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New Joint Commission medical staff standards

By Skip Freedman, M.D.

The Joint Commission (JCAHO) medical staff standards released this year broaden peer review and push it into new areas of physician evaluation as well. Besides defining the two new evaluation standards, the commission is also pushing hospitals toward unbiased and evidence-based decisions in credentialing and privileging.

According to the Joint Commission, there are now two types of physician evaluations: a focused evaluation (MS.4.30) and an ongoing professional practice evaluation (MS.4.40). These standards now outdate many hospital policies and practices governing both internal and external peer review, and call for a comprehensive revision to comply with physician performance evaluations. The implication is that hospitals and clinics must address conflict of interest when credentialing, privileging and conducting peer reviews of physicians.

Focused and Ongoing Evaluations Explained

The focused evaluation is an intense appraisal of a practitioner’s credentials and current competence. The focused evaluation covers credentialing. It applies to new medical staff applicants, current practitioners who request new privileges or when the hospital has no evidence of a practitioners’ competence. It also applies to practitioners with negative performances or those falling short of the volume of cases required for assessing practice competence.

The ongoing professional practice evaluation goes beyond the historical case-by-case peer review and evaluates clustered practice areas in the hospital. Hospitals and clinics now must supplement traditional evaluation practices with reliable outcome and performance data. This information can come from many sources, such as direct observation, practice patterns, aggregated analyses of resource usage, patient outcomes, complaints, peer review, and comparative performance measurements against large databases like the Society for Thoracic Surgery registry, or the American College of Cardiology and American Heart Association for interventions on surgery.

New Standards Increase Conflict of Interest

One side effect of the new Joint Commission standards is that the increased intensity of physician evaluations bumps up against conflict of interest more frequently. As hospital credentialing and privileging requirements necessitate more comprehensive peer reviews, hospital administrators and internal peer review committees must always consider conflict of interest situations when they conduct either focused or ongoing evaluations. Ignoring probable conflicts of interest opens the door for a “conflicted” specialist practitioner to review another inadvertently, which can decrease the quality of care, as well as patient safety.

To meet quality of care guidelines, insure objectivity and bring about positive outcomes to protect patients, practitioners must review only others who are “like specialists.” That is, cardiologists should review cardiologists, not other internal medical specialists. Demographics alone increases the chance a reviewer will have a professional, social or personal connection with other peer specialists that may taint the objectivity of a review. The size of the hospital group and the size of the community are factors in finding “like specialists” with no potential conflict of interest. In smaller communities and hospital groups, it is likely that a “like specialist” will have a conflict of interest, because the community and the pool of specialists are smaller and the potential for professional or personal interaction is higher.

Reviewing practitioners should be educated about all potential conflict of interest issues. Hospitals must understand the web of economic, competitive, and social or personal relationships that can raise concerns. Whenever a reviewer is in partnership, competes for patients or socializes with the reviewed physician, the question of conflict of interest should be raised. Ideally, a reviewer who knows this will alert the committee chair when a conflict exists and request an alternate reviewer. When a suitable one is not available, the committee chair should consider an external peer review.

Once a hospital establishes transparent standards and the interconnections of its medical staffs’ relationships, it can manage them. With this knowledge, a hospital then can randomly select several cases from all practitioners to meet the ongoing evaluation requirement. Other hospitals are scheduling rotating ongoing evaluations of their medical staff several times a year with independent review organizations to eliminate conflict of interest concerns about their reviews. However, using either process, the hospital can validate the competence of every practitioner to perform specific privileges once no conflict of interest is involved.

Granting Privileges and Credentials

In the past, hospitals did not treat the credentialing, licensing and privileging of physicians as a peer review activity. Today they must. Due to long-standing personal and professional relationships, staff constraints, limited time and similar issues, these processes in the past often defaulted to “rubber stamp” evaluations at some hospitals. Now the Joint Commission recommends all members of the medical staff regularly undergo a professional practice evaluation to re-credential them for continued membership and to reassign privileges, and it suggests re-evaluations at least every two years.

Re-credentialing, when correctly executed, involves evidenced-based validation of a physician’s knowledge, skills, ability and behavior. As a result, hospitals increasingly view re-credentialing as a peer review activity and put practices in place to:

· Investigate and assess the professional and personal backgrounds of practitioners seeking initial appointment or applying for new privileges.

