Credentialing and privileging monthly: Summer number conundrums

Summertime often brings many changes. School is out and folks pack up for vacation. The only major sport in action is baseball—which brings us to the discussion about numbers. For most baseball fanatics, one of the major factors associated with game are the stats. People will argue, compare, or challenge each other about home runs, batting averages, earned run averages, and any other numbers related to individual ballplayers, teams, and leagues. Those who argue that hitting is more important will place greater emphasis on the hitting stats, while those who claim that pitching requires more skill focus on strike outs and the like. The age-old debate as to which of these are more important rages onward.

For medical staffs, summertime tends to bring on a slew of new applications. This means that the medical staff is charged with making numerous decisions regarding physicians’ competence to exercise privileges. And this is where the medical staff numbers conundrum begins.
 
What is the definition of current clinical competency? Historically, department chairs and credentials committee members poured over applications and references and, in the absence of negative information, made recommendations regarding the applicants’ privileges. This isn’t good enough in today’s world—privileging decisions must be based on an objective, criteria-based process.

Clinical competency, then, needs a good, objective definition. At The Greeley Company, we use a two part equation that states that:

Competency = Have you done it recently + When you did it, you did it well

The first part of the equation is quantitative and is typically defined by numbers. The second part is the qualitative aspect and is defined using results of available individual quality data.

Most physician leaders have no problem using quality data results when making privileging decisions. However, when it comes to creating and applying performance numbers, they resist (Similar to the reception that proposed tax hikes get). And, to a great extent, this resistance is understandable.

There are very few defensible benchmarks out there that define current competency. Cardiac surgery literature states that a surgeon needs to be involved in a minimum of 75-100 cases a year to ensure competence. The validity of this number has been challenged.

The situation becomes further complicated by diverse privileging schemes. The old laundry list would require the medical staff to create a separate competency threshold for each privilege granted. Not only are benchmarks scarce, but very few physicians actually perform all the privileges they have been granted in a two-year period. Core privileges, at its extreme, lumps so many different privileges into one pot that creating a single performance number to cover all of them becomes impossible. Hence the conundrum.

While there is no magic bullet yet, we do have some suggestions for how medical staff leaders can begin to approach this:

1. Performance numbers are the only way to make the privileging process objective. However, no standard numbers exist. Therefore, choose the minimum reasonable number of cases per privilege group that medical staff leadership feels comfortable with and that common sense can defend.
2. Consider regrouping privileges into bundles or clusters that make sense when applying a single number. This is the brave new world of privileging. I recommend, as a guide, grouping together privileges that require similar skills and knowledge so that any activity in that subset can apply to the entire group. For example, orthopedic surgery may group all hand-related privileges together and separate those for shoulder and elbow. The number of hand procedures would then apply to the entire hand list but a separate number would be created for the shoulder/elbow privileges.
3. Plan to evaluate and revise privilege listings annually. As the practice of medicine evolves, many privileges that were once considered special and required their own criteria usually evolve into standard practice and can be drawn into a larger group. Of course, the opposite is true as well. When reevaluating privileges, use information that is available. As the American Board of Medical Specialties moves toward implementing maintenance of certification programs, it will collect benchmark data that can be applied to performance criteria.
4. Don’t get discouraged. It is tough to make decisions when the rules seem to change faster than the sands shift in the Sahara. This really comes down to medical staff leadership defining what your organization’s definition of competency really is.

Hopefully, creating privileging criteria numbers is one that you and your medical staff can grapple with successfully long before the hitting versus pitching debate ever gets decided.

If you need any assistance dealing with privileging systems or creating criteria, we would be glad to assist you at The Greeley Company.

Enjoy your summer and whatever activities it brings.

Mark Smith, MD, FACS, CMSL is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.