Transcript Document

Web Conference
April 3, 2008
12 – 1 p.m.
For audio, call:
1-888-850-5066 code 222177#
Sponsored by:
Association of
Washington
Public Hospital
Districts
Significant funding provided by:
Office of Rural Health Policy through the
Washington State Department of Health
Speakers
Robert J. Walerius
Greg Montgomery
Dana Livingstone Kenny
Robert J. Walerius
• Credentialing = confirming licensure,
malpractice insurance, board
certification if required, references,
restrictions on practice, and
background
• Privileging = scope of training and
current experience to hold clinical
privileges requested
• Medical Staff Office collects relevant
information from applicant and others
• File containing application and
information is forwarded to the
Medical Staff for review and a
recommendation to the Board
• The Board has ultimate
responsibility for approving who
can practice in the hospital and
what clinical privileges are held
• Delegation to the Medical Staff
does not relieve the Board of
responsibility
• A direct correlation exists between
the competence of the Medical Staff
and quality and patient safety
• Quality and safety are core fiduciary
responsibilities
• We are entering a new area of
heightened focus on quality and
patient safety
Institute for Healthcare Improvement
“5 Million Lives Campaign”
• Goal: protect patients from 5 million
incidents of harm over 24 months
• IHI estimates 15 million incidents of
medical harm yearly in hospitals
• 40 to 50 incidents of harm for every
100 hospital admissions
• 40,000 incidents of harm daily
“5 Million Lives Campaign” (cont’d)
• Prior 100,000 Lives Campaign had
3,100 participating hospitals
• New campaign seeking 4,000
hospitals
• 12 interventions targeted to reduce
harm
• One intervention is to enlist active
governing board support to improve
quality
CMS new focus on quality:
• “Never Pay” plan – CMS will not
reimburse for 8 conditions CMS
deems to have occurred because of
mistakes – October 1
• Pay for Performance – value-based
payment plan
• New federal protection rules for
confidential reporting of mistakes
Theories of Liability
• Board needs to understand
theories of liability to evaluate
potential risks to the hospital
when deciding on privileging
Theories of Liability: (cont’d)
– Corporate negligence:
• Independent duty to patients to exercise
care in selecting, retaining, and
supervising the performance of the
Medical Staff
• Hospital’s role is not just to furnish
facilities and equipment for physicians to
practice in isolation
Theories of Liability: (cont’d)
• Medically unnecessary services:
– Patient is unnecessarily exposed to
risks of medical procedure and CMS
incurs needless costs
– CA case – hospital paid $59.5 million
to settle false claims allegations that
hospital negligently credentialed and
monitored cardiologists
Theories of Liability: (cont’d)
• Failure of Care:
– Care provided is so deficient that it
amounts to no care
– Liability for billing CMS for services
not actually rendered
• Board must understand
performance goals that will
allow the hospital to provide
high quality and safe care
• Attention to credentialing and
privileging is essential to drive
increased quality and safety
Suggested Board Questions:
• Are the roles of the Board and
medical staff clear, understood,
and in writing?
• Are qualifications for staff
membership and privileges in
writing and followed?
Board Questions: (cont’d)
• What data on clinical competence
is reviewed by the medical staff?
• Does the medical staff engage in
meaningful peer review and
corrective action?
• Is the Board involved?
Dana L. Kenny
Legal Requirements
• Accreditation: JCAHO Standards:
– 60 WA hospitals JCAHO accredited; 35 not
accredited
– Governing Board: Sets the framework for supporting
quality patient care, treatment and services
– Surveys: based upon accreditation cycle (every 3639 months)
• Washington hospital licensing laws (RCW
70.41 and WAC 246-320). Enforcement:
– Surveys for compliance every 18 months (except for
JCAHO accredited)
– Agreement with CMS for Medicare/Medicaid
recertification survey
Legal Requirements
• CMS Conditions of Participation (42 CFR 482.22)
– Hospitals 42 CFR.482.22. Governing Body shall:
• Ensure that criteria for selection are individual
character, competence, training, experience and
judgment
• Ensure that the Medical Staff is accountable to the
governing body for the quality of care provided to
patients
• Enforcement: generally delegated to Department
of Health by Agreement
– Critical Access Hospitals 42 CFR 485.601
• Governing body assumes full legal responsibility
for determining, implementing and monitoring
policies governing hospital’s total operation.
Legal Requirements
• Conditions of Participation: Quality
Assessment and Performance
Improvement 42 CFR 482 .21.
