Board of Registration in Medicine

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Board of Registration in Medicine

• Expert Panel on Credentialing

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Anthony D. Whittemore, M.D.

• Chair Expert Panel on Credentialing
• Senior Vice President and Chief Medical Officer
• Brigham and Womens Hospital
• Professor of Surgery
• Harvard Medical School

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The Charge

• To develop specific standardized criteria to
  assure competency for credentialing that all
  hospitals would be expected to meet in the
  biennial process.

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The Problems

• Current credentialing process does not assure
  that staff are safe and competent.
• Some aspects perceived as burdensome and
  punitive

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Solutions

• Provide criteria to assure competency
• Ensure process portrays a supportive posture, not
  disciplinary or punitive

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Board of Registration in Medicine Expert Panel on
Credentialing

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BWH Medical Staff

• Institutional Appointment Process
• Application
• Approval

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BWH Medical StaffApplication Process

• BWH Provider Services
• Completion and verification of Application
• CORI Check (Criminal Offender Record Information)
• Verification of Education and Training, Board
  Certification
• State Board of Registration in Medicine (all
  states where a license has been held) (Mass state
  license required, therefore CME)
• Current Competence (Personal References)
• Work history, experience (10 years for initial
  appointment)
• OIG Medicare Exclusion (verified monthly)
• National Practitioner Databank
• Review of malpractice history from all previous
  carriers
• Verification of additional certification
  including DEA
• Verification of all gaps in work history

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BWH Medical StaffApproval Process

• Academic Department
• Department Credentialing Committee
• Department Chief
• Institution
• MSCC (Medical Staff Credentials Committee)
• MSEC (Medical Staff Executive Committee)
• CIC (Care Improvement Council)
• BWH Board of Trustees

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BWH Medical StaffApproval Process

• Academic Department
• Department Credentialing Committee
• Reviews completed/verified application and
  delineation of privileges
• Classifies as Category I or II
• Approves / disapproves appointment

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BWH Medical StaffApproval Process

• Category I
• No Category II Criteria
• Approval Process
• MSCC
• CIC (PCAC)
• Approval
• Appointment becomes effective
• BOT ratifies CIC decision

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BWH Medical StaffApproval Process

• Category II
• Incomplete application
• Failure to meet requirements for appt/reappt in
  Bylaws
• Pending/final disciplinary or other adverse
  licensure action
• Disciplinary or other adverse action at BWH or
  any other institution such as revocation,
  restriction or denial of appt or privileges
• Medicare/Medicaid Sanctions (exclusion list)
• National Practitioner Data Bank
• Previous adverse recommendation by MSCC, MSRC, or
  CIC
• Recommended for Category II status by Dept, MSCC
  or CIC
• gtLawsuits within 5 years

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BWH Medical StaffApproval Process

• Category II
• Professional Liability Claims (5 year interval)
• Any settlement gt 1 million
• gt2 claims
• OB/GYN, Orthopedists, Neurologists,
  Anesthesiologists
• Plastic Surgeons, Urologist, Surgical Oncologists
• General Surgeons, Neurosurgeons.
  Otolaryngologists
• gt1 claim
• All other physicians

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BWH Medical StaffApproval Process

• Category II Approval Process
• Institution
• MSCC (Medical Staff Credentials Committee)
• substantiates or revises category status.
• MSEC (Medical Staff Executive Committee)
• CIC (Care Improvement Council)
• BWH Board of Trustees for final action

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BWH Medical StaffApproval Process

• Actions
• Approval
• Approval with restrictions
• Monitoring program
• Limitation of Privileges
• Remedial program
• Denial (Category 3)

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Todays Procedures

• Current process does not adequately address
  competence.
• Department Chiefs endorsement during the process
  is best guide at present.

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Competence is.

• a combination of skills, abilities and
  knowledge needed to perform a specific task
• (U.S.Dept of Education)
• the habitual and judicious use of
  communication, knowledge, technical skills,
  clinical reasoning, emotions, values and
  reflection in daily practice for the benefit of
  the individual and community being served.
• (Hundert, et al, 1996)

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Competence is

• Finding and managing information
• Resolving ambiguous problems
• Emotional intelligence
• Responding to novel situations with flexibility
• Time management
• Teamwork
• Professionalism

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Specialty Boards

• Initial Specialty Board Certification
• Written exam - Fund of Knowledge
• Oral Exam -
• Logical thought processes
• R/O certifiable mental disorders (DSM-IV)
• Does not assess sustained competency
• Recertification
• Fund of current knowledge
• CME Requirements

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Specialty Boards

• Current initiatives to address a flawed process
• American Board of Medical Specialties (ABMS)
• ACGME Core Competencies
• Maintenance of Certification
• Federation of State Medical Boards (FSMB)
• National Alliance for Physician Competence

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The ACGME Outcome Project

• Core Competencies

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General Competencies

• Patient Care
• Medical Knowledge
• Practice-Based Learning and Improvement
• Interpersonal and Communication Skills
• Professionalism
• Systems-Based Practice

