In a recent commentary, surgeon credentialing was described as a “big blind spot.” A recent court case appears to back up that claim.
- Perform trend analysis, and query the National Practitioner Data Bank.
- Have a process to adequately track credentialing files, along with a policy and procedure on credentialing.
- For mature surgeons learning new procedures, consider extensive training in a fully proctored environment.
Surgeon credentialing is a “big blind spot” for healthcare providers, according to a recent published commentary in the The Journal of the American Medical Association.1 The authors point to a current case, the first of its kind to make it to court, involving a surgical robot from Intuitive Surgical in Sunnyvale, CA.
In that case, a jury ruled that Intuitive wasn’t liable for the death of a patient who had undergone a robotic prostatectomy. The surgeon’s only training had been from Intuitive’s program, and the hospital’s credentialing criteria were based completely on the company’s program, the lawsuit claims. The hospital and surgeon settled before the case went to trial. The case against Intuitive is being appealed, and a ruling could come this summer. The case is being eyed closely: More than 20 other cases involving robots and training are pending. The authors of the recent JAMA commentary say that healthcare providers lack robust processes for credentialing and privileging surgeons on new technology and procedures. They call on providers and professional societies to address the issue.
In an interview with JAMA, one of the authors said surgeons and healthcare facilities have little guidance on what qualifies as “adequate” training.
“We should acknowledge that new technologies and new procedures have benefits, but that sometimes the technology gets ahead of the evidence,” says Justin Dimick, MD, MPH, faculty member at the University of Michigan (U-M) Medical School. Dimick says that marketing by the manufacturer often drives demand for new procedures and techniques. “We need to rein in the technology so that it doesn’t extend beyond where we know it’s beneficial, and where there are knowledge gaps, we have to perform rigorous studies to address them,” Dimick says.
This study is not the only recent publicity on the issue of credentialing. In the investigation following the death of Joan Rivers, the Centers for Medicare and Medicaid Services said one of the items that could have contributed to Rivers’ death was that the clinic failed to ensure that she was cared for only by physicians granted privileges in accordance with the clinic’s bylaws. (For more information, see “Malpractice caused Joan Rivers’ death, critics say,” Same-Day Surgery, February 2015, p. 21.)
While some professional associations offer online classes that teach new skills, these classes often are basic and not likely to help with credentialing, says U-M medical student Jason Pradarelli, who helped co-author the JAMA commentary.
A look at accreditation statistics confirms the challenge that credentialing poses for ambulatory organizations. When looking at statistics from organizations that were surveyed by The Joint Commission in 2014, 52% of ambulatory organizations and 47% of office-based surgery facilities were noncompliant with HR.02.01.013: “The organization grants initial, renewed or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.”
Here are some of the specific issues:
• Providers don’t understand why credentialing is necessary.
Surgeons often know each other, notes Marshall Baker, MS, FACMPE, who is a surveyor with the Accreditation Association for Ambulatory Health Care and president and CEO of Physician Advisory Service, a Boise, ID, consulting firm that offers physician alignment and strategic positioning for physicians and related healthcare organizations.
When a new surgeon comes to an outpatient surgery center, he or she often has been in the community for years and is well known, Baker says. “There’s the classic response, ‘I don’t need to know any more about this individual. I’ve known them X years. They wouldn’t be practicing in this community if they didn’t have a license.’”
• There is a question of who will do the credentialing.
Some outpatient surgery facilities might have inadequate staffing to manage the credentialing process, say sources interviewed by Same-Day Surgery.
The problem is particularly prevalent in an office-based or solo environment, Baker says. The surgeon might have the position that “I have a license and insurance and all the requisites to practice here. Now you’re forcing me to jump through a formal number of hoops.”
Resentment also comes up in reappointment, Baker says. “Since nothing has changed since day one, they react,” he says. “They say, ‘Why do I have to go through this again?’”
The solution? Just do it, Baker says. “I think that some settings have made it a little too complicated,” he says. “I think they try to read too much into it.”
Consider these solutions:
• Have peer review and ongoing monitoring.
