professional practice evaluation

December 12, 2024

Posted on by Courtney Patterson

QUESTION:
The MEC recently learned that a department chair placed a physician on a “period of FPPE to include proctoring until such time as the requirement for supervision is lifted.”  This has raised some red flags within the Medical Staff leadership.  We are a bit worried about the use of the word “supervision” here.  Also, another main concern is that we revised our peer review process several years ago and, while our policy allows department chairs to perform clinical case reviews, send letters of guidance, and conduct informal collegial conversations with practitioners, the policy pretty clearly states that if something more intensive/intrusive – like a formal, planned collegial intervention meeting or performance improvement plan – is envisioned, the matter should be referred to the multi-specialty peer review committee or MEC for management.

Should we “undo” the actions of the department chair and “redo” the peer review according to our policy?  Since it’s already in progress (the practitioner has already been notified of the requirement) should we just let it ride out? This feels like quite a mess.

ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:
You know the saying, “An ounce of prevention is worth a pound of cure”?  Well, right now you need a pound of cure.  It happens!  You are right to have some concerns about the process that has been followed thus far in reviewing this matter.  And the concerns you articulated in your question are astute.  The use of the word “supervision” probably is inappropriate and inapplicable here.  Most proctoring that is performed in the peer review world is observational only and does not involve true supervision by the proctor.  The role of the proctor is to observe and report back to the peer reviewers his/her opinions about the performance of the individual subject to review.  The proctor often consults with the practitioner collegially during that process, but the consultation does not generally rise to the level of supervision and the proctor generally does not have any authority to dictate how the practitioner provides the medical care in question.  Using the word “supervision” to describe the proctoring could give the wrong impression about these matters.  And just as importantly, it could set a negative tone, making this practitioner (and others, in the future) more defensive and less likely to be cooperative with the proctoring process.

It would also appear that the department chair overstepped his role in the process by implementing an activity (proctoring) that is generally reserved for performance improvement plans.  To the best of our knowledge, there are no legal or accreditation standards that dictate “who does what” in peer review.  But, your policy should serve as the guide for peer review activities within your hospital and medical staff.  And the way your policy has been drafted – to divvy up responsibility for certain interventions such that lower-level interventions are within the authority of individual leaders, but more intrusive interventions require committee action – are “best practice” within the industry.  Relying on multi-disciplinary committees to implement performance improvement plans provides a check and balance, helping to eliminate personal variation, as well as alleviate any concerns that competitive motives formed even part of the motivation for the action.

Now, for your real question:  Should you undo the action of the department chair?

In this case, that is probably the best course of action.  Of course, diplomacy is key.  As a first step, the MEC might simply ask a few individuals (the officers?  A Leadership Council?) to meet with the department chair and ask him to reconsider his decision.  Those leaders can also work with the department chair to notify the practitioner that the previous determination has been rescinded and, upon further consideration, it has been determined that the matter should be forwarded to the multi-specialty peer review committee for further consideration and determination of next steps.

With that done, you can then focus on the “ounce of prevention.”  Leadership roles turn over very frequently – and Medical Staff leaders are usually not provided any training in advance of their leadership terms.  Methodically providing an orientation letter to new leaders and regularly providing leadership education and training is a great way to help leaders navigate their many (and sometimes complex) roles.

An orientation letter can be used to summarize duties and make leaders aware of the Bylaws and policies that apply to them (and should be consulted when performing duties).  It does not need to be a “manual.”  A few pages often does the trick.  For example, the department chair’s role in peer review (as outlined in the policy you describe in your scenario) could be summarized as follows:

As department chair, you are also an important part of implementing the Medical Staff’s professional practice evaluation/ clinical peer review process.  Cases may be referred to you for clinical review, with a request that you report your opinions (on the forms provided).  You may conduct clinical reviews yourself or, where you lack expertise, assign the review to another clinical specialty reviewer within your department (to be reported back to you by the deadline that you set).  If your review reveals new or lower-level concerns that might be best managed through brief, informal collegial counseling or guidance, you may address the matter directly with the practitioner (reporting that outcome to the PPE Professional so that it can be recorded in the hospital’s files and reported to the multi-specialty peer review committee for oversight purposes).  More significant concerns and/or more significant interventions are generally referred to the multi-specialty peer review committee for review and management.  For more details, please refer to the Medical Staff Professional Practice Evaluation Policy.  A copy can be obtained…[describe where/how to obtain the policy]…

If you have a quick question about this, e-mail Rachel Remaley at RRemaley@hortyspringer.com.

