MEDICAL STAFF MATTERS
Credentialing for Excellence
Darla S. Holland, M.D.
Kaiser Permanente Southern California/IMQ
Objectives for today
• Discuss the elements of robust preapplication/initial application process
• Describe how Medical Staff Professionals can
support Medical Staff Leaders in their
attempts to maintain a high functioning
Medical Staff
Objectives (continued)
• Discuss some challenging credentialing
situations
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The Low Volume Practitioner
The No Volume Practitioner
Allied Health Practitioners
The Physician With Challenging Behaviors
The Impaired or Ill Physician
The Aging Physician
The Physician Working Under Contract with the
Hospital
Objectives (continued)
• Provide tips for “herding cats”
Begin at the Beginning
Dr. Cutter is an initial applicant for membership to
the Medical Staff. He went to college at UT
Arlington, Medical School at UTMB in Galveston,
did a surgical residency at Baylor and Vascular
Fellowship at County USC.
CV shows no gaps in time. He just finished his
fellowship
Did some moonlighting at The Holiest Medical
Center while in fellowship
Board eligible in surgery
Contrast Dr. Cutter with Dr. Mobile
• Dr. Mobile is a new applicant to the Medical Staff. He went
to Medical School in Guadalajara, graduating in 1974, did
his residency in internal medicine at Albert Einstein and
became Board Certified in Internal Medicine in 1977
(boards are not time limited). He practiced from 19771979 in Florida, 1979-1985 in Texas, 1985-1996 in
Albuquerque, and from 1996 through present in Portland,
Oregon. He has three closed malpractice cases (one with
payment of $440,000 four years ago for alleged failure to
diagnose a DVT in a post operative patient who had
undergone a total hip replacement. The other two cases
were closed without judgment. There are two open
malpractice cases.
More about Dr. Mobile
In one case he was merely a covering physician.
The other case resulted from a retained
foreign body (a guidewire was sheared off
during the insertion of a central line four years
ago). Dr. Mobile is applying for privileges to
admit and care for hospitalized patients and
for ICU privileges, including Swan Ganz
placement and privileges to do EGD and
colonoscopies
Now for Dr. Rust…..
• Dr. Rust went to Medical School at NYU
• Boarded in Emergency Medicine
• Had difficult twin pregnancy six years ago and
had to go on bed rest for three months. After
her children were born she stayed home.
Now they are in Kindergarten and she wants
to go back to work. She has 50 hours of CME
every year.
Initial Application Criteria
1. Can the applicant have a restricted license?
2. What is the interval in which you examine
malpractice activity?
3. Must the applicant be Board Certified or
“eligible”? Is there an interval beyond
training for which the individual must have
passed Boards in order to be considered?
4. Is the individual familiar with call
requirements?
Initial Application (cont)
5. Is the individual applying to a closed
department?
6. What does the Public Records check reveal?
7. Is there any thing concerning in a Google
Search or Social Media query?
8. Can the individual explain gaps in practice?
9. Does the individual need to have a personal
interview?
New Applicant Issues….
• Dr. Cutter
• Straightforward…remember to get information from
the moonlighting job as he is not in a training program
there
• May need to be assigned a mentor that has a different
relationship than a proctor
New applicant issues
Dr. Mobile
• Need to query every practice experience, if
possible
• Needs to provide evidence of current
competence (outcomes) from privileges that
are outside the scope of his training and
certification
• Needs to have privileges tailored for his
training/experience
New applicant issues
Dr. Rust….
Is she a candidate for a re-entry program?
-Best template for Reentry program comes from
City of Hope
-Program describes a process for individuals
previously on their Medical Staff and out for
three years or less
-Describes very tight supervision, including
cosigning of orders
Re-entry programs
• Most hospitals will not bring anyone on staff
with no activity for more than one
reappointment cycle
• Numerous programs exist to assess
competence in individuals out of practice
• In California two most well known are PACE in
San Diego and the Cedars Sinai Reentry
program.
Public Records Check
To do or not to do (some counties are still doing
this manually on paper….)