Don’t rely solely on clinical record reviews for reappointment, Baker says. “It needs to involve trend analysis for any procedure events that would trigger the question, ‘why did this happen?’” When there has been a questionable outcome, the procedure needs to be reviewed from check-in through discharge, he says.
The most common ‘oops’
Ongoing monitoring is important, Baker says. Some facilities are guilty of leaving the credentialing file closed after the appointment or reappointment is done.
“Probably the most common ‘oops’ we have on survey is that they have not queried the National Practitioner Data Bank,” Baker says. “It’s just a matter of dedicating time and at least appointing a credentials specialist on your staff to shepherd all of this, to make sure everything necessary is in the file.”
Solo practices can exchange peer review responsibilities with someone in their community, Baker says.
Having experienced surgeons review videotapes of surgeons performing procedures, and offer ratings and feedback about their skills, also might help, Pradarelli says. Healthcare facilities can use this system to determine which physicians should be credentialed and which ones need further training, he says. Pradarelli points out that this approach is used in the bariatric surgery quality improvement effort led by U-M surgeons and funded by Blue Cross Blue Shield of Michigan. U-M performed research that indicated the surgeon ratings in this system were linked to how well patients did after surgery.
• Assign a staff member.
You can use a credential verification organization to gather the data, says Steve Chinn, DPM, MS, MBA, consultant for Joint Commission Resources in Oak Brook, IL. If you are a freestanding center, a non-competing accredited hospital might be able to help you gather information, Chinn says. If you are in a joint venture with a hospital and most of your surgeons also practice at that hospital, you might ask the hospital to contract out to perform your credentialing verification as they are obtaining the same information for their own credentialing of the same physicians, he says.
You can use your own staff, but they might be unfamiliar with the requirements needed for proper credentialing and recredentialing, he says.
“Education and ongoing training for staff is important,” Chinn says. Consider having these staff members join medical staffing associations or state medical associations so they can connect with other individuals who do the same work, he advises. “Sometimes having a friendly person to bounce a question off of can serve as the necessary resource needed to make the credentialing process seamless,” Chinn says.
Credentialing is not a simple task, he says. “The staff responsible have to understand precisely what they are looking for and need to be detail-oriented, as well as able to follow up and follow through,” Chinn says.
Also, provide ongoing training, he emphasizes.
• Have extensive training and proctoring for surgeons.
For now, an extensive training experience in a fully proctored environment might be the best approach for mature surgeons to learn new procedures, Dimick says. This type of environment could benefit healthcare facilities because they can ensure their surgeons can perform new operations and use new technology safely, he says.
• Have a system.
Some facilities have no system in place to adequately track credentialing files, Chinn says.
“Regardless of whether an outpatient surgery center has a paper system or an electronic system, if it does not have a systematic way of making sure everything is in place before obtaining approval or tracking the reappointment in two years, the process will fail,” he says.
Electronic systems might not be customizable, Chinn says. “Surgery centers might consider leasing software or purchasing web-hosted applications, where the software resides in the ‘cloud’ and not on servers,” he says.
Electronic systems might include automatic reminders for when required documentation, such as license or medical malpractice insurance certificates, are about to expire.
Also, sometimes medical staff members try to fast track or shortcut the facility’s system and processes, Chinn says.
The solution? Develop a policy and procedure documenting the time it takes to gather and confirm credentialing information, he says. “While the majority of physicians are going to be OK with the process in place, there may be some who expect shortcuts,” Chinn says. “The policy and procedure can serve as your defense by outlining the checks and balances that must be in place in order to provide safe and quality patient care.”
1. Pradarelli JC, Campbell DA Jr, Dimick JB. Hospital credentialing and privileging of surgeons — A potential safety blind spot. JAMA 2015; 313(13):1313-1314; doi:10.1001/jama.2015.1943.
- Viewpoint and interview in The Journal of the American Medical Association. Web: http://bit.ly/1JoyYrC.
- For organizations accredited by The Joint Commission, the organization offers a free BoosterPak on Credentialing & Privileging in Non-Hospital Settings. Access at http://bit.ly/1eiqo3K.
- The Joint Commission also offers a free resource titled The Who, What, When and Where’s of Credentialing and Privileging. Web: http://bit.ly/1cQl46w.