Assessing the competence of a practitioner who is active at another facility

How do you assess the competence of a practitioner who is clinically active at another facility with very little or no activity in your organization? MSPs see these types of cases all the time when they credential a new practitioner’s request for clinical privileges when that practitioner has been actively practicing elsewhere. Thus, MSPs should be very familiar with the tools and techniques that allow them to gather evidence of current competence. Those tools and techniques include the following (remember, put the burden on the applicant to obtain the required information):

1. If the low- or no-volume practitioner has significant clinical activity at another facility that is reflective of the scope of clinical privileges that he or she is requesting at your facility, send a peer reference questionnaire to responsible individuals at that site (e.g., department chair, section chief) seeking confirmation of the practitioner’s medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, professionalism, absence of disciplinary issues, judgment, behavior, and any additional factors relevant to making recommendations for clinical privileges.
2. In addition, seek references from those individuals who can attest to the practitioner’s interpersonal skills, professionalism, absence of disciplinary issues, judgment, and behavior (e.g., hospital’s CEO, director of medical records, directors of clinical units).
3. Collect volume data as available from the ongoing professional practice evaluation (OPPE) from the other institution. To gather this information, put the burden on the practitioner applying for privileges. The practitioner should ensure the provision of all elements that are required by your organization, including:

• Process data
  
  • Nationally required core measures (physician relevant)
  • Blood use data
  • Illegibility/nonapproved-abbreviation incidents
  • Patient complaints
• Outcomes data
  
  • Claims-based data (e.g., C-sections, complications, mortality rates [preferably risk adjusted)
• State public databases
  
  • Peer review final case ratings
• Volume of clinical activity at the other facility for the past six to 12 months
  
  • Admissions
  • Procedures
  • Deliveries
• Confirmation of medical staff status “in good standing” with no disciplinary actions, no con-templated investigations, and no ongoing investigations or quality/peer review adverse actions

Source: The Medical Staff's Guide to Overcoming Competence Assessment Challenges