california association of medical staff services ... · credentialing & privileging: the...
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California Association of Medical Staff Services
CREDENTIALING Basics, RED FLAGS & Dr. Death
Erin Muellenberg Principal
Polsinelli [email protected]
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Where we are going…..
Credentialing Purpose
Legal Requirements
Basics
Red Flags
Dr. Death
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Who granted him privileges?
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Credentialing Purpose
Patient Safety! –MSP’s are the gatekeepers of
patient safety
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Credentialing & Privileging: The Cornerstone of Quality & Patient Safety
Credentialing defined:
– The process of obtaining, verifying, and assessing the qualifications of a health care practitioner to provide patient care services in or for a health care organization.
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Credentialing
Assesses an applicant’s professional abilities
Detects professional incompetence, malevolence, behavioral problems or other red flags
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Credentialing & Privileging: The Cornerstone of Quality & Patient Safety
Privileging defined:
– The companion piece to credentialing is “privileging,” which is the process of authorizing a licensed or certified healthcare practitioner’s specific scope of patient care services. Privileging is performed in conjunction with an evaluation of an individual’s clinical qualifications and/or performance.
• MedPro Clinical Risk Dept. 2014
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Legal Requirements
Title 22, Sec. 70701 (a)
Medical staff members are required to:
– Demonstrate current competence, to a medical staff committee, on initial appointment, and every two year thereafter.
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Legal Requirements
Conditions of Participation
– The governing body must “ensure the criteria for selection [of the medical staff] are individual character, competence, training, experience, and judgment.” 42 CFR 482.12
– The medical staff must examine credentials of candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates.
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Conditions of Participation
Composition of the Medical Staff
Medical Staff conducts appraisals of its members
Examine the credentials for applicants and make recommendations to the governing body
Telemedicine
Medical Staff organization and accountability
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Conditions of Participation
The hospital must have an organized medical staff that operates under bylaws approved by the governing body and is responsible for the quality of medical care provided to patients by the hospital.
42 CFR §482.22
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Conditions of Participation
Medical Staff must adopt and enforce bylaws – Be approved by the governing body
– Duties and privileges of each category
– Describe medical staff organization
– Describe qualifications
– Include H&P requirement
– Privileges criteria
– Autopsies
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The Joint Commission
MS. 06.01.03
The hospital collects information regarding:
– Current license
– Training
– Experience
– Competence, and
– Ability to perform the requested privileges
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Privileges must be
Individualized – Practitioner – Facility/Service
Relevant – Current – Realistic
Supported by Objective Evidence – Training – Experience
Continuously Monitored – OPPE
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Legal Corner
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Cases of Negligent Credentialing
1. Elam v. College Park Hospital • Public information • Multiple lawsuits
2. Johnson v. Misericordia • False information & omitted information on the application • Hospital did not verify the information
3. Frigo v. Silver Cross Hospital (2007) ($7,775,688) • Physician did not initially meet eligibility requirements
• Reappointed without meeting eligibility requirements
4. Kadlec v. Lakeview Anesthesia Assoc. and Lakeview Medical Center • Peer references provided misleading information
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Red Flags
Reports of problems in an applicant’s professional practice
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Red Flags
All past or pending state licensing board, medical staff organization, or professional society investigative proceedings
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Red Flags
Unexplained or unaccounted time gaps
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Red Flags
No response to a reference inquiry from an applicant’s past affiliation
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Red Flags
Disciplinary actions by medical staff organizations, hospitals, state medical boards, or professional societies
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Red Flags
Any claims or investigations of fraud, abuse and/or misconduct from professional review organizations, third-party payers, or government entities
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Red Flags
Little or no verified coverage from a professional liability insurance policy
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Red Flags
Jury verdicts and settlements for professional liability claims (which should still be individually reviewed)
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Red Flags
Inability to maintain a medical practice within the facility’s service jurisdiction for any amount of time
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Red Flags
Failure to fill out the form and replaced instead with a brief neutral letter
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Red Flags
Time-gaps that are unaccounted for or information from applicant does not match information received from other organizations
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Red Flags
Vague or narrow answers from references or references fail to provide a thoughtful and complete evaluation
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Red Flags
Failure to disclose information
– e.g., Referral to WBC because thought it was “confidential”
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Red Flags
Time off during training
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Red Flags
Inability to verify information
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Red Flags
Unsupervised practice location
– Office based
– Telemedicine
– Locum tenens
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Red Flags
References from different specialties or unable to attest to current competence
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Red Flags
Multiple changes in insurance companies during career
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Red Flags
Rumors, discussion, or documentation from peers, staff, patients or others related to professional conduct or possible impairment
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Red Flags
Age or Disability
– Current competence to practice privileges requested
– Refusal to obtain Fitness for Duty Evaluation
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Red Flags
No response to a reference inquiry
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Red Flags
Reference suggests call for more information or affiliation requires special release
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Red Flags
Trust your gut!