Redundancy that yields information about civil
litigation, potential substance abuse concerns,
and potential character concerns
Proctoring/Focused Practitioner
Practice Evaluation
• Most common concerns identified at Survey
– FPPE was not done at the initial granting of
privileges (the individual has a very active practice
but has not completed proctoring
– FPPE is not consistently done in all departments
– FPPE is not done for Allied Health
– Surveyors/staff cannot identify which practitioners
have not yet completed their proctoring
requirements
Reciprocal Proctoring
Question: Can we accept proctoring from
another institution?
Answer: Yes, but……
1. The Proctoring Reports MUST have been
completed within the past two years.
2. If OPPE data is used in the consideration, it
must include elements referable to the
privilege, and…..
Reciprocal Proctoring
At least ONE case must be completed in the new
facility using the staff, equipment and policies
of the hospital requiring the proctoring
For an outside proctor of a new service……
The Medical Staff must consider the evidence
that this individual is indeed an “expert”
before granting temporary privileges. It is not
possible to proctor and expert.
Ongoing Professional Practice Eval
(OPPE)
• Standards have been in place for at least two
survey cycles
• Needs to take place at an interval that is more
frequent than annual
• Needs to reflect the performance of a single
individual (must NOT attribute on single element
to multiple practitioners)
• “One should be able to look at the OPPE profile
and know the type physician being monitored”
As a Medical Staff Professional…
Who is your BFF?
Key individuals
• Quality/Performance Improvement Director
• Risk Manager
• Hospital Counsel (and if applicable) the
Medical Staff Counsel
• Information Management (Medical Records)
Manager
Quality Management
• Source of potential OPPE indicators (always try
to use metrics that Quality is already
collecting)
• Medical Staff needs to know when FPPE
triggers are met and if an FPPE is
ongoing/being reported
• Can provide the data necessary to make
intelligent credentialing decisions
Risk Manager
• Has information about internal cases/trends
that may lead to litigation.
• Usually has a handle on what issues stand out
as potentially problematic areas.
Hospital Counsel
• Important source of advice about Licensing
Board reporting, timeliness of actions, and
denial of Medical Staff Membership
• Can provide communication tools or draft
letters to applicants.
Information Management
• Provide reports about Medical Records
completion
• Provide other metrics, particularly about
completeness of records.
Reappointments
• High Volume practioner
• Low volume
-low volume in your hospital but high volume
elsewhere
-low volume in my hospital but no volume
elsewhere
-no volume
High volume practitioner
• Make sure that it is clear that the quality data
is indeed present as the Chief considers the
file at the time of reapproval
• Better if the reports/ data can be initialed
Low Volume Practitioners
• High volume elsewhere (i.e. Call coverage)
obtain quality data or OPPE profile from
another hospital
Alternatively Letter of Recommendation
can be obtained if it reflects the time
period that one is examining
• Low volume elsewhere
Again, the burden of evidence lies with the
applicant
No volume practitioner
• Very few privileges are able to be considered
“Ride-a-bike”
• Are privileges part of a “cluster” where there
is implied competence
• Is the individual a candidate for a Leave of
Absence?
Contracted Physician Groups
• Focus on OPPE Performance Metrics that can
be benchmarked
• Urge regular scrutiny of these metrics as part
of the contract oversight process.
• When possible use metrics that are publically
reported
Telemedicine
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MS.133.01.01 Elements of performance
A 1. All licensed independent practitioners who are responsible for the patient’s care,
treatment, and services via telemedicine link are credentialed and privileged to do
so at the originating site through one of the following mechanisms:
1. The originating site fully privileges and credentials the practitioner according
• to Standards MS.06.01.03 through MS.06.01.13.
2. The originating site privileges practitioners using credentialing information
• from the distant site if the distant site is a Joint Commission–accredited
• organization.
3. The originating site uses the credentialing and privileging decision from the
• distant site to make a final privileging decision if all the following
• requirements are met:
• 1. The distant site is a Joint Commission–accredited hospital or ambulatory care
• organization.
• 2. The practitioner is privileged at the distant site for those services to be provided
• at the originating site.
Telemedicine Standards (cont.)
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3. For hospitals that use Joint Commission accreditation for deemed status
purposes: The distant site provides the originating site with a current list of
licensed independent practitioners’ privileges.