April 20, 2023

Posted on by Courtney Patterson

QUESTION:
Our peer review committee recently developed a plan for a physician that involved proctoring of a number of the physician’s cases.  It came up in our meeting as to whether patients had to be informed that their physician is being proctored.  Is this required?

OUR ANSWER FROM HORTYSPRINGER ATTORNEY LEEANNE MITCHELL:
Proctoring is part of the confidential peer review/professional practice evaluation process.  But, as a practical matter, patients may need to be made aware of the fact that another physician may be involved in their care.  Proctoring – whether in surgical or non-surgical situations – often includes not only review of the patient’s medical record but also an examination of the patient, which means that some explanation regarding that individual’s presence must be provided.  While not always the case, if proctors are instructed to intervene in a surgical procedure if necessary, the patient should be in­formed that the proctor may participate in the procedure and that information should be included in the patient’s written consent to the procedure.

While it is the proctored physician’s responsibility to inform his or her patients about the proctoring, the patient does not have to be informed of the reason for the proctoring.  A simple statement will suffice, such as:  “The hospital and our team are committed to providing appropriate care.  Dr. Proctor will also be [working with me/may examine you/review your medical record/scrub in and be ready to assist in your procedure if necessary].”

Finally, documentation completed by the proctor should not be included in the patient’s medical record.  We recommend that proctors be provided with “proctoring forms” that elicit information in as objective a format as possible about the issues that are being assessed, and that these forms be maintained as part of the hospital’s peer review/professional practice evaluation process – not as clinical records maintained in the medical record.

February 16, 2023

Posted on by Courtney Patterson

QUESTION:
Our bylaws say that new medical staff members are “provisional” for at least 12 months, sometimes for 24 months.  Is this the same thing as focused professional practice evaluation?

OUR ANSWER FROM HORTYSPRINGER ATTORNEY LEEANNE MITCHELL:
No – or at least it shouldn’t be!  Focused professional practice evaluation (“FPPE”) is the Joint Commission terminology for the period of focused review that is required for following the grant of any new clinical privileges as the way of confirming practitioner competence – this means a focused review of all privileges for new applicants and all new privileges for existing practitioners (i.e., increases in privileges).  FPPE can be accomplished in many different ways – chart review, proctoring/direct observation, external reviews, even discussions with others who are involved in the care of the individual’s patients.  The Joint Commission does not mandate the duration of FPPE for any practitioner and, in fact, have specifically noted in the past that using a traditional 12-month provisional period as the time frame for performing FPPE could be overly burdensome for practitioners who had high volumes.

To that end, there is no requirement that hospitals and medical staffs maintain a provisional appointment status, though we do still see many hospitals that continue to utilize that status, generally as a way to assess the “citizenship” aspects of medical staff appointment – like behavior, attendance at and participation in medical staff affairs, completion of medical records, fulfillment of call obligations, etc.  In addition, at the same time, but generally for a much shorter duration, all new members are subjected to FPPE, the requirements of which depend on the practitioner’s specialty and clinical privileges.  The key is to understand that if a medical staff is going to maintain a provisional status or process, it should be addressed separately from the FPPE to confirm competence process.

September 16, 2021

Posted on by Courtney Patterson

QUESTION:
We’re developing new case review forms for our peer review process and wondered whether we should ask reviewers to assign a numerical score to various aspects of care.  Do you recommend scoring cases in this way?

ANSWER:

No!  In our experience, scoring has the following drawbacks:

(1)        Too much energy is spent assigning the score, which distracts from the most important questions:  Is there a concern with the care provided, and if so, how can that concern be addressed?

(2)        Numerical scores can’t capture the complexity of a case in the same way as a longer narrative.

(3)        Physician reviewers may be uncomfortable assigning low scores which indicate that care was “inappropriate” or “below the standard,” especially if those scores are accompanied only by short statements such as “care below the standard.”  As a result, they choose higher scores indicated “care appropriate” even if there are concerns.