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Credential and Privilege to include the Six Core Competencies
Patient care
Medical/clinical knowledge
Practice-based learning and improvement
Interpersonal and communication skills
Professionalism
System based practice
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Case Study
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Ex-Neurosurgeon Christopher Duntsch Sentenced to Life Feb. 17, 2017
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https://www.youtube.com/watch?v=agknsYW_Uew
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MD & PhD – Univ. of Tenn. Health Science Center
Neurosurgery residency – 2004-2010 – Program Director
– Sent to impaired MD program
– Not allowed to operate independently
Post residency stayed in research and ran Discgenics
July 1, 2011 recruited to Baytlor Plano
Christopher Duntsch
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Residency letter – “His work ethic, character, and ability to get
along with others were beyond reproach.”
Fired from group after first surgery
November 2011 Kenneth Fennel – wrong site surgery
December 30, 2011 – Robert Passmore - Asst. surgeon grabs Duntsch and begs him to stop. Nurses fail to report incident
Christopher Duntsch
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January 11, 2012 - Barry Morguloff – Dr. Randall Kirby was the assistant surgeon – Surgery was a “horror”
February 12, 2012 – Jerry Summers – Woke up a paraplegic
Summary suspension – not reported – Privileges reinstated
March 12, 2012 – Kelly Martin – Dead – Post operative hemorrhage following laminectomy
April 2012 – Suspended & Resigned
Christopher Duntsch
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April 20, 2012 resignation letter states relocating practice
April 20, 2012 reference letter provided to Duntsch from Baylor
Christopher Duntsch
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Christopher Duntsch
July 2012 – Dallas Medical Center grants temporary privileges
July 2012 – Feolla Brown does from post operative hemorrhage
July 2013 – Texas Medical Board suspends license
March 2014 – lawsuit filed against Baylor
July 2015 - Indicted
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Dr. Death Plano neurosurgeon allegedly botched surgeries in Dallas and Plano in 2012 and 2013, killing or maiming up to 15 patients.
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How Does it Happen?
Deviation from the Process….Not the performance of any individual
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How Does it Happen?
Pressure for quick results
Presumption that everything is fine
Money! Profit!!!
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Credentialing – – Watch for red flags & follow up
Impairment – – Identify and manage
Action – – Take when necessary
Reporting – – Follow the law
Reference letters – Factual – notice to others
Information Sharing – Proactive
Lessons Learned (Again)
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Don’t Let the Tail Wag the Dog!
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Reporting
Medical Board of California 805 & 805.01 Reports
– Medical disciplinary cause or reason
• Restriction
• Suspension
• Termination
• Denial of membership or privileges
• Summary suspension over 14 days
• Resigns or leave of absence while under investigation
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Reporting
National Practitioner Data Bank – Professional review action based on competence or
conduct that affects or could affect patient care and adversely affects privileges or membership for more than 30 days • Reduction • Restriction • Denial • Revocation • Surrender or failure to renew • Resignation while under investigation • Summary suspension of more than 30 days
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