Multiple dead/paralyzed patients spotlights peer review, credentialing
Credentialing is one of the most challenging standards for outpatient programs
Peer review is one of the most critical aspects of credentialing. If this step is neglected, and you wait until recredentialing to review a physician's performance, you might end up with worse than a bad outcome on an accreditation survey.
Consider this case: Christopher Duntsch, MD, a self-proclaimed expert in minimally invasive spinal surgeries, moved to Texas and was credentialed. Despite numerous poor outcomes and complaints from staff members and fellow physicians, he continued to operate for more than a year at one Texas hospital then another. He and his work were described as "the worst surgeon I've ever seen" and "surgical misadventures." At one point, the hospital where he was working ordered him to be supervised for every surgery. However, the edict wasn't enforced. During one case, the surgical staff had to physically restrain him to stop him from continuing to operate on a patient. The result of his work was four patients paralyzed and two patients who died. The Texas Medical Board indefinitely revoked his license because the board members decided that Duntsch posed a grave danger to patients.
"Respondent is unable to practice medicine with reasonable skill and safety due to impairment from drugs or alcohol," the state board concluded.1-2 (To see the full suspension order, go to http://bit.ly/14ZKAl5.)
A minimally invasive surgeon recently was suspended in Iowa after hospital officials learned that another state board had filed disciplinary action against him two years previously, according to a news report.3That state board concluded that the surgeon practiced medicine with a "mental disability" (narcissistic personality disorder) and engaged in unprofessional conduct. He previously had used latex gloves while performing surgery on a patient with a known history of latex allergies, according to the news report.
When should facilities intervene? "The first time something [adverse] happened: paralysis, a death in OR, hemorrhaging requiring blood usage, any major complication, immediately," says Joyce K. (Deno) Thomas, senior vice president of operations at Regent Surgical Health in Westchester, IL. Regent calls this process "intensive" peer review. The medical chart is pulled and every detail is examined by the medical executive committee (the director of nursing, the administrator, and the medical director) in a closed-door session, Thomas says.
At Regent, the case is given a "severity indicator" that can range from a non-significant finding all the way to S5, which means privileges are removed. The required action is graded from no action required (normal care) to 5, in which privileges are lost temporarily until there is a further investigation. At that point, the case goes before the board, Thomas says. The board agrees with the decision, disagrees, or asks for further information before making a final decision.
At Hanover, MA-based Ambulatory Surgical Centers of America (ASCOA), incident reports during a credentialing period are taken to the QA/PI committee and possibly peer reviewed, says Ann Geier, MS, RN, CNOR, CASC, senior vice president of operations. Peer review is "extremely important" and includes chart reviews, tissue review, and medical necessity, Geier says. Look for trends, and compare the physician's outcomes to internal and external benchmarks, she says. For example, what is the provider's infection/complication rate?
"You will concentrate on post-op infections, return to OR, unscheduled hospital admissions, excessive blood loss, neurological deficits, prolonged PACU stays, etc.," Geier says.
Any time there is a crucial incident with a patient, such as a patient transferred to a hospital because of some unforeseen circumstances, the peer review process should examine whether there was anything about these circumstances that could have been foreseen, says Ray Grundman, MSN, MPA, FNP-BC, CASC, senior director of external relations and surveyor, Accreditation Association of Ambulatory Health Care (AAAHC). Grundman says, "Ask, is there something more we need to know about patients we're admitting? Are we screening them properly?" (For advice on how to handle peer review at a small facility, see below.)
When it comes time for recredentialing, expand your focus, Thomas advises. "At reappointment, it's not just about looking at the big, OMG ones," she says. Thomas reviews data collected over two years though the QA program such as patient transfers to hospitals, infections, intraoperative complications, admissions to hospitals within 24 hours, and deaths within 24 hours. Keep a tally sheet, and break out the numbers for each physician, she suggests.
In the case above with reports of patients being paralyzed or dying, recredentialing, "if it was done conscientiously and thoroughly," should have caught the problems, Geier says. "The peer review, combined with the complaints voiced by other physicians, should have triggered so many red flags," she says. (See Geier's list of red flags, see below.)
Effective peer review is "intricately connected to reappointment and recredentialing," Grundman says. Credentialing and recredentialing show up as a major area of noncompliance (standard HR.02.01.03) in the first six months of 2013 for ambulatory programs (50%) and office-based surgery programs (60%) accredited by The Joint Commission. Recredentialing should be performed every two to three years, depending on your bylaws and your state regulations, sources say. Medicare has clarified that three years is acceptable for organizations that undergo deemed status surveys, Grundman says. However, make sure you are adhering to the timetable spelled out in your bylaws, he advises. Some facilities say they recredential every two years, but it ends up being about two and one-half years.
"They can change the bylaws and give themselves more time, but if the bylaws say one schedule, they need to maintain that," Grundman says.