• Governing Body shall:
– Ensure that program reflects
complexity of hospital and services,
involves all hospital departments and
focuses on improved health outcomes
and the prevention and reduction of
medical errors
Meeting Legal Requirements
JCAHO Standards:
• Past – general review based upon “paper”
credentials
• Now – recognition of “active”
credentialing
• Credentialing/Privileging: collection,
verification and assessment of
information
• More than “paper credentials” required
• Objective, evidence-based
• Purpose: more comprehensive evaluation
of a practitioner’s professional
competence
JCAHO Standards:
General Competencies
1. Patient Care
2. Medical/Clinical Knowledge
3. Practice-based Learning and Improvement
4. Interpersonal and Communication Skills
5. Professionalism
6. Systems-Based Practice
Privileging: JCAHO Standards
• Process for evaluating requests for
particular privileges:
– Ensuring qualifications based upon
ongoing review
– For surgeries: developing and approving
a procedures list
– Assessment of resources
– Recommendations to the governing body
for applicant-specific privileges
Expedited Credentialing/
Temporary Privileges
• Staggered cycles of renewal
• Expedited credentialing by Board: when Board
not scheduled to meet soon
• Cannot be approved by medical staff:
– Initial appointment and reappointment
– Authority can be delegated to at least two voting
members of Board. Otherwise, temporary privileges
when:
• Complete application awaiting approval (120 days) or
• Important patient care need (verification of licensure and
current competence)
– Process for locums: must meet standards for temporary
privileges
– Medical staff develops criteria for expedited process for
granting privileges
Focused Professional Practice
Evaluation  Used When:
1. Practitioner has credentials to
suggest competence, but additional
information needed (initial appointment
and anytime additional privileges are
granted)
2. Questions arise about practice during
course of ongoing practice evaluation
Quality Improvement Programs
and Ongoing Professional Practice
Evaluation (maintaining privileges)
• Quality Improvement Programs:
Licensing Requirement. RCW 70.41.200
– Mechanism for periodic review of:
• Credentials
• Physical and mental capacity
• Competence in delivery of health care services
• Evaluation of staff privileges
JCAHO Standards
• Ongoing professional practice
evaluation:
– Identifying professional practice
trends that impact quality of care and
patient safety
– Focus on “Continuous Quality
Improvement”
Suggested Board Questions:
• Does the Medical Staff have:
– Process for temporary privileges?
Expedited privileges?
– Processes for considering “general
competencies” for
credentialing/privileging?
– Process for focused review and ongoing
professional practice evaluation?
Greg Montgomery
Peer Review and
Corrective Action Scope
• Clinical competence refers to judgment
regarding the nature and timing of treatment
and technical skills in executing the proper
treatment
• Professional conduct refers to physician
conduct when acting in a professional
capacity including any impairment or
behavior that interferes with the orderly
operation of the hospital.
Peer Review and Corrective Action
Professional Conduct
• “Corrective action taken in response to multiple
complaints about physician disruptive conduct
involving abusive treatment of nurses, technicians,
and fellow physicians was appropriate. Clinical
incompetence involving patient injury is not a
necessary basis for corrective action.”
• “The disruptive physician is by definition
contentious, threatening, unreachable, insulting
and frequently litigious. He will not, or cannot
play by the rules, nor is he able to relate to or
work well with others.”
Peer Review and
Corrective Action Options
• Educational
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CME
Physician’s assistance programs
Counseling
Proctoring/Preceptoring
Voluntary limitation of privileges
Mandatory second opinion
Suspension
Revocation
• Restrictive
Peer Review and
Corrective Action
Road to the Board
• Request for corrective action
• Investigation and Recommendation
to MEC
• MEC Recommendation to the Board
• Right to Hearing with Report and
Recommendation
• Right to Appeal
Peer Review and
Corrective Action Board’s Role
• Hearing Record
• Bylaws provide standard
Peer Review and
Corrective Action Board’s Role
• Appellate Review Committee
• Appeal Statement
• Oral Presentation
• Decision
Peer Review and
Corrective Action Immunity
• Requirements for immunity for
professional review action
– Reasonable belief that action was in
furtherance of quality health care
– Following reasonable effort to obtain facts
– After adequate notice and hearing
procedures afforded physician
– Reasonable belief that action warranted by
facts known after reasonable effort to
obtain and notice and hearing
Peer Review and
Corrective Action Investigation
• Physician entitled to a reasonable
investigation, not a perfect
investigation
• “Facts so obviously mistaken or
inadequate as to make reliance on
them unreasonable”
• “Fabricating damaging evidence or
purposefully overreacting is not part
of legitimate peer review”
Peer Review and Corrective Action
Notice and Hearing
• Inform physician of issues
• Issues can change during course of
investigation as long as there is notice
• Opportunity to be heard at each step
in process - Investigation Committee,
MEC, Fair Hearing, Appeal
Decision
• Process
• Facts
– Conflicts
• Conclusions
Peer Review and Corrective
Action Key Immunity Question
• Was the action undertaken in the
reasonable belief that it would further
quality health care based on facts
known at the time
• Courts will not substitute judgment of
the medical staff or governing body or
reweigh evidence
Robert Walerius – (206) 622-8484
[email protected]
Dana Kenny – (206) 622-8484
[email protected]
Greg Montgomery – (206) 622-8484
[email protected]