QUESTION: A brand new member of our Credentials Committee, who is opposed to a request from a physician in a different specialty to apply for a privilege to perform a procedure that member performs himself, has been lobbying other committee members to deny the request and has asked that the request first be referred to his department for a vote. A written application has not been submitted. The potential applicant did not have residency training in this procedure but, rather, took a short course conducted by an equipment vendor. The physician requesting the privilege has threatened a lawsuit on antitrust grounds, because he has learned about the lobbying. How can we manage this situation?
ANSWER: If your Bylaws or Credentials Policy does not have a section on how to manage requests for privileges that cross specialty lines, consider deferring consideration until such language is adopted and implemented. It is a best practice to have the Credentials Committee develop eligibility criteria before processing requests (both for new privileges and for practitioners seeking privileges in different specialties). If current criteria refer to residency training in one specialty, the committee can review possible alternate pathways. Any physician, including the potential applicant, can submit proposed criteria for education, training and experience. The committee should also consider how FPPE would work, indications for the procedure, and how call coverage and complications would be handled. How much training is sufficient to demonstrate competence? A survey of other hospitals would be a helpful step to demonstrate objectivity. Also, a Credentials Committee member who is in an affected specialty has a conflict of interest and should be recused from the process (but he can submit proposed criteria). It is best if recusal is discussed with the affected member in advance of the meeting. The minutes should reflect that he left the room before final deliberation and vote on the criteria. A conflict of interest should not be viewed as a judgment on the individual’s character but, rather, as a step to protect the integrity of the process. And, departments should not vote on criteria or specific requests; that is too easily challenged as a conspiracy in restraint of trade. The applicant’s request should not be processed until either new eligibility criteria are adopted by the Credentials Committee, MEC (and Board), or the current criteria are confirmed. A determination of ineligibility is not a “denial.” (If the Credentials Committee and MEC recommend, and the Board determines to adopt, eligibility criteria with an alternate pathway that would enable this request to be processed, the interested committee member should also recuse himself from the consideration of the application.)
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QUESTION: A physician who has been on our staff for only a few months has been experiencing complications, with several cases falling out. So, as part of the initial FPPE, I (as the new Service Line Chief) called this physician into a collegial intervention meeting. He showed up with the head of his group practice, who is not a member of any medical staff committees. When I said that the meeting was a confidential peer review meeting, both physicians left. Now what? Was I right or did I miss an opportunity?
ANSWER: You are correct that collegial intervention meetings are confidential and that individuals who are not members of an authorized peer review committee should generally not be present. All medical staff members have an obligation to work constructively and cooperatively in the peer review process. This should be covered in new physician orientation, as well as in a statement of expectations that is provided to applicants (and also sent along with the letter of appointment, to be signed by the newly appointed physician).
However, a new medical staff member, especially one who is right out of training, may not be aware of or understand the requirements for Focused Professional Practice Evaluation for all new privileges and may be fearful that collegial intervention is actually a disciplinary step. That’s why it’s important for leaders to emphasize the nature of collegial intervention and performance improvement. Of course, leaders engaging in collegial intervention must be authorized by a peer review committee structured in a manner to fall within the protections of the applicable state peer review law.
There may be times when participation of a respected physician mentor who could serve as moral support for a new physician might make sense, with certain safeguards. You could consider telling the new staff member that he may be accompanied by the head of his group, so long as the head of the group signs a peer review confidentiality agreement. Some state peer review laws explicitly cover group practices as well as hospital medical staff committees; and, in some health systems, information sharing policies encompass affiliated group practices. This would offer added protection. (You may also want to be accompanied by another authorized leader, perhaps a vice chief or chair of the peer review committee.)
The purpose of a collegial intervention meeting is to emphasize that the medical staff leadership strives to help all physicians be successful so long as they are willing and able to do what it takes. Leaders may need to remind the head of the group of the expectations for all members, and educate the head of the group who may have had no leadership experience, about the peer review process and the applicable regulatory and accreditation standards. If both are willing to participate constructively, this approach may help de-escalate the situation.
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QUESTION: Our hospital is accredited by the Joint Commission. When we perform FPPE to confirm competence for new Medical Staff members, we typically evaluate the physician’s first five cases. We’ve recently heard rumblings that this may no longer be acceptable. What’s up?
ANSWER: Based on recent reports from hospitals, it appears that Joint Commission surveyors are requiring hospitals to be more rigorous in how they perform FPPE to confirm competence.
The point of FPPE for new physicians is to confirm that a physician who looks good on paper (via the credentialing process) looks just as good in actual practice. FPPE can have the added benefit of helping new physicians become familiar with the hospital (e.g., through conversations with proctors about standard operating procedures, etc.).
Evaluating a physician’s first five cases may not give the hospital a realistic view of the physician’s practice. For example, if the physician is a general surgeon and those first five cases are all appendectomies, the hospital would have no confirmation of how well the physician performs other, unrelated procedures.
Fortunately, groups of privileges may require similar skills and judgment. Thus, the evaluation of a practitioner’s ability to exercise one privilege may be used to confirm a practitioner’s ability to perform one or more other privileges. These are sometimes referred to as “Index Privileges.”
Thus, while FPPE to confirm competence should generally include more than a physician’s first five cases, there’s no need to individually evaluate every privilege a physician has been granted. Instead, hospitals can identify groups of privileges that require similar skills, and use those groupings to help them confirm that a physician is competent to perform all the privileges that have been granted.