Reforming Credentialing to Improve Quality & Safety of Care
One of the most important governing functions of a hospital’s medical staff is to ensure that physicians practicing in the hospital are clinically competent and behave professionally. This is accomplished through the credentialing and re-credentialing process. Credentialing in this context refers to both the process of appointing physicians to the medical staff and granting specific privileges to the physicians. While medical staffs have some leeway in determining the essential elements for appointment (e.g., board certification) and privileging, the major external constraints on this process come from Centers for Medicare and Medicaid Services (CMS). CMS maintains that hospitals meet the conditions of participation (CoP) for Medicare and Medicaid in order to receive payment. The best description of what constitutes compliance with CoP is found in the CMS-approved State Operations Manual.
CMS does not conduct surveys to demonstrate compliance. Private accrediting organizations, such as The Joint Commission (JC) and Accreditation Commission for Health Care, Inc. (ACHC), that have demonstrated congruence with CMS standards are certified to conduct surveys and to deem hospitals compliant with CoP. And, in cases where CMS has concerns about on-going compliance with CoP, state agencies are contracted to conduct a survey using the State Operations Manual.
Due to concerns of government overregulation, CoP, while certainly prescriptive, is lacking specifics on policies and processes that would maintain reliability across hospitals and ensure the quality of care that society expects in this era of value-based care.
Fortunately, the accrediting organizations have filled in many of the gaps. One of the most visible and important instances of an accrediting organization extending CoP is related to JC’s guidance around focused professional practice evaluation (FPPE) and ongoing professional practice evaluation (OPPE).
As per JC standards, FPPE and OPPE are essential elements of credentialing and re-credentialing. FPPE is an evaluation of the competence of a practitioner with regard to a specific privilege and to be used when a practitioner first joins the medical staff, when he/she asks for a new privilege, or when events trigger concerns about a practitioner’s competence for a previously-approved privilege.
However, it is left to the discretion of the medical staff to define the triggers for a FPPE as well the FPPE process (e.g., data collection method and length of observation period). JC suggested triggers include higher than expected deaths, surgical complications, complaints from patients or other medical staff, sentinel events and deviation from clinical guidelines. Once triggered, FPPE processes may include chart review, direct observation, discussions with the physician’s peers and staff or a deeper review of trends in mortality, complications and morbidity.
OPPE is an evaluation used to support the re-credentialing of practitioners and may be used to trigger a FPPE. JC expects that the OPPE occurs more frequently than every 12 months, e.g., every 8 months. JC suggests that data collected and reviewed for OPPE might include those that might trigger a FPPE such as morbidity and mortality data, compliance with practice guidelines, sentinel events, and concerns raised by patients and staff. CMS and JC expect that OPPE will tie to the hospital’s quality assessment and performance improvement program (QAPI), which monitors data on “...quality indicators...and other aspects of performance that assess processes of care, hospital service and operations.” And based on these data, hospitals prioritize improvement activities on high risk or problem areas.
The processes related to FPPE and OPPE and, by extension, criterion for determining whether someone is competent for initial privileging (or continued privileging) are determine by the medical staff (and approved by governing body, e.g., board of trustees of hospital). I would argue that in most instances, the general public can count on the medical staff’s professional sense of responsibility to evaluate and determine competency especially if the signal strength is strong in either direction, i.e., clear evidence that a practitioner is high performing or low performing.
However, a problem may arise when OPPE and FPPE are not consistently, and reliably applied. Problems may also arise when initial credentialing documents or OPPE reveal a weak signal suggesting poor competency. There may also be problems when there is moderate strength signal that is confounded by patient-level factors, staff-level factors or by an urgent need for credentialing (or re-credentialing). These situations become more critical when the privilege relates to a complex procedure for a high-risk condition.
Many hospital medical staff’s OPPE and FPPE processes work very effectively to ensure the highest quality and safest care. Based on what I have learned about the approach of such programs and my own first-hand experience, I offer the following recommendations, consistent with guidance from JC, to hospital medical staffs focused on improving their privileging process:
Each organizational unit of medical staff (department or division) must develop a checklist of data to be collected for OPPE for each relevant privilege and describe in detail triggers for FPPE.
For complex and high-risk procedures, the sensitivity of the triggers should be low;
Patient, peer or staff complaints about physician competency, physician communication or physician behavior, as well as the occurrence of sentinel events should be included in OPPE as triggers for FPPE;
The medical staff office must monitor for regular, timely and consistent application of OPPE.
FPPE must be rigorous with a predetermined evaluation process for each privilege.
For initial privileging, especially when outcome data related to a specific privilege submitted as part of the medical staff application are incomplete, the medical staff should make clear to applicant that final privileging is contingent on successful completion of FPPE.
For instances when OPPE triggers FPPE, including at the time of re-credentialing, FPPE should be conducted for as long and thoroughly as necessary to erase any doubt about competency.
For highly complex high-risk procedures, it may be necessary for medical staff to hire outside consultants to review data and, if warranted, to proctor the physician to ensure an unbiased determination of competency.
A robust credentialing process that includes OPPE and FPPE can make more likely that the physicians appointed to and maintained on the medical staff are providing the highest quality and safest care. Medical staffs must be willing to make the process rigorous and reliable enough to achieve this outcome, even if the physicians see this process as an intrusion into their autonomy.