Is there a threshold for incompetence?

Dear Colleague,

The Joint Commission has challenged the credentialing field to make granting or denying privileges an objective, evidence-based process. Although a worthy goal, the state of privileging today makes achieving this goal daunting, at best. Medical staffs know they should continuously measure physician performance through peer review (ongoing professional practice evaluation, or OPPE). But they should also continuously evaluate the data resulting from this measurement. The question this data needs to answer is, “Is the physician competent to carry out the privileges granted?” The answer to this question can be yes, maybe, can’t tell, or no. Let’s examine each of these possible answers one at a time.

If the answer is yes, the data indicates that the physician has demonstrated current competence for the privileges he or she holds. The medical staff and hospital can comfortably authorize the physician to continue practicing with his or her current privileges. In the past, such an evaluation was only carried out at reappointment. Today, the bar has been raised so that periodic and systematic reassessment of a physician’s competence occurs more frequently. Although no regulatory agency specifies how frequently medical staffs must review and evaluate this data, practice in the field is settling around reviewing this data about every six to eight months, or two to three times between each reappointment cycle.

If the answer is maybe, this means that the peer review data raises concerns about the physician’s competence. The physician should then undergo a focused professional practice evaluation (FPPE) so that the medical staff can take a deeper look at the physician’s performance. You may do this retrospectively, in real time through proctoring, or prospectively. The key is to look for measures that demonstrate competence or the lack of it.

If the answer is can’t tell, you have a different problem. This answer arises when the peer review metrics do not provide meaningful or helpful data related to a physician’s competence. In this case, your peer review program may be measuring the wrong “stuff.” This creates an opportunity to work with your physicians to hone your peer review metrics so they more closely measure competence.

The most pressing problems, as well as the greatest responsibilities and liabilities, arise when the answer is no, the physician is not competent to carry out the privileges granted. The challenge is in knowing when a physician crosses this line. Unfortunately, a clear line delineating  a physician as competent on one side and incompetent on the other rarely exists. This circumstance causes two types of problems. The first is, without such a clear line, most medical staffs delay effective action, creating significant risks for patients and excess liability for the hospital and other physicians sharing the care of patients with the problem physician. The second problem is that without a clear line, medical staffs risk prematurely taking corrective action to restrict a physician’s privileges, giving rise to unwarranted professional injury to the physician, an unnecessary and expensive fair hearing, and a potential lawsuit.

How, then, should a medical staff determine when a surgeon’s high complication rate crosses this line? How will they know when a hospitalist’s excess mortality ratio warrants action? Initially these are the wrong questions to ask. The initial goal of all peer review should be accurate measurement and feedback so that physicians have a chance to self correct. In other words, a single bad outcome, unless truly demonstrating blatant incompetence, should not cause a physician to cross the line from competent to incompetent. But if, after receiving repeated feedback regarding the need to improve, a physician’s poor performance persists, at some point the line separating competence from incompetence will be crossed.

Though this is rarely a clear line, there exists somewhere a threshold. The future of peer review and privileging will increasingly focus on establishing such thresholds, recognizing when physicians approach them, and helping physicians so that they do not cross the threshold. In other words, our goal should be to use peer review and privileging to help physicians succeed, including indentifying and responding to opportunities to improve. But if they do not improve, if they cross the threshold, the physician will have demonstrated incompetence and will warrant a restriction of privileges. Building peer review and privileging processes with this in mind will help create the future of credentialing.

All the best,

Rick Sheff, MD

Principal and Chief Medical Officer

The Greeley Company, a division of HCPro, Inc.