Credentialing and Privileging: A Review of the New Standards
Choosing who to credential — and for what privileges — are the most important decisions hospital administrators make to ensure quality care. But do they have the information they need to choose wisely? In the eyes of the Joint Commission (formerly the Joint Commission on Accreditation of Health Care Organizations), the answer is no. Robert Wise, vice president of the JC’s Division of Standards and Survey Methods, argues that common practices in credentialing and privileging are too narrow in scope; they don't consider how practitioners work in a team, he says, nor to they reflect current realities in medical care, such as practitioners performing new skills after residency that aren’t part of their specialty training.
For these reasons and more, the Joint Commission on January 1, 2007 introduced its new credentialing and privileging standards, aiming to foster more evidence-based selections. Described in Sections 4.00 to 4.45 of the Joint Commission's Comprehensive Accreditation Manual for Hospitals: The Official Handbook, the standards alter the landscape in key ways. Gone are the days when new privileges could be awarded solely based on a peer’s recommendation. The Joint Commission now wants hospitals to add “focused reviews” of an applicant’s daily work habits. What’s more, the standards call for more frequent performance evaluations, beyond those already required every two years for re-privileging.
Three years in the making, the new standards are the most substantial overhaul of credentialing and privileging since JCAHO formalized the process in 1953. Back then, JCAHO's “minimum standard” merely suggested that physicians could be accepted to the hospital staff if they graduated medical school in good standing, were legally licensed, competent, and “worthy in character.”
John Herringer, associate director of the Joint Commission’s Department of Standards and Interpretations, says the new standards bring procedures in line with “six general competencies” recently identified by the Accreditation Council for Graduate Medical Education; these include patient care, medical/clinical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.
But their implementation could entail administrative burdens. “The standards add a lot of detail to what was already kind of an overwhelming process,” says Regina Burzynksi, senior director of patient care assessment at Emerson Hospital, an IHM member hospital in Concord, MA. “That’s not to say the information won’t be good for us to have, it’s just going to difficult to get. You have to set up systems to be able to do this and designing those systems takes time."
The Focused Review
Two new concepts drive the Joint Commission's current approach. The first, called the Focused Professional Practice Evaluation, or more simply, “the focused review,” addresses two specific activities: how to evaluate practitioners that are new to the organization and how how to evaluate existing practitioners seeking privileges for procedures that they've never performed for the organizations awarding the privileges.
According to Herringer, most of the focused reviews elements were drawn from prior versions of the Official Handbook. Those elements are now grouped in section M.S. 4.30 of the current handbook, along with a new element (denoted EP 1) that states precisely: “A period of focused professional practice evaluation is implemented for all requested privileges.”
That statement represents a fundamental shift in the Joint Commission’s approach, Herringer says. Previously, administrators could rely chiefly on peer recommendations to assess an applicant’s capabilities. If those recommendations were positive, privileges were generally granted. The new approach calls for monitoring the applicant’s performance for a certain duration, ideally with an eye towards the six competencies described above. Herringer stresses that hospitals can choose both the evaluation criteria and the duration of the focused review. He also emphasizes that hospitals have a year to design their approach — EP 1 won’t go into effect until January 1, 2008. (The remaining performance elements are in effect now, however). “Hospitals can look at a number of factors to guide the review process,” he says. “For instance, they could review a practitioner’s diagnostic and prescribing patterns, and interactions with staff.”
According to Wise, peer reviews were de-emphasized because they’re too non-specific and subjective; some physicians might be reluctant to speak poorly of colleagues, he explains, particularly if they're on friendly terms. The focused review, on the other hand, should provide more a more objective basis for privileging decisions, he says.
The Ongoing Evaluation
The second concept behind the Joint Commission’s new approach is called the Ongoing Professional Practice Evaluation. That concept, described in Section 4.40 of the Official Handbook, was produced to replace “privileging by exception,” a trend that was never endorsed by the Joint Commission, Herringer says. With privileging by exception, hospitals automatically renew privileges every two years for practitioners who haven’t had any major problems or sentinel events, meaning accidental patient deaths or injuries.
Those days are over. To comply with the new standards, hospitals will have to evaluate practitioners on a more ongoing basis and review privileges more frequently than every two years. The Joint Commission doesn’t stipulate how often the reviews should occur, but Herringer suggests every three to six months could be reasonable. Likewise, the Joint Commission doesn’t direct hospitals to consider any specific parameters, leaving those decisions up to the hospitals themselves. However, the standards do suggest that parameters such as patterns of blood and pharmaceutical use, requests for tests and procedures, length of stay patterns, morbidity and mortality data, and a practitioner’s use of consultants are all appropriate.
