New medical staff standards aim to ID problems before sentinel events occur

Credentialing, privileging should be 'educational, not punitive'

The Joint Commission's revised medical staff standards, which became effective Jan. 1, reflect the reality that credentialing and privileging is "really the single most important activity that an organization can do to ensure there are quality practitioners," according to John Herringer, associate director of standards interpretation for The Joint Commission, based in Oakbrook Terrace, IL.

For 2007, The Joint Commission has identified two types of reviews aimed at measuring physician competence based on evidence: focused professional practice evaluation (MS.4.30) and ongoing professional practice evaluation (MS.4.40).

The new standards have "given quality professionals new energy," says Skip Freedman, MD, executive medical director of AllMed Healthcare Management in Portland, OR. "This is an opportunity to raise the bar for how you do this," he says. "The new standards should greatly expand the hospital's peer review process beyond just the occasional bad thing that happens."

The previous standards required a periodic review only every two years, without giving a specific requirement for the evaluation process and allowing the use of peer recommendations. In 2005, this was specified as "relevant practitioners compared to the aggregate," but peer recommendations were still allowed when sufficient data were available.

"We realized that the standards weren't helping organizations to monitor the practitioner's performance and potentially identify performance issues earlier than every two years, and to implement any required action to resolve those on an earlier basis," says Herringer. "So we started to look at the whole concept of credentialing and privileging."

Organizations will need to determine which processes they will use for the focused review, who is going to be performing the review, and what approach will be used — whether looking for a certain number of procedures or certain number of admissions.

The requirement for overview of new privileges, part of the focused review, will not go into effect until Jan. 1, 2008. "Our organizations range greatly in size — we have five-member medical staffs up to 1,000, so we really don't know how many requests for new applicants they get, or how many requests for new privileges," Herringer explains. "It may require some additional resources. That is why we are giving people a year to figure this out."

If your medical staff consist of two departments, medicine and surgery, each with 50 members, the department chair probably can't do the review. "But if you have many specialty departments with three or four members, you might be able to have the department chair do the focused reviews, because he is not looking at that many people," she says.

Not a punitive process

"Peer review is a great opportunity to partner with physicians to help each other keep abreast of the ever-changing standards of care," says Angela Lenox, peer review manager at Memorial Hermann Texas Medical Center in Houston. "If people keep viewing it as a punitive process, we will miss this great opportunity."

For both the focused and ongoing evaluations, your organization's written policy should emphasize that the peer review process is intended to be "educational, not punitive," says Phil Zarone, JD, an attorney with the health care law firm Horty, Springer & Mattern, based in Pittsburgh. Policies should avoid assigning "scores" and instead, focus on narrative evaluations that can be used as a basis for improving a practitioner's performance, he recommends.

Your process should emphasize communication between the peer reviewers and the practitioner under review, and the practitioner should be invited to provide input early and often, advises Zarone. "The policy should recognize the wide range of options that are available to develop a performance improvement plan to help the practitioner get better," he says.

This approach requires staff buy-in and awareness that the goal of the process is to make sure that good care is being provided, not to target individual practitioners. Many times, patients have comorbidities and no matter what is done, they aren't going to get better, acknowledges Herringer.

"If you are using everybody to monitor the quality of care, it is no longer a punitive process; it is a very constructive process," says Herringer. "You don't want to see the sentinel events and find out after two years this guy has really lousy practice and why didn't we know that earlier."

Compliance might mean spending more resources, and that will depend on your current process. "If you are meeting monthly and looking at all the data, you might have data for an extra 10 people but it might not mean much of a change," says Herringer. "But if nobody is looking at the data except every two years, it may mean developing a new computer program or hiring more people."

The reality, though, is that many organizations currently look at data only every two years, and most have a peer review program that is outlier-based. "We want to be more proactive, but you can start small. Look at two charts a year for everybody — just randomly pull them," says Herringer.

The bottom line is that The Joint Commission doesn't want hospitals to wait until high infection rates or unexpected deaths occur to find out there is a problem with a provider. "Don't wait for something to happen. If nothing happens, then you have never looked at anybody," Herringer says. "Did nothing happen by luck or because nobody is doing a great job?"

Although The Joint Commission's performance improvement standards (MS.3.20) already had required the medical staff to incorporate performance improvement information into the ongoing evaluation of a practitioner's competence, the new standards impose somewhat more detailed requirements, and show that The Joint Commission is serious about this issue, says Zarone.

"The biggest challenge will be changing the mindset that a practitioner's performance need only be evaluated in a serious way once every two years, at reappointment," says Zarone.

It may be relatively easy for departments and the medical staff to adopt specialty-specific criteria for ongoing professional practice evaluation as required by The Joint Commission, and to generate reports every so often showing how a practitioner is doing. "The harder part will be asking medical staff leaders to find the time to review the data and sit down with practitioners on a periodic basis to discuss any potential issues," predicts Zarone.