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Expert Panel Framework

• Specific Criteria
• Patient outcome metrics
• Complaints
• Claims
• Accomplishments
• 360 Evaluations
• Certifications
• Other competency assessments recommended by
  boards, agencies or societies
• Interactive direct observation

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Performance Detail Measures for Vascular Surgery
Multiple Measures for Operational Efficiency,
Quality Outcomes and Patient Satisfaction
Report Link bring user to detailed data
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Report Link In Hospital Mortality Rate
Displays Deaths by HCFA DRG Code
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Report Link Surgical Site Infection Rate
Displays Infections by Wound Class
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Report Link Inpatient Satisfaction with Physician
Displays Responses to Individual Questions in
Section
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Expert Panel Framework

• Inventory of initiatives
• FSBM / Physician Competence Summit III
• ABMS (ACGME) / Outcome Project
• JCAHO / Standards MS 1-5
• NCHL / Competency Model
• Best Practices
• Liability Carriers / CRICO Forum
• Aviation

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Expert Panels Framework

• Define Competency
• Standard processes in MA hospitals
• Best Practices
• Metrics
• procedural
• cognitive
• Monitoring Process
• Remediation Process

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Board of Registration in MedicineCommonwealth of
Massachusetts

• Report of the Expert Panel on Credentialing
• Guidelines for Competency-Based
• Hospital Credentialing

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Expert Panel Suggestions

• Professionalism
• Demonstrates personal integrity
• Is honest and trustworthy
• Demonstrates respect, compassion, and integrity
• Holds self accountable to patients, society, and
  the profession
• Is committed to excellence and on-going
  professional development
• Demonstrates self-awareness and diligence with
  respect to personal physical and emotional health
• Measures 17, 18

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Expert Panel Suggestions

• Core Competencies
• Patient Care
• Medical Knowledge
• Practice Based Learning And Improvement
• Interpersonal and Communication Skills
• Professionalism
• Systems-Based Practice

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Expert Panel Suggestions

• Professionalism
• Maintains personal competence
• Pursues continuous professional development
• Participates in self- and others assessment of
  competency
• Displays intellectual curiosity
• Works within limits of competence
• Measures 1, 3, 4, 5, 7, 8, 11, 12, 17, 18

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Expert Panel Suggestions

• TABLE II Measures applicable to assessment of
  clinical competence
• ABMS Specialty Board certification,
  re-certification and/or MOC
• Malpractice Claims
• Co-worker or peer recognition of excellence or
  complaints
• Academic recognition of excellence or complaints
• Professional society recognition of excellence or
  complaints
• Patient/Family recognition of excellence or
  complaints
• Outcomes analysis
• Deaths
• Complications
• Readmissions
• Portfolio analysis of outcome data and 360
  reviews for performance improvement
• Appropriateness analysis (unnecessary surgery,
  imaging, etc.)
• Process indicators (core measures, e.g., eye
  exams, B-blockers, etc)
• Peer review record (American Board of Internal
  Medicine ABIM tool, etc.)
• Retrospective record review
• Communication assessment (Kalamazoo and other
  instruments)
• Observation assessment of a standardized
  patient

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Expert Panel Suggestions

• Professionalism
• Demonstrates personal integrity
• Is honest and trustworthy
• Demonstrates respect, compassion and integrity
• Holds self accountable to patients, society and
  the profession
• Is committed to excellence and on-going
  professional development
• Demonstrates self-awareness and diligence with
  respect to personal and emotional health
• Measures 17,18

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Expert Panel Suggestions

• Professionalism
• Places patients interests first
• Is responsive to the needs of patients and
  society that supersedes self-interest
• Treats patients with respect regardless of their
  life choices and beliefs
• Avoids financial conflicts of interest when
  possible fully inform patients if they exist
• Observes ethical principles when providing or
  withholding clinical care
• Does not allow personal views of patients
  circumstances or life choices to affect the
  treatment recommended or provided
• When patients wishes conflicts with physicians
  convictions, physicians must be transparent and
  offer care with an alternative health care
  provider
• Maintains confidentiality of patient information
• Measures 3, 6, 13, 17, 18

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Expert Panel Suggestions

• Professionalism
• Ensures competency and professionalism of
  colleagues as applicable
• Participates in teaching and training of
  physicians and students
• Participates in assessment of competency of
  colleagues
• Challenges colleagues when their actions are
  inappropriate or unsafe
• Takes action as necessary to protect patients
  from unsafe acts of colleagues
• Provides support for colleagues improvement
• Facilitates the learning of colleagues and
  co-workers
• Facilitates the learning of residents and
  students
• Measures 3, 5, 17-20

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Expert Panel Guidelines

• Document is designed to enable hospitals to
  comply with external mandates
• Joint Commission
• Federation of State Medical Boards
• ACGME