Ensure someone on your staff is the lead person to keep files up to date, and be certain that this step continues when there is job turnover, he says. Audit your own records, and have a checklist for everything, with a tickler file for time-sensitive items, Grundman says. "Not everyone's license renews at the same time," he points out.
Consider these other essential elements of recredentialing:
• Recheck the paperwork to ensure it's current.
Recheck the license, says Joyce K. (Deno) Thomas, senior vice president of operations at Regent Surgical Health in Westchester, IL. "It's all online and very easy," Thomas says. Also, ensure staff members haven't had any state actions taken against them, Thomas says.
Ensure providers' malpractice insurance is renewed, up to date, and matches what your organization says they have to have, which can vary by state, Grundman says. If the physician allows the insurance company to list you as a named insured, you will hear directly from the insurance company if there is a lapse in coverage, sources say.
Also ensure the physician's immunizations are up to date, Grundman adds. Check board certification, and look at the specialty board requirements. These requirements will help you assess and monitor competency, Geier advises.
"Ensure that the physician has maintained board certification if this is required by the facility. If not, why not?" she says. "Did the physician require proctoring on site? What were the results?"
• Examine medical records.
Look at medical records to determine if there is adequate documentation of the surgical procedure, Grundman says. "Did the physician follow accepted norm for how these procedures are performed?" he asks. "Is this the most standard and up-to-date knowledge we're using?" (For information on monitoring physician outcomes, see story below.)
Also, answer these questions, Geier suggests: Are charts complete within the centers timeframe set in its policies? Are op notes dictated in a timely manner?
"Physicians and other providers do not like completing recredentialing forms, but the center/facility needs to focus as much attention on these as on the initial applications," Geier says. "Things can change, and it's your responsibility to ensure that you've taken the time and made the effort to ensure a qualified competent provider to each of your patients."
What provider outcomes should you check?
When recredentialing outpatient surgery providers, determine if someone is monitoring for surgical site infections (SSIs) or other complications after patients go home, says Ray Grundman, MSN, MPA, FNP-BC, CASC, senior director of external relations and surveyor, Accreditation Association of Ambulatory Health Care (AAAHC).
"This is an obligation of the medical staff: to have ongoing monitoring to ensure the medical staff member maintains a high level of competence and qualification," Grundman says.
Look at use of new technology, says Ann Geier, MS, RN, CNOR, CASC, senior vice president of operations. "If the provider used new technology, how competent were they?" Geier says. "Look at the complication rate."
Check the National Practitioner Data Bank (NPDB). Joyce K. (Deno) Thomas says, senior vice president of operations at Regent Surgical Health in Westchester, IL, says, "It's the bad girl/bad boy report card." Also review where providers have privileges to ensure they still are in good standing, Thomas says.
Have the board determine the minimum number of cases the physicians must perform in the center, Geier says. "If they do not perform the minimum number, it makes it very difficult to determine competency," she says. "Other facilities rarely share information, if asked."
If a low number of cases were performed or you are trying to recredential PAs or CRNAs who don't come to your center very often, you might need to rely on "new" peer references, Geier says. "Focus on competency, and try to use open-ended questions rather than checklists," she says.
Check patient satisfaction surveys and patient complaints. For recredentialing, "the provider has a track record in your center, and you should look for positive and negative feedback from your patients and families that relate to the provider," Geier says.
Is your facility small? Use this tip for peer review
Peer review is a challenge for very small facilities, acknowledges Joyce K. (Deno) Thomas, senior vice president of operations, at Regent Surgical Health in Westchester, IL. You might have two physicians, in different specialties, and they might not feel comfortable weighing in on whether complications are normal or not, she says.
In that case, Thomas has taken identifying information for the physician and patient out of the patient record and contacted a physician who is fellowship-trained in that specialty in another city. She pays them a few hundred dollars to review the case.
"If you're really concerned about the practice of the doctor, it behooves you to pay and have someone in another community take a look at it," Thomas says. "You're not destroying patient confidentiality. You're not destroying the doctor's reputation, but you have intensive peer review of the complication."
She has received rave reviews from The Joint Commission, Medicare, and her state for this process. "They felt that was the true meaning of peer review," Thomas says. And the benefits that extend beyond accreditation, she says. "If there is a risk of a lawsuit, and you're really questioning if the doctor has the required skill level, that $200 [or more] could mean the difference between your current situation and a $100,000 lawsuit."
1. Nicholson E. Authorities say a Plano neurosurgeon killed, paralyzed and left sponges inside patients. Dallas Observer. June 27, 2013. Accessed at http://bit.ly/18ifCF9.
2. Elbein S. Anatomy of a tragedy. The Texas Observer. Aug. 28, 2013. Accessed at http://www.texasobserver.org/anatomy-tragedy.
3. Kaufman K. Shenandoah hospital suspends doctor after learning Iowa board filed disciplinary action. Omaha (NE) World-Herald. Sept. 10, 2013. Accessed at http://bit.ly/14n3z6m.