QUESTION:
The MEC recently learned that a department chair placed a physician on a “period of FPPE to include proctoring until such time as the requirement for supervision is lifted.” This has raised some red flags within the Medical Staff leadership. We are a bit worried about the use of the word “supervision” here. Also, another main concern is that we revised our peer review process several years ago and, while our policy allows department chairs to perform clinical case reviews, send letters of guidance, and conduct informal collegial conversations with practitioners, the policy pretty clearly states that if something more intensive/intrusive – like a formal, planned collegial intervention meeting or performance improvement plan – is envisioned, the matter should be referred to the multi-specialty peer review committee or MEC for management.
Should we “undo” the actions of the department chair and “redo” the peer review according to our policy? Since it’s already in progress (the practitioner has already been notified of the requirement) should we just let it ride out? This feels like quite a mess.
ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:
You know the saying, “An ounce of prevention is worth a pound of cure”? Well, right now you need a pound of cure. It happens! You are right to have some concerns about the process that has been followed thus far in reviewing this matter. And the concerns you articulated in your question are astute. The use of the word “supervision” probably is inappropriate and inapplicable here. Most proctoring that is performed in the peer review world is observational only and does not involve true supervision by the proctor. The role of the proctor is to observe and report back to the peer reviewers his/her opinions about the performance of the individual subject to review. The proctor often consults with the practitioner collegially during that process, but the consultation does not generally rise to the level of supervision and the proctor generally does not have any authority to dictate how the practitioner provides the medical care in question. Using the word “supervision” to describe the proctoring could give the wrong impression about these matters. And just as importantly, it could set a negative tone, making this practitioner (and others, in the future) more defensive and less likely to be cooperative with the proctoring process.
It would also appear that the department chair overstepped his role in the process by implementing an activity (proctoring) that is generally reserved for performance improvement plans. To the best of our knowledge, there are no legal or accreditation standards that dictate “who does what” in peer review. But, your policy should serve as the guide for peer review activities within your hospital and medical staff. And the way your policy has been drafted – to divvy up responsibility for certain interventions such that lower-level interventions are within the authority of individual leaders, but more intrusive interventions require committee action – are “best practice” within the industry. Relying on multi-disciplinary committees to implement performance improvement plans provides a check and balance, helping to eliminate personal variation, as well as alleviate any concerns that competitive motives formed even part of the motivation for the action.
Now, for your real question: Should you undo the action of the department chair?
In this case, that is probably the best course of action. Of course, diplomacy is key. As a first step, the MEC might simply ask a few individuals (the officers? A Leadership Council?) to meet with the department chair and ask him to reconsider his decision. Those leaders can also work with the department chair to notify the practitioner that the previous determination has been rescinded and, upon further consideration, it has been determined that the matter should be forwarded to the multi-specialty peer review committee for further consideration and determination of next steps.
With that done, you can then focus on the “ounce of prevention.” Leadership roles turn over very frequently – and Medical Staff leaders are usually not provided any training in advance of their leadership terms. Methodically providing an orientation letter to new leaders and regularly providing leadership education and training is a great way to help leaders navigate their many (and sometimes complex) roles.
An orientation letter can be used to summarize duties and make leaders aware of the Bylaws and policies that apply to them (and should be consulted when performing duties). It does not need to be a “manual.” A few pages often does the trick. For example, the department chair’s role in peer review (as outlined in the policy you describe in your scenario) could be summarized as follows:
As department chair, you are also an important part of implementing the Medical Staff’s professional practice evaluation/ clinical peer review process. Cases may be referred to you for clinical review, with a request that you report your opinions (on the forms provided). You may conduct clinical reviews yourself or, where you lack expertise, assign the review to another clinical specialty reviewer within your department (to be reported back to you by the deadline that you set). If your review reveals new or lower-level concerns that might be best managed through brief, informal collegial counseling or guidance, you may address the matter directly with the practitioner (reporting that outcome to the PPE Professional so that it can be recorded in the hospital’s files and reported to the multi-specialty peer review committee for oversight purposes). More significant concerns and/or more significant interventions are generally referred to the multi-specialty peer review committee for review and management. For more details, please refer to the Medical Staff Professional Practice Evaluation Policy. A copy can be obtained…[describe where/how to obtain the policy]…
If you have a quick question about this, e-mail Rachel Remaley at RRemaley@hortyspringer.com.
