Is your privileging system effective?

Dear medical staff leader:

I was working recently with a number of medical staff leaders of a terrific health system to develop new clinical privileging forms for a hospital start-up that is part of the leaders' health system.

To prepare for this project, I reviewed the system's current "flagship" medical center's privilege forms. I mentioned to one of the physicians that the current privilege forms are excellent. The forms include well-defined criteria related to education, training, clinical activity, etc., that a physician must satisfy to apply for privileges in a surgical specialty. A lot of time and thought had gone into developing this privileging approach.

The physician, chair of the surgery department, agreed that the forms and criteria were good. However, despite the good criteria, he believed there were some incompetent surgeons practicing at the medical center. He asked why his system's privileging process allowed these physicians to treat patients? What was wrong with the process? I couldn't offer an opinion without first asking the following questions:

1. Was the organization actually applying the current criteria?
2. Do surgeons have and use physician performance reports to provide credible and accurate information about performance, such as complication rates, mortality rates, and other indicators that can be compared to surgeons with similar privileges.

The answer to both of these questions was yes. The department chair said the surgeons in question met education, training, and clinical activity requirements established by the hospital, and received comprehensive performance reports.

After more discussion, the real issue was clear: the medical staff organization was unwilling to take the next step and act on data when the performance reports indicated areas of weakness. The medical staff was hesitant to "take a stand" against a colleague. In addition, volunteer department chairs, who are not reimbursed for their leadership duties, lacked time to react to the data.

At the end of my conversation with the department chair, it was clear to me that the chair didn't think it was his responsibility to develop a plan to help surgeons improve or to protect patients by recommending a reduction in the surgeons' privileges. However, our conversation also led me to conclude that the medical center's medical executive committee (MEC) was struggling with the issues and that, although moving slowly, the MEC would eventually do the right thing. The patients in this hospital depend on the medical staff leaders to take these next hard steps.

I know that when you make tough decisions, there is usually no pat on the back or positive acknowledgement from your peers. In fact, the opposite may happen. I've had the honor of working with medical staff leaders for more than 25 years and I know that leaders want to make the best decisions for patients. Leaders know that although they may not often receive accolades, their colleagues in the medical staff office, quality department, administration, and board understand and appreciate their work.

That's it for this week. To all you medical staff leaders, thank you for the hard work that you do to improve patient care.

Until next time,

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