· Take care to assign only the specific privileges supported by the practitioner’s training and experience.

· Periodically assess all members of the medical staff based on their performance before their reappointment.

Depending on a practitioner’s medical staff status – a new applicant or an existing practitioner requesting new privileges – the peer review process may involve solely a focused review, or both a focused and an ongoing review. For a new applicant, a focused evaluation process qualifies the practitioner for medical staff membership and specific patient care privileges. One way to handle this is for a non-conflicted, like-specialty peer reviewer who’s currently on the medical staff review a sampling of the new applicant’s cases from other facilities where he already has existing privileges. For a practitioner requesting new privileges, conducting a focused evaluation after granting privileges can confirm competence further. In either case, when no “same specialist” is available, hospitals can consider an external peer reviewer to find one.

Whenever a current medical staff member requests a new privilege, hospitals must apply the focused evaluation process to qualify them. Again, the commission standards expect hospitals to base their decision to grant, limit, or deny requested privileges on evidence-based and clinical performance information. It is also common for a current member of the medical staff to request privileges for which the hospital has no documented evidence about the practitioner’s ability. This may be due to a several reasons:

· New knowledge, education or techniques.

· A low volume of cases.

· Clinical practice patterns not included in the performance data routinely reviewed by the medical staff.

· An insufficient number of the physician’s cases undergoing peer review.

Managing Conflict of Interest

Conflict of interest is one of the most difficult issues to overcome when conducting peer reviews among colleagues working together at the same hospital. The expansion of peer review for the physician evaluation processes makes managing it an increasingly important consideration. Any internal peer evaluation must always factor in conflict of interest situations among its physician reviewers. Avoiding conflict of issue situations necessitates hospitals and clinics to educate the medical staff and establish expectations regarding conflict of interest.

Finding a suitable “peer” or “like specialist” within a hospital group or small community is sometimes impossible. If one does exist, more than likely there are issues surrounding personal or professional relationships, perceived competition for patients or other conflicts of interest. Yet to conduct a legitimate peer review, it is important for the physician under review to be “true peer,” that is, a physician in a similarly-sized hospital with similar capabilities, and in exactly the same medical specialty. In Oregon, some smaller hospitals have banded together a sort of “evaluation consortium” to handle physician evaluations and to eliminate bias. When necessary, they refer cases to independent review organizations (IROs) to match a reviewing physician with the one under review.

This approach helps them avoid many of the potential conflicts of interest hospital administrators and peer reviewers ought to know, including:

· Reviews involving doctors who are partners in a business or are or member of the same practice group.

· Cases where doctors have a social relationship (for example, they attend the same small golfing club).

· Review of a case for a hospital in which the reviewer has a financial or other interest (i.e., managing employee, medical director, hospital board member or stockholder).

· Review of cases involving groups where the reviewer practices.

· Cases where a referral relationship exists.

· Cases where the physician participated in the patient’s care or treatment plan.

· Cases where any financial or other relationship exists or is contemplated (this may even include the physician or any family members at the same residence) with any entity that made the initial determination, or with any of the suppliers or providers of the hospital.

· Cases involving relatives who are patients.

· Cases in which the physician has any prior involvement in the specific case under review.

To avoid conflict of interest concerns during credentialing and privileging evaluations and assure patient safety and quality care, a hospital should develop and communicate its policy and expectations regarding conflict of interest to its staff and have a policy in place about when it is appropriate to engage outside reviewers. Hospital quality managers and risk mangers are starting to recognize the importance of removing conflict of interest from the peer review process. Many are putting appropriate polices and processes in place, including policies about the use of external evaluations. They are learning that hospitals and peer review committees must conduct systematic, well-documented and credible evaluations that deliver both immediate and long-term improvements in patient safety and quality care, and that it takes unbiased physician evaluations to reduce undesirable patient outcomes, improve patient safety, lower risk and advance quality initiatives within their hospital.

Skip Freedman, M.D., is the medical director at AllMed Healthcare Management, an independent review organization based in Portland, Ore. He is a longtime emergency physician and practices at several hospitals in the Portland-Vancouver metropolitan area.

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