Julie L. Seitz Associate Counsel Provider Operations

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Julie L. SeitzAssociate Counsel Provider

Operations

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Disclaimer

The views expressed are those of the speaker and not necessarily those of Catholic Health Initiatives. This presentation is for educational purposes only and is not intended as legal advice.

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Bio

• 1995 JD from Emory School of Law (Atlanta, GA);• 1995-2001: Health care litigator for large law

firm;• 2001-present: Associate Counsel Provider

Operations for Catholic Health Initiatives.• Catholic Health Initiatives is a national nonprofit

health organization with headquarters in Denver. We are a faith-based system that includes 77 hospitals; 40 long-term care, assisted- and residential-living facilities; and two community health-services organizations in 20 states

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Goals

• Identify factors affecting hospitals’ efforts to assure ongoing physician competency;

• Identify hospital challenges to assuring ongoing physician competency;

• Identify current practices in hospitals’ efforts to assure ongoing physician competency;

• Discuss the link between hospital efforts and states’ lack of or future implementation of MOL requirements.

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Current Environment for Hospitals’ Assurance of Ongoing Competency

• February 2008 FSMB Draft Report on MOL identifies factors in Section II, Environment Assessment. Those same factors are equally applicable to hospitals.

• Public Expectations:– Increased focus on “transparency” in health

care;– More informed consumers;– Liability environment: negligent

credentialing, vicarious liability, breach of fiduciary duties.

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Current Environment for Hospitals’ Assurance of Ongoing Competency

• Increased Emphasis on Continuous Improvement in Medicine:– CMS initiatives on Value Based

Purchasing;– Hospital financial performance tied more

directly to the quality of clinical care provided by physicians, as opposed to just the nursing staff;

– Push towards evidence based medicine;– Pressure to respond to rapidly evolving

technology.

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Challenges to Hospital Assurances of Ongoing Competency

• Time and personnel intensive: – Decrease in interest of engaged medical staff

members to assist;– Nursing and other personnel shortages.Physician shortages makes it difficult to do peer

review or peer comparisons, reluctance to risk losing physician in specialty.

Specialization of physicians makes it difficult to do peer review or peer comparisons; raises the question of what does the physician need to be competent to do?

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• Less hospital-based practice to evaluate due to development of office based practices, ASCs, freestanding care centers, hospitalists,

• Lack of a single “gold standard” for maintenance of competency: Board certification, differences among national professional organizations.

• “Turf wars”: For example, radiology v.cardiology; general surgery v. vascular; gastroenterologists v. surgeons.

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• Lack of flow of information between state licensure agency:– Lack of information about open

investigations of physicians;– Length of time it takes to conclude state

investigations;– Settlements with physicians to end the

administrative process.

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Current Practices in Assuring Ongoing Competency

• Medicare Conditions of Participation and Joint Commission requirements impose a duty on Medical Staffs and Hospitals to assure physicians are competent and are granted appropriate privileges.

• Historically, competency evaluated at two points in time: at initial appointment and every two years at reappointment.

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• Increasing focus on assuring ongoing competency.

• The Joint Commission: new nomenclature, but not new concept:– MS 08.01.01 (2009 Standards): The

organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.

– Focused professional practice evaluations (FPPE)

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MS 08.01.03 (2009 Standards): Ongoing professional practice evaluation (OPPE) information is factored into the decision to maintain existing privileges(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time or renewal.

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• Emphasis on practitioner specific review at initial appointment or upon grant of new privileges: Credentials Committees and MECs recommend observation, chart review, data to be collected.

• Reappointment data collected: use of medications; use of blood and blood products; operative procedures; clinical practice patterns; departures from established practices; autopsies; sentinel events data, patient safety data.

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• Going beyond data and incorporating incident reports, grievances, documentation/charting issues, professionalism.

• Key indicators determined by specialty (OB c-section rates).

• Focus on indicators for primary care.

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• Using OPPE and FPPE to assess competency in the “gap” periods.

• Changing focus of “peer review” from being associated only with disciplinary process.

• Changing focus to “clinical quality” reviews: routine reviews and collaborative reviews of all practitioners, just not those whose cases “fall out” on indicators.

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Convergence with MOL

• Hospitals are limited to assessing competency based on what occurs within their walls and only within the scope the physician practices at the facility.

• Physicians are practicing less and less within hospitals.

• These trends make it more important that there is another entity overseeing competency assessments.

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• The only entity consistent to all physicians in the state is the state licensing agency.

• State licensure agency can serve as the repository of all information about a physician.

• CLE should be related to the physician’s practice.

• Analogy to lawyers: many states require CLE every reporting period related to professionalism and ethics.

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• More transparency in state investigations of physicians;

• More consistency in imposition of discipline and clearer determinations about physicians;

• Exchange and flow of information between hospitals and licensing agencies.

Julie L. Seitz Associate Counsel Provider Operations

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