The Joint Commission stresses that hospitals must evaluate competence in systems-based practice; a new care-delivery model that integrates connections between patients, providers, payers, and governing bodies. “Doctor’s don’t work in isolation,” Herringer says. “When they order something they have to be cognizant of how it’s going to be carried out.” But he concedes that measuring systems-based performance could be challenging. “It’s probably the hardest [type of information] to access on an ongoing basis,” he says.
Hospitals Meeting the Challenge
To enhance care, the Joint Commission’s new standards push data management limits at hospitals around the country. To comply with the standards, they’ll have to compare performance indicators against a variety of benchmarks that might trigger more detailed reviews. Hospitals will also have to make those comparisons quickly and reliably. But taken in isolation, the patient record systems used at many hospitals today don’t allow those types of analyses to be easily made. “We generally have to take our reports and download them to spreadsheets so we can manipulate the data,” Burzynski explains. “And for the most part, those data are neither current nor continuous, so we’re always behind the eight ball.”
IHM is now working to help its member hospitals overcome these problems. The Physician Quality Management System (PQMS), an IHM data analysis tool, extracts performance data and compares it to internal, regional, and national benchmarks. Those comparisons are then made available in IHM’s monthly reports. “It’s getting the data out into a more user-friendly format,” Burzynksi says.
To that, Lesa Stock, Director of Medical Staff Services at Citizen's Memorial, an IHM-member hospital in Boliver, MO, adds “We can show the reports to our peer reviewers so they can get a better handle on what our doctors are doing; it's allowing us to move away from a manual extraction process.”
Peter Short, Senior Vice President for Medical Affairs at the Northeast Hospital Corporation, an IHM member hospital in Beverly, MA, says automated systems could be invaluable as the new Joint Commission standards go into effect. “In terms of specifics, some of the performance indicators [the Joint Commission suggests we use] have been measured before, but not in ways that allow you to compare one doctor with another,” says. “Doing that manually is next to impossible. But with an automated system, we can look at re-appointment cases on a quarterly basis to see if there’s a need for intervention.”
From a typical hospital’s viewpoint, many challenges remain before that goal can be achieved, however. Those working to implement the standards face a range of unknowns: How will they evaluate and compare complication rates by specialty? Who will review the performance data; will it be the specific department chairs, or will they have to establish review groups within their Medical Examination Committees? Will they have to add resources to accommodate the increased workload?
“My concern is that we’re a relatively small facility,” Stock says. “And we have a limited number of specialists on staff. So, for instance, if we have an ob-gyn doctor who wants to do a new procedure that’s just being introduced, will we have to get outside resources for peer review? Will we have to pay for that? Some of these new requirements could add to our overhead.”
As a first priority, hospitals will have to identify new screening indicators that reflect performance. Antibiotic use-patterns, interactions with nursing staff, and other day-to-day work practices could all be up for enhanced scrutiny. In the case of low-volume practitioners — who work rarely at the hospital doing the evaluation — gathering performance data could be particularly difficult. Other hospitals where the practitioner also works may be willing to release it, but there’s no guarantee that they will. Herringer points out that in some states, performance data is protected under peer review statutes, so hospitals can’t make it available even if they want to. Thus, low-volume itself might serve as a trigger for a focused review, he suggests. “But that’s a time-consuming process that puts a burden on hospitals,” Herringer admits. “Some hospitals might then say, ‘If you’re not using this privilege, it’s taking way too much overhead from out point to continue to watch over it.’ And in fact that privilege could end up getting removed.”
Interacting with the Joint Commission
Moving forward, the Joint Commission will first look to see how hospitals define their approach to meeting the standards and various performance elements. Joint Commission surveyors will then “determine whether the defined approach meets the intent of the requirement and evaluate whether the approach is consistently implemented,” according to Herringer.
Meanwhile, hospitals have their hands full getting up to speed. Evaluating performance in a systems-based atmosphere, where emerging technologies appear at a daunting pace, calls for progress in automation and continuous fine-tuning of new methods. “Historically, we’ve been looking at performance from a 100,000 foot level,” Short says. “If we really want to do a good job, we need to look at it in a lot more detail. But to do that, we’re going to need a way to get at this data quickly and efficiently. We need to know what the doctor is doing because the doctor is at the core of it all.”