard not to replace good committed leaders due to the calendar,convienance, bylaws, or staff whim. In truth, placing an uninterested, busy, harried physician on a committee with the idea that this will groom her for leadership is a poor second to good leadership training and mentoring. Great Business support for the organization High quality, efficient work and decision making. No unnecessary delays. Recognition that delay is expensive. Make the case for continuous process improvement Study and discard ineffective paradigms. Change the organizations mentality from Credentialing as a barrier to Credentialing as a key business strategy. 7
Constant improvement Change is needed, current system has massive hard wired duplication of effort built in. Traditions have become barriers to progress due to belief that they are inviolate. If one can envision the future one can make it happen. Describe you desired future Constant Improvement No duplication of effort No unnecessary delays in decision making No unnecessary bureaucracy No duplication of effort How many times must the nation confirm that Jim went to medical school with the medical school itself? How many times must it do documented that she went to a good residency in general surgery? Why must both HR and the MS office conduct criminal background checks? Who says that an application must be 6 pages and that the physician must personally sign each page? 8
Duplication and bureaucracy Why do we continue to ask most of the questions on an application? Example: Where did you go to college. Medical school Residency List all states in which you are or have ever been licensed List your publications (When we do not require any) List your CME courses (When we do not require any) Duplication and bureaucracy Why do we ask for paper copies of documents Why do we ask that each page be signed and dated Constant Improvement Why don t we ask applicants: Describe in your own words your clinical work over the past 12 months. Be specific and relate your description to your requested clinical privileges Describe how you will be assisting the medical staff and hospitals in meeting their patient care missions Describe your most recent negative interaction with another physician or nurse. 9
Constant Improvement Recognize that the rules for delegating to a CVO are not onerous and do not require certification, NCQA, or URAC blessing ( although that does make things easier) Any hospital may delegate PSV to a designated third party after some study and exchange of agreements. This could be another hospital, CVO, Locums agency, Don t make telemedicine credentialing difficult. Constant improvement All processes are improvable Those who create a process resist changing that process. Observe the parallels to our credentialing activities Military (orders) and now credentials Applications to college Credit bureaus Auto rental outlets Commercial pilots Cross country truckers A Few Complexities Temp privileges for applicants to the staff-will soon be a thing of the past Appointment to the staff for locums and telemedicine docs (all they need and want are clinical privileges) Privileges for clinical activities new to the organization Turf battles ( going, going, gone; with employment becoming the primary affiliation model.) Numerous department chairs involved in the process.(moving toward a small number of dedicated leaders charged with the responsibility for review. 10
A Few Complexities Credentials committee review of clean files (gone in many organizations and going in the remainder) Waiting for regularly scheduled ME, Cred Committee and board meetings to review files. (We have recognized the benefit of special meetings held electronically, with practical quorum requirements.) Extreme lack of knowledge on the part of most physicians concerning the multiple purposes and complexities of credentialing. (resolving due to employed physician leaders shouldering the heavy lifting. A Few Complexities Confusion between service line administration/direction and medical staff responsibility and structure. Beginning to respond to evolution, understanding, diminishment of politics, and concentration on substance and not form 11