(4)        Scores may put physicians on the defensive, especially since most scoring systems don’t allow for the provision of nuanced information.

These characteristics of scoring can undermine efforts to make the peer review process educational rather than punitive.  Accordingly, we recommend having a peer review/professional practice evaluation (“PPE”) system that focuses on actions and performance improvements rather than scoring.

March 25, 2021

Posted on by jwilbert

QUESTION:       Can our professional practice evaluation/peer review committee use e-mail to communicate with physicians about the review of clinical or behavioral concerns?

ANSWER:           Yes.  Physician leaders have told us that they prefer communicating via e-mail (both internally and with the physician under review) because it’s quick and less formal than regular mail.  The lack of formality can help to reduce anxiety on the part of the recipient and convey the message that the PPE/peer review process is meant to be educational, not punitive.  In contrast, using certified mail sends the message that the Hospital is anticipating a confrontation and that lawyers will soon be involved.

Using e-mail to discuss PPE/peer review matters would not, on its own, waive the peer review privilege under state law.  However, there are several best practices that should be adopted:

    • All e-mails should include a standard convention, such as “Confidential PPE/Peer Review Communication” in the subject line.
    • E-mail should not be sent to non-Hospital accounts unless the e-mail merely directs recipients to check their Hospital e-mail.
    • If the e-mail contains any Protected Health Information (as that term is defined by the HIPAA Privacy Rule), the e-mail must comply with the Hospital’s HIPAA policies. Often, this will require that the e-mail be encrypted.
    • If an e-mail includes a deadline for a response (for example, a request for input or to attend a meeting), the Hospital may want to send a text message or call the physician to say that the e-mail is being sent. The goal is to ensure the physician is aware of the e-mail so the deadline is not missed.  However, the Hospital’s policy should also make clear that failure to send a text message or make a phone call is not an excuse for the physician to miss a deadline.

Of course, there are times when it’s more appropriate to use a formal letter.  If a physician has not responded to prior collegial efforts, a letter may help to convey the seriousness of the matter.  Also, the applicable Medical Staff policy should always be checked to ensure it does not require correspondence to be sent via certified mail or some other form of “Special Notice.”  This is typically the case where a matter has progressed to a formal Investigation or a Medical Staff hearing is under way.

June 29, 2017

Posted on by hortyspringer

QUESTION:        We’ve taken steps in the last year to change the perception of peer review from punitive to educational.  We’ve eliminated scoring, increased the use of educational sessions to share lessons learned from the review process, and created accountability for fixing system/process concerns that are identified during the review process.  Overall, our physicians feel the process is much improved.  However, there are occasional holdouts who refuse to provide input when their cases are under review, and who seem intent on simply delaying the review process.  What can we do?

ANSWER:            Obtaining timely and meaningful input from the physician under review is an essential element of an effective and fair professional practice evaluation (“PPE”) process.  Giving the physician an opportunity to provide input enhances the credibility of the process and encourages everyone involved to think critically about a case.

There are several fundamental rules to obtaining input.  Most importantly, PPE policies should state that no “intervention” (such as an educational letter or a performance improvement plan) will occur until a physician has been given the opportunity to provide input.  Also, physicians should be given the opportunity to provide both written and verbal input by meeting with those conducting a review.  Input can be obtained at any point in the process, and multiple requests for input may be made.

If a reviewer has questions about a case, the physician should be notified of the concerns.  Any letter to the physician must be carefully drafted to avoid giving the impression that a decision about the case has already been made.

The PPE policy should also make clear that a physician cannot stop the review process by not providing input.  PPE policies should state that individuals who fail to provide input when requested by the PPEC can be deemed to have temporarily and voluntarily relinquished their clinical privileges until the input is provided.  Such relinquishments do not entitle the physician to a Medical Staff hearing or appeal, nor are they reportable to any federal or state government agency.  Instead, they are merely an administrative “time-out” until the physician provides the requested information.

To learn more about PPE best practices, join Paul Verardi and Phil Zarone by dialing in for the upcoming audio conference: Professional Practice Evaluation Policy — Special Topics on July 11.