4. The originating site has evidence of an internal review of the practitioner’s
performance of these privileges and sends to the distant site information that is
useful to assess the practitioner’s quality of care, treatment, and services for use
in privileging and performance improvement. At a minimum, this informationincludes all adverse outcomes
related to sentinel events considered reviewable by
The Joint Commission that result from the telemedicine services provided; and
complaints about the distant site licensed independent practitioner from
patients, licensed independent practitioners, or staff at the originating site. (See
also LD.04.03.09, EP 9)
Note 1: This occurs in a way consistent with any hospital policies or procedures
intended to preserve any confidentiality or privilege of information established by
applicable law.
Note 2: In the case of an accredited ambulatory care organization, the hospital must
verify that the distant site made its decision using the process described in Standards
MS.06.01.03 through MS.06.01.07 (excluding EP 2 from MS.06.01.03). This is
equivalent to meeting Standard HR.02.01.03 in the Comprehensive Accreditation
Manual for Ambulatory Care.
Telemedicine According to CDPH
• Only options #1 and #2 are acceptable in California.
• Hospitals must either do primary source verification
and grant privileges
OR
• Use the distant sites credentialing packet and grant
privileges.
• The hospital may NOT accept another entity’s
credentialing decision (in the state of California)
• There must be a focused review (proctoring) for all
telemedicine.
What is Telemedicine?
• When tools facilitate patient care, the use of the
tool is a matter of clinical judgment for a
practitioner.
• When the tool or media replaces face to face
contact, telemedicine is implied.
• Telemedicine privileges need to be granted for
hospital practitioners
• Great care needs to be exercised to assure that
the individual delivering care is indeed the
individual who has been privileged.
Credentialing the “Problem
Practitioner”
• Goal should be to keep the physician practicing
• Counseling by the appropriate Department Chief
or the Chief of Staff should take place and be
documented in the Credential File.
(documentation can take the form of a summary
of the discussion or a letter to the practitioner)
• In most cases, referral to Well Being Committee
should occur.
Supporting the Medical Staff with
“Problem Practitioners”
• Regular reports to MEC by the Well Being
Committee are essential
• When concluding a counseling session,
followup to the discussion should be defined
and next steps outlined for any issue that
recurs after an initial counseling session.
• Tracking til resolution is important.
• Impairment or illness can be considered;
patient safety always trumps privacy.
Age and Professional Assessments
• Airline pilots have their skills assessed
regularly and routinely beginning at age 40
• California requires more aggressive
assessment of driving skills at age 70.
The Aging Practitioner
• Very few hospitals/organizations are doing a
routine assessment of the aging physician
• Theoretically, with a robust Ongoing
Professional Practice Evaluation, skills are
being evaluated continuously. Aging concerns
would be picked up
• The few that do begin at 70.
CPPPH (California Public Protection
and Physician Health, Inc.)
• Nonprofit entity sponsored by numerous medical
societies including the CMA, malpractice insurers, the
CHA
• Drafting white paper, probably available this summer
that will be vetted and revised
• Anticipate that a specific age for screening be
recommended
• Anticipate that an instrument will be recommended
(and will be administered in the Medical Staff Office)
• Anticipate that screening would then trigger focused
review
Developing Medical Staff Leaders
• Encourage Bylaws revisions that call for longer
tenures for leaders.
• Encourage senior physicians to mentor
interested physicians to develop leaders
• Meet with Department Chairs to explore the
components of a Credential File
• Describe scenarios from past deliberations to
give new leaders an understanding of how
credentialing processes work
Developing Medical Staff Leaders
(cont)
• Recommend attendance at a Medical Staff
Leadership Development Conference
• Advise Medical Staff Leaders to establish
regular revision process for Privilege
Templates.
• Connect with Medical Staff Peer Group and
bring learnings to Medical Staff.
Final Thoughts
• You are the glue that holds the hospital
together.
• You are indispensable to the Medical Staff
Leaders and are usually the individual in a
hospital to whom the leaders are the closest.
As such you have enormous ability to
influence.
• In such a role you protect the safety of the
patients of California, so……
THANK YOU!
Darla S. Holland, M.D.
Darla.S.Holland@kp.org
411 N. Lakeview
Anaheim, CA 92807
714-279-4358 (office)
714-501-0759 (mobile)
It’s not enough that we do our best; sometimes we
have to do what’s required.
Sir Winston Churchill