Understanding Focused and Ongoing Professional Practice Evaluations
The 2007 Joint Commission (JCAHO) standards strengthen and extend the peer-review process. They call for hospitals to make unbiased credentialing and privileging decisions based on physician performance. Hospitals evaluate that performance using two types of professional practice evaluations — focused and ongoing. These more precise and expanded standards aim for higher-quality hospital peer review, credentialing and privileging processes when assessing physicians and many hospitals must update their policies and procedures.
Focused Professional Practice Evaluation
A “focused evaluation” (MS.4.30) is an intense assessment of a practitioner’s credentials and current competence. It applies to new doctors applying for medical staff positions and practitioners requesting new or expanded privileges in cases where the hospital lacks documented evidence of their competence. It also applies to any practitioners who receive a negative evaluation or lack the case volume required.
When appointing medical staff, the hospital must confirm with primary sources whether a practitioner requesting medical staff membership and privileges has the obligatory current training, knowledge, skills and abilities. The hospital also must consider the same requirements for practitioners undergoing re-credentialing. The new standards also call for privileges to be based partially on the results of peer review and ongoing professional practice evaluations.
Proctoring
Proctoring is another form of “focused evaluation” and involves one-on-one evaluation of a practitioner’s performance by another peer practitioner, or proctor. There are two ways to accomplish proctoring — direct observation and retrospective review. Direct observation means putting two doctors on one procedure. This reduces the physician’s, the proctor’s and the hospital’s productivity. When real-time evaluations are not feasible, retrospective focused evaluations of the proctoree’s cases is an alternative. When “same specialty” peer reviewers are not available internally, external peer review can substitute, something hospitals should consider.
Ongoing Professional Practice Evaluation
Ongoing professional practice evaluation (MS.4.40) applies to practitioners already granted patient care privileges. It extends beyond the classic peer recommendations and case-by-case peer review. Now reliable outcome and performance data must supplement traditional practices. This information comes from multiple sources including:
• direct observation
• complaints
• practice patterns
• patient outcomes
• aggregate analyses of resource use
• peer review and comparative performance measurement projects with large databases (e.g. Society for Thoracic Surgery registry)
Hospitals On Their Own
While the Joint Commission provides some general guidelines, it leaves the scope of the review and information needed for professional practice evaluations up to hospitals and the discretion of the medical staff. However, evaluations must also consider information gathered during Joint Commission mandated performance improvement (PI) activities, including:
• adverse events, including sentinel events
• appropriateness of care, including significant departures from generally accepted standards of practice
• appropriateness of operative and other procedures
• autopsy findings
• medical assessment and treatment
• medication use
• use of blood and blood components
Many hospitals are choosing to interpret this standard as adopting a more proactive and systematic review of practitioner performance, by scheduling quarterly departmental reviews. These can be done either internally, or if conflicts of interest exist, by outsourcing to an external peer review organization, such as an IRO.
Define Clearly Information Needed
To objectively judge a practitioner’s ability to provide safe, effective and appropriate patient care, hospitals and their medical staff must define clearly what additional information is needed. It may also include the assessment of a practitioner’s interpersonal skills, communication ability, professional behaviors, and performance as a team member. Implicit in the Joint Commission’s professional practice evaluation is the call for practitioner assessments at least every two years.
Granting Privileges Credentialing and Re-Credentialing
Credentialing physicians, licensing independent practitioners and granting of privileges, is now a peer-review activity. At least every two years, all members of the medical staff must undergo a professional practice evaluation that re-credentials them for and reassigns them specific patient care privileges. In the past, long-standing personal and professional relationships, staff constraints and limited time, often reduced the process to a “rubber stamping" at some hospitals. When correctly done, re-credentialing involves evidenced-based confirmation that a physician’s knowledge, skills, ability and behavior are satisfactory. More and more hospitals view re-credentialing as a peer-review process and putting practices in place that:
• investigate and assess the professional and personal backgrounds of every practitioner applying for privileges at initial appointment;
• delineate privileges by assigning specific privileges appropriate for the practitioner’s training and experience; and
• periodically reappoint each member of the medical staff based on performance assessments.
Practitioner’s Status Can Determine Type of Review
Whether the practitioner is a new applicant or one requesting new privileges, the peer review process may involve solely a focused review or both focused and ongoing review.
For a new applicant, the focused evaluation process qualifies the practitioner for medical staff membership and specific patient care privileges. Conducting a focused evaluation after privileges are granted can confirm competence further. For example, when evaluating a new applicant, a “peer” practitioner currently on the medical staff could review a sampling of the new applicant’s cases from other facilities where the applicant currently has existing privileges. When no “same specialist” is available to avoid conflict of interest, hospitals could consider using an external peer reviewer to supplement this capability.
Any time current medical staff members request new privileges, hospitals must apply the focused evaluation process to qualify them. The Joint Commission standards expect hospitals to decide to grant, deny or limit privileges requested based on clinical performance. It is common for a current member of the medical staff to request privileges for which the hospital has no documented evidence of the practitioner’s competence. This may be due to a low volume of cases; clinical practice patterns not included in the performance data routinely reviewed by the medical staff; or a lack of physician cases undergoing peer review. Hospital must make a decision about privileging based on evidence. In cases where practitioners lack performance information, it can randomly select some of their cases to undergo either internal or external peer review. Through that peer evaluation, the hospital can determine the competence of a requesting practitioner to perform a privilege.