Navigating the Stormy Waters: Strategies for …

1 Navigating the Stormy Waters: Strategies for medical staff Professionals to ensure smoother sailing Session Code: MN04 Time: 10:00 11:30 Total CE Credits: Presented by: Heather Fields, JD and Sarah Coyne, JD 1 Navigating the Stormy Waters: Strategies for medical staff Professionals to ensure smoother SailingOctober 6, 2014 Presented by: Sarah Coyne and Heather FieldsAgendaPeer review ImmunityPeer review Access to PHI and ConfidentialitySocial Media LAWS AND STANDARDS AFFECTING peer review - Medicare Conditions of Participation- The Joint Commission (or other accrediting agency)- State Law ( peer review , confidentiality , reporting)

2 - Health Care Quality Improvement Act / NPDB regs- Federal Patient Safety and Quality Improvement Act- medical staff Bylaws/ Polices- A Mish Mash of Other Federal Safety and confidentiality Laws2 Medicare Conditions of ParticipationGive the ORGANIZED medical staff responsibility for peer Not the Not Hospital DEFINITELY not Human the balance between governing body and medical staff creating a system of checks and balances for each individual NOT confuse employment disciplinary review with medical staff peer review and don t let anyone else confuse the two either!

3 Joint Commission:Performance MeasurementAn ongoing process involving continuous evaluation of a practitioner s performance. Focused professional Practice Evaluation (FPPE) Ongoing professional Practice Evaluation (OPPE)(Focused professional Practice Evaluation) FPPEE valuating the privilege-specific competence of the practitioner who does not have documented evidence of competently performing the requested privilegeWhen is it used? When a provider is initially granted privileges; When new privileges are requested for an already privileged provider; and When poor performance involving a privileged provider is identified (through OPPE or other means, , complaints)3 FPPE TriggersThe triggers for performance monitoring must be clearly defined.

4 Triggers may be single incidents or evidence of a clinical practice pattern. Practice notes: Many policies we see do not have clearly defined triggers Policies sometimes fail to allow elevation to the corrective action processFPPE ProcessThe performance monitoring process must be clearly defined and include each of the following elements: Criteria for conducting performance monitoring; Method for establishing a monitoring plan specific to the requested privilege; Method for determining the duration of performance monitoring; and Circumstances under which monitoring by an external source is Information for the FPPEM ethodologies include: Periodic chart review ; Direct observation; Monitoring of diagnostic and treatment techniques; Interviews/ input with others involved in care.

5 , might monitor first cases of a high risk surgery4 Goals: Part of the effort to monitor professional competency To identify areas for possible performance improvement by individual practitioners To use objective data in decisions regarding continuance of practice privileges OPPENeed a Clearly Defined ProcessNeed a clearly defined OPPE process to evaluate each professional Clearly defined includes, but is not limited to, Who is responsible for reviewing performance data; How often the data will be reviewed; The process to be implemented to use the data and make decisions on privileges; and How data will be incorporated into the quality Used in the OPPEC riteria may include the following: review of operative and other clinical procedures performed and their outcomes; Pattern of blood and pharmaceutical usage; Requests for tests and procedures; Length of stay patterns; Morbidity and mortality data; Practitioner s use of consultants.

6 Other relevant criteria as determined by the medical for Collecting InformationMethodologies for collecting information include: Periodic chart review Direct observations Monitoring of diagnostic and treatment techniques; and Discussion with other individuals. Some types of data apply to all practitioners, and there might need to be specific data for other types of Results After EvaluationDetermine the practitioner is performing well or within desired expectations and no further action is that an issue exists that requires a focused action, including summary suspension.

7 As that zero performance should trigger a focused review whenever the practitioner actually performs the the privilege should be continued because the organization s mission is to be able to provide the privilege to its RecommendationsPeer evaluations: : In circumstances where there are insufficient peer review data available when evaluating an applicant for privileges, the organized medical staff uses peer recommendations. A recommendation(s) from peers reflects a basis for recommending the granting of privileges. Peers: appropriate practitioners in the same professional discipline as the applicant who have personal knowledge of the Does peer review Cross Over to Corrective Action?

8 Concerns in an initial application for appointment to a medical staffConcerns in a reappointment applicationPeer review process/ FPPE/ OPPE/ Quality AssurancePatient/ staff complaintsConduct considered below the standard of care, an imminent danger to the health and safety of patients, disruptive to hospital operations, unprofessional, and/or unethicalCorrective Action Appropriate?Collegial intervention is kinder and gentler, and usually a good first step (unless egregious).Everyone involved should keep detailed documentation of any actions taken prior to commencing corrective action can be a point of no return in the hospital/physician s relationship can lead to claims, process should err on the side of fairness to the staff Bylaws Corrective ActionThe corrective action process must be followed EXACTLY as laid out in the Bylaws Bylaws should contain clear enumeration of grounds for corrective action Bylaws should contain a clear.

9 Specific plan laying out due process rights 7 peer review IMMUNITY PolicyEncourage health care providers to perform quality control reviews aimed at improving services, free and open discussion to improve treatment by the ability of physicians with quality issues to move from place to : immunity from civil liability for peer Govt. SolutionsHealth Care Quality Immunity Act (HCQIA)National Practitioner Data Bank (NPDB)8 Health Care Quality Improvement ActTwo types of immunity: For those providing information in a professional review action (PRA) -- unless they lied.

10 For those conducting the PRA, if taken:1. in the reasonable belief that it was in furtherance of quality health care;2. after a reasonable effort to obtain the facts of the matter;3. after adequate notice and hearing procedures are afforded to the physician involved; and4. in the reasonable belief that the action was warranted by the facts To Investigate- Must be in furtherance of health care Must involve a reasonable effort to discern the facts of the Once the physician is under investigation, voluntary surrender of privileges triggers report to Policies should define clearly when investigations If the resignation is to AVOID investigation, that is also Notice And HearingTwo kinds of notice-Notice of the action ( a recommendation to limit privileges)