JCAHO's new credentialing, privileging standards require provider-specific data

Surveyors will be looking for continuous evaluation

New standards for the credentialing and privileging of practitioners call for a more objective and evidence-based process for monitoring performance. The standards from the Joint Commission on Accreditation of Healthcare Organizations, which are effective Jan. 1, 2007, also require a process for intervening when safety and quality-of-care issues are identified.

"More detailed information will need to be collected on an ongoing basis," says John Herringer, associate director of JCAHO's standards interpretation group and lead interpreter for medical staff standards.

To comply with the standard, organizations will need to continuously collect additional information about physician performance. "That will definitely be a challenge," says Christina W. Giles, CPMSM, MS, president of Medical Staff Solutions, a Nashua, NH- based consulting firm specializing in assessment and development of medical staff organizational structures in the hospital environment. "In my experience with clients all over the country, currently the weakest link in the credentialing and privileging program is how much information and the type of information that gets collected at reappointment or reprivileging time."

In general, the Joint Commission wants organizations to start reviewing selected data on an ongoing basis, to determine whether a practitioner can maintain his or her privileges. "The issue was really that people were doing this every two years, and there wasn't a process to evaluate people on a continuous basis," says Herringer. "Organizations are not going to be just looking at the person every two years. They are going to be looking at them continuously."

Provider-specific data

Organizations will define the criteria to be collected for ongoing professional practice evaluation themselves. The Joint Commission says this may include the following: review of operative and other clinical procedures performed and their outcomes, pattern of blood and pharmaceutical use, requests for tests and procedures, length-of-stay patterns, morbidity and mortality data, and the practitioner's use of consultants. "But because we use the word 'may,' that indicates that they still have to define it. Organizations can include things other than the examples we give," says Herringer.

The new requirements will require provider-specific data to be collected, but many hospitals have collected only aggregate physician data to trend performance improvement, says Nancy J. Auer, MD, FACEP, chief medical officer for Swedish Health Services in Seattle.

"Many institutions went this route believing — correctly — that the physicians wouldn't participate in performance improvement activities if they knew they personally were being profiled," says Auer. "Data systems are not perfect. It is imperative that physicians work with their institutions to help turn the data into credible information."

Organizations are supposed to be collecting data on each individual, says Herringer. "You should always be looking at the provider data. For example, if, on average, antibiotics were prescribed 300 times but Dr. Jones is prescribing them 700 times and has high infection rates because he is over-prescribing, it's pointless to just look at the aggregate," he says.

In order to get to the aggregate physician data, you need to have the practitioner-specific data anyway, he notes. "You want to look to see, how is he practicing compared to the rest of his peers for that particular measure?" Herringer says.

What organizations were failing to do is compare the provider-specific data with the aggregate data, says Herringer. "They always had the data, but they weren't comparing the person to the aggregate. That's why we added that to the standard in 2004. It does come from the performance improvement data, but those are broad categories."

Depending on what you are measuring, you may or may not have data for every practitioner for a given measure. For example, if you decided you wanted to look at something related to Cesarean sections for operative and other procedures, then you are omitting all the other surgical procedures, so you won't have data for the other types of surgeons.

"We've never said you have to find a measure that relates to every different type of surgical procedure that you could possibly do," says Herringer. "You may not have data for every practitioner for that measure. For some practitioners, you really could end up having no data."

For instance, psychiatrists don't do surgical procedures, or if the medication used in your measure doesn't relate to psychiatry, you won't have any data there. "It's totally possible that your measures won't relate to certain people. What we're trying to move away from is collecting data about everybody, as opposed to just linking it to the performance improvement measures," says Herringer.

You're required to define what data you're going to collect for every practitioner, and it must be related to performance improvement measures, and you will look at whatever data you have for that person. "But you wouldn't necessarily have data for everybody," says Herringer.

For this situation, organizations can attempt to obtain data from other facilities where the person practices, but data are often protected under peer review statutes. In this case, the organization would obtain additional peer recommendations, and the lack of data might be defined as a trigger for focused review, says Herringer.

"When we're granting privileges, we don't necessarily have data and competencies for every single procedure," says Kathy Downs, CPMSM, CPCS, CPHQ, director of medical staff services at Paradise Valley Hospital in National City, CA. "It may be that, for low-volume practitioners in particular, we will have to end up getting data from other hospitals, and that may be difficult."

Take action on problems

Hospitals also are required to act on what the data are telling them, always with the goal of improving performance. Surveyors will want to see how individual departments have used the information to improve patient care.

"At Swedish, we are revamping our data collection tools to collect physician-specific data," says Auer. "This approach is really effective. You can't just wait to provide feedback to physicians at re-credentialing if you want performance to improve."

For example, the organization had trouble eliminating dangerous abbreviations until data were collected that included the name of the physician and the type of do-not-use abbreviation used. "We fed this data, in an educational fashion, back to the physicians on a weekly basis," says Auer. "Our performance improved dramatically."

Indicators that will trigger a chart review at Paradise Valley Hospital include unplanned return to the operating room, readmission within 24 hours, a certain amount of blood lost, and unplanned removal of an organ.

After physicians review the patient's chart, any additional questions are sent to a committee for further discussion. "Sometimes, the physician whose case it is will even be there as a member of the committee and can explain what happened. Or they may send a letter to the physician asking for a written explanation, or they will ask him or her to come to the committee meeting to clarify questions," says Downs. The committee then determines what further action, if any, needs to be taken.

The organization has been moving toward "core" privileges for many procedures that physicians can do by virtue of their training, such as appendectomies for general surgeons, as opposed to "non-core" privileges that require special or additional training such as laparoscopic hernia repair. "We will just have to be more vigilant with the non-core procedures, especially for those physicians who perform most of their procedures at other facilities," says Downs. "It may be difficult to get the needed information from other hospitals."

