QUESTION: We are a six-hospital system and are doing our best to address and anticipate the health care needs of patients with COVID-19. Two of our hospitals are Critical Access Hospitals, which is why our medical staffs are not unified. Nonetheless, we have a system CVO and our bylaws, credentials policy and privileging criteria are consistent. If we want to be flexible about deploying needed practitioners to our various hospitals by using temporary privileges for those practitioners who do not hold privileges at each hospital, must we get new peer references from their primary system hospital? What are our other options for granting privileges for these practitioners at hospitals in our system where they are needed?
ANSWER: Technically, each hospital with a separate CCN and license is supposed to get a peer reference to confirm current competence, under both Joint Commission and DNV GL NIAHO standards, without reference to whether a hospital is part of a system. However, under these difficult circumstances, of course it makes sense to take advantage of the system’s knowledge of privileging at other system hospitals to speed up the availability of practitioners to go where they are needed most. Here are some options:
- For those who are somewhat risk averse and have the time and resources, the system CVO (or centralized Medical Staff Office) could pre-populate a short “application” form so there would be little the “applicant” would need to do other than sign electronically. That form could refer to a standard department chief/chair peer reference communication to be used within the system, which confirms current competence based on OPPE (or FPPE if applicable for recently appointed practitioners) or the last reappointment recommendation/report. However, those under a performance improvement plan or investigation would not be eligible except on a case-by-case basis.
- Pursuant to a system information sharing policy, Board resolution, or agreement, the standard department chief/chair peer references could be accessed electronically throughout the system or the actual recent OPPE or reappointment reports could simply be made available directly without the need for the separate peer reference form.
- A system could simply let the practitioners go where they are needed, via a Board and MEC resolution, and justify it later if surveyors question it. Will surveyors really cite hospitals for having moved quickly to get known practitioners to respond to the community? We doubt it.
- A few systems have created a category on each medical staff in the bylaws for all physicians who are appointed to other hospitals’ staffs. The CVO has all the information. The physicians in that category are permitted to exercise privileges at all system hospitals where the services they provide are offered, even though they designate a primary hospital. (One reason that systems do this is to create a panel of peer reviewers to review cases at other system hospitals when there is a potential conflict, or to use those physicians as locum tenens in system hospitals to avoid contracting with locum tenens firms and thereby getting unknown physicians.)
- Another option is for each hospital to grant disaster privileges quickly and as needed, in reliance on the CVO’s files containing licensure, and verify identity when they report for duty.
Join Charlie Chulack and Barbara Blackmond for the next installment in our Grand Rounds audio conference series on April 7 on Making the Most of your Relationship with Credentials Verification Organizations (CVOs).
QUESTION: A physician on our medical staff has made numerous inappropriate entries into the EMR. These include critiques of other physicians, the hospital, and its staff. We have approached the physician several times to inform him that a patient’s medical record is not an appropriate forum for these comments, but he claims he has the First Amendment right to put whatever he wants to in the records, and continues to do so. What can we do?
ANSWER: The regulatory and accreditation requirements set forth by the Joint Commission and both federal and state law make it clear that they require the medical record to document objective clinical information relative to an individual patient’s medical condition that will enable a patient’s caregivers to provide the appropriate patient care. Entering comments in a patient’s medical record that are critical of the hospital or of other individuals are inappropriate editorial statements, which do not advance the care of a patient. In addition, they clearly create and increase legal risks to the hospital and to all individuals involved in the care of the patient.
A physician who has a complaint or concern regarding an administrative policy, the hospital’s utilization practices, or the care provided by any other individual should be advised that the medical record is not the proper forum for that issue and should be directed to register those concerns through appropriate medical staff or administrative channels. Most times, providing this education and counseling to the physician is sufficient to resolve the concerns. If not, however, the physician should be advised that continuing disregard of the policy concerning the proper content of medical records will be referred for review under the Medical Staff Professionalism Policy.
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.
QUESTION: Can text messages be used by our physicians and other health care professionals to communicate about patients and issue orders?
ANSWER: The Joint Commission recently issued guidance regarding the use of text messaging in patient care. The guidance was developed in collaboration with the Centers for Medicare & Medicaid Services (“CMS”). Thus, even if your hospital is not accredited by the Joint Commission, it should pay attention to the guidance because of CMS’s involvement in developing it.
The guidance includes the following:
(1) All health care organizations should have policies prohibiting the use of unsecured text messaging – that is, short message service (“SMS”) text messaging from a personal mobile device – for communicating protected health information.
(2) The Joint Commission and CMS agree that computerized provider order entry (“CPOE”) should be the preferred method for submitting orders as it allows providers to directly enter orders into the electronic health record (“EHR”).
(3) In the event that a CPOE or written order cannot be submitted, a verbal order is acceptable.
(4) The use of secure text orders is not permitted at this time.
For more information, please click here.