There will be more data generated as a result of The Joint Commission's new requirements, says Zarone. "Quality professionals will hopefully have an expanded role in reviewing that data and communicating certain results to the practitioner, such as those that do not necessarily require physician review, such as failure to complete H&Ps, to the practitioner."

Look at all your data

Data collection requirements call for "a lot of work to be done by a lot of people," says Christina W. Giles, CPMSM, MS, president of Nashua, NH-based Medical Staff Solutions. "This needs to be a team effort." Include physicians, medical staff presidents, quality professionals, risk professionals, advanced practice registered nurses, physician's assistants, and any other practitioners who are granted privileges at a particular organization.

Most medical staffs have developed specialty- or department-specific indicators, which they have been using to assess some level of competence of their members, but the traditional approach has been, "'If there is a lack of negative information then that means everything is OK,'" says Giles.

Now, documented evidence of competence must be provided, says Giles. "In other words, we must have information that portrays that the practitioner is qualified to perform the privileges requested — which is totally different than what has been done."

By requiring hospitals to consider the Accreditation Council for Graduate Medical Education competencies in credentialing and privileging activities, The Joint Commission is recognizing a broader understanding of the term "competence," says Zarone.

"In the past, there may have been a tendency to focus on technical proficiency. Now, The Joint Commission is explicitly recognizing that a practitioner's ability to work as a member of a team is critical to providing safe and effective care," says Zarone.

Although the medical staff bylaws of many hospitals have addressed behavioral issues for years, The Joint Commission had not really required them to do so. "Now, every hospital will have to think about 'competence' in a much broader way," says Zarone.

The ongoing practice evaluation was added because The Joint Commission wants organizations to look at data as they become available instead of waiting two years, in order to take action on performance issues earlier. "Why would we want you to wait every two years when three months of data could have identified a problem and some sort of action taken?" asks Herringer.

To comply with the ongoing review requirement, The Joint Commission wants you to "look at everything — the good data, too, not just the bad data," says Herringer. Your "bad" data will serve as triggers to identify potential problems and comply with the focused review requirements, but good data are also important information.

"It's excellent news that somebody is an exemplary practitioner. And you might be able to extract some of his practice patterns to the rest of the medical staff," says Herringer. "For example, all of Dr. Brown's [congestive heart failure] patients have excellent outcomes, he has a shorter length of stay and the cost of care is less. His outcomes are better than somebody else's, so can we learn from him?"

Other practitioners might be encouraged to adopt some of a high-performing physician's practices, such as medication regimens or therapy orders.

This is altogether different from the approach most organizations currently use —- to look for negative patterns or trends, which then get sent for peer review. "Everybody seems to associate data collection with trying to identify problems, but I want to see both," says Herringer. "You can learn things from good data, too. We want to know who the good practitioners are."

If your peer review process is triggered only by negative events, staff won't want to participate because punishment is the expected outcome, says Herringer. "That's not what we want it to be. We want you to learn and move forward based on good examples," he says.

For too long, peer review has been delegated to sentinel events with a reactive focus instead of proactive, says Freedman. "An awful thing happened, so let's circle the wagons and figure out what to do," he says. "The Joint Commission is trying to be more predictive, instead of putting the fire out once it starts to burn."

You can do the right thing and have a bad outcome, and you can also do the wrong thing and not have a bad outcome, says Freedman. "If you're not doing an ongoing review, how would you know the difference?" he asks. "Sooner or later something's going to happen, but that's not the first time it's been done. It's just the first time it went sour."

If doctors are put on the defensive, they are less open to receiving education that could change their future skills and behavior, says Freedman, and will be less defensive if a rotating approach is used. "If you realize that your cases are being looked at just because it's your turn, you are less defensive than if cases are only being pulled because something bad has happened," he says.

[For more information, contact:

Skip Freedman, MD, Executive Medical Director, AllMed Healthcare Management, 621 SW Alder Street, Suite 740, Portland, OR 97205. Phone: (503) 274-9916. Fax: (503) 223-6244. E-mail:

Christina W. Giles, CPMSM, MS, President, Medical Staff Solutions, 32 Wood Street, Nashua, NH 03064. Phone: (603) 886-0444. Fax: (810) 277-0578. E-mail: Web:

Angela Lenox, Peer Review Manager, Memorial Hermann Texas Medical Center, Houston, TX. Phone: (713) 704-5076. E-mail:

Phil Zarone, Horty, Springer & Mattern, 4614 Fifth Avenue, Pittsburgh, PA 15213. Phone: (412) 687-7677. Fax: (412) 687-7692. E-mail: Web:]