JCAHO's credentialing and privileging standards do not reference the concept of core privileges, nor do they suggest or promote a particular format for granting privileges, notes Herringer. However, the following activities would be expected to occur during the credentialing and privileging process for any type of format utilized, he says:

  • The core privileges must be clearly and correctly defined to reflect the specific activities and procedures performed at the organization that the majority of the applicable group of practitioners can do.
  • There should be a method for the applicant to request only certain items in the core privileges if he or she does not want the full set of core procedures.
  • If it is determined that the applicant cannot perform certain activities, then the core privileges must be modified for that applicant, who is then appropriately notified of the modification along with other organization staff. For example, if the core surgical privileges include laser procedures but an applicant is not competent in laser surgery, then the laser privileges are deleted from that applicant's core listing and other appropriate staff in the organization are notified of the modification.
  • The organization must evaluate each applicant's education, training, and competence to perform each activity listed in the core privileges. "It cannot be assumed that every applicant can do everything listed," says Herringer.

How is competency defined?

Defining competency is up to the individual organization, says Herringer. "They really have to determine what qualifications they want people to have. It could be they want a training program, a certain volume of activity, or board certification," he says. "We don't define it. There are certain rural parts of the country where they couldn't get a board-certified person if they wanted to."

There is a lot of disagreement about what defines competency among organizations. "If no charts have fallen out and there have been no complications for surgery, for example, does that indicate competency? Or do they have to perform a certain number of procedures competently to validate that they are competent — or both?" asks Downs.

Currently, the organization's process involves looking at whether any charts have fallen out for review and what the doctors' outcomes are, and also the numbers of procedures performed.

For any organization, the first step in the process is to determine what defines competency. "While JCAHO has done a great job of incorporating the six core competencies that have been established by the Accreditation Council of Graduate Medical Education [ACGME] and the American Board of Medical Specialties [ABMS], it still leaves us out there not knowing exactly how to do what we need to do," says Giles. "I think we will have to zero in and look at outcomes."

Some hospitals have begun to make some of their outcome information public, but this is usually based more on procedures than practitioners, says Giles. "So I do think that we have the ability to track the information. It's just a matter of figuring out who is going to collect it, how is it going to be maintained, and how is it going to be presented."

Medical staff in most hospitals are aware that physician report cards are being developed at all levels of the organization, but there is still some reticence on the part of medical staff and hospitals to actually use that information at reappointment or reprivileging, according to Giles.

"I think the biggest challenge is going to be what type of privileging process are we going to use, so that we know the practitioner is competent to perform what they are asking," she says. The challenge is getting the doctors to buy into whatever system is used for measurement, says Giles.

"But the advantage there is that the ABMS and some of the others are going to be moving forward in trying to define how they are going to measure it," says Giles. "Hopefully we can use some of the same mechanisms."

Research what all the different American boards of specialties are using, recommends Giles. "They all have different maintenance of certification programs and there may be some things that can be borrowed from that."

For example, the ACGME has done a lot of work on the six core competencies and what kind of data they are going to collect and use to measure residents, so some of those ideas can be "borrowed."

"I think that hospitals have done a good job of going in and stopping someone if they are totally incompetent. But I also think that sometimes the peer review process takes a little too long to get going," says Giles.

Many organizations currently lack triggers to take action on a continuous basis. "You could potentially have two years of problems and then start to take action. Waiting every two years is not necessarily appropriate," says Herringer. "You will have to clearly define what triggers performance monitoring. There could be a variety of triggers that say 'We need to watch this guy,' such as a number of complaints, sentinel events, or increased infection rates."

Change mindset of physicians

As of Jan. 1, 2008, the Joint Commission will require a Focused Professional Practice Evaluation. "This will be challenging for organizations to implement, and that's why it's been delayed," says Herringer. "Criteria need to be defined for when they are going to grant a privilege for a new applicant vs. criteria for an applicant with a documented record of performance at the organization."

Any practitioner who is totally new to the organization will get a period of focused review, and in addition, any practitioner asking for a new privilege also will be under focused review.

Medical staff will always have to be involved in defining the credentialing and privileging process, including implementation of the Focused Professional Practice Evaluation, since the bylaws have to be approved by both the medical staff and the hospital's governing body.

Depending on what type of performance monitoring is done as a result of triggers identified, members of the medical staff might be involved in that as well.

"They might say that a standby physician is needed for every one of these surgeries, or it might involve certain other physicians reviewing the record and documentation," says Herringer. "We don't specifically tell organizations how to monitor them. They have to decide that for themselves."

The goal of the process is to prove that physicians are competent, not the opposite, according to Giles. "So what we have to do is change the mindset of the medical staff — instead of looking for the negative, that the whole process is looking for the positive," she says. "We have to provide proof that they are doing a good job. So they should be helpful in trying to identify what mechanisms we can use to show that."

[For more information, contact:

Nancy J. Auer, MD, FACEP, Chief Medical Officer, Swedish Health Services, 747 Broadway, Seattle, WA 98122. Telephone: (206) 386-6071. E-mail: Nancy.Auer@swedish.org.

Kathy Downs, CPMSM, CPCS, CPHQ, Director of Medical Staff Services Paradise Valley Hospital, 2400 E. 4th Street, National City, CA 91950. Telephone: (619) 470-4156. Fax: (619) 472-4502. E-mail: DownsKA@ah.org.

Christina W. Giles, CPMSM, MS, President, Medical Staff Solutions, 32 Wood Street, Nashua, NH 03064. Telephone: (603) 886-0444. Fax: (810) 277-0578. E-mail: chriswg@medicalstaffsolutions.net.]