Obtaining competency data for low-volume providers

The following question comes from one of our readers:

Our department of surgery wants to mandate that, in order to be eligible for reprivileging in cardiac surgery, the physician must have performed a minimum of 25 cardiac surgical procedures at our hospital in the past two years, regardless of whether the physician has performed hundreds of such cases elsewhere in the past two years.  Is this advisable?

This is a very interesting question.  Many organizations have taken the position that when there is a clinical activity requirement for a specific procedure or group of procedures, the procedures can be done at any accredited hospital.   In the past, there has usually not been a minimum number of procedures that must be done at the hospital where the physician is asking to be reprivileged. 

However, this is changing because of the difficulty in obtaining clinical performance information from organizations where practitioners are performing procedures.  The focus these days by the regulatory and accreditation agencies is on competency.  And as potential patients, I think that we can all agree that this focus is appropriate. 

The 2007 Joint Commission standards require that decisions to renew existing privileges are objective and evidenced-based (see MS.4.15).  EP #9 under MS.4.15 requires that "the hospital has a process to determine whether there is sufficient clinical performance information to make a decision to grant, limit, or deny the requested privilege."

Many organizations will not provide information about clinical performance to other organizations that seek that information for credentialing and privileging.  For example, clinical performance information from the hospital where the physician has performed "hundreds of such cases" is often not forthcoming.  Many hospitals choose to release information to other hospitals limited to whether or not the physician is on the staff and is in good standing (you all know the types of letters to which I'm referring), and provide no information at all about his or her clinical performance. 

MS.4.70 requires that when there is insufficient peer review data available when evaluating an applicant for privileges, the medical staff uses peer recommendations. 

What is your organization's position on releasing information about professional/clinical performance?  Do department chairs respond to requests for peer recommendations about practitioners with significant clinical activity in their department?  Or do those letters go to the medical staff office for the routine response that the physician is on the staff and is in good standing? 

If those are the types of letters that we provide to other organizations, and the type that we receive, hospitals that are determined to have evidence of acceptable clinical performance may be forced to require a minimum amount of clinical activity to take place within the hospital in order to have their own performance data to use for renewal of privileges. 

So the question of whether or not the practice of requiring a minimum amount of clinical activity at a hospital is advisable becomes one of: Is there any alternative? 

Until next week,

Vicki L. Searcy, CPMSM
Practice Director, Credentialing & Privileging
The Greeley Company
vsearcy@greeley.com
www.greeley.com