Part 4: Strategies for solving the challenges posed by low-volume providers

Dear medical staff leader:

Many organizations have faced the challenges posed by a practitioner on the medical staff who wishes to rescind a leave-of-absence (LOA). Consider this scenario: A practitioner who has been part of the medical staff for a number of years opts to take a LOA for the maximum amount of time allowed under the medical staff bylaws. Keep in mind that many medical staff bylaws and associated documents allow practitioners to take LOAs for between six months and two years. During the LOA, the practitioner did not practice medicine anywhere-not at another hospital and not in the community. Now the practitioner is ready to return to practice. How can you assess his or her competency?

It is virtually impossible to assess the current clinical competency of a practitioner who is not active in any clinical setting.  However, your first step should be to consult your policy. Unfortunately few hospitals have adopted a policy that addresses this challenge. If that is the case at your institution, consulting The Greeley Company's "5Ps" rule:

• It is our Policy to follow our Policy. In the absence of a Policy it is our Policy to develop a Policy.

The policy may simply state that the organization will not consider an application or request for privileges for any practitioner who has not engaged in clinical or hospital activity within the last 24 months. However, such a policy may close the door to applicants you may wish to consider for your medical staff. It may also conflict with your current LOA policy.

If your organization decides to process such requests, it must then determine how to verify the practitioner's competency. Your organization may implement a policy that requires such practitioners to successfully complete a mini or full residency. The practitioner should obtain a recommendation from the residency program director attesting to current competency. Further, the policy should state that the practitioner's clinical work must be directly supervised in a controlled environment. This might require the physician to co-admit patients, work in conjunction with a senior physician or proctor, and have 100% of his or her cases reviewed over a defined time period.

This latter requirement can be addressed in your focused professional practice evaluation (FPPE) policy, which The Joint Commission requires as of January 2008. In essence, an FPPE policy must address how proctoring will occur under any of the following circumstances where privileges are granted:

• A practitioner new to your medical staff (without regard to level of prior clinical practice activity)
• A practitioner known to your medical staff but granted new privileges
• A practitioner known to your medical staff who wishes to reactivate privileges after some lapse in time as defined by your policy
• A practitioner known to your medical staff whose competence has been called into question by the organization's peer review program's ongoing professional practice evaluation (OPPE) process.

A clear policy coupled with a strong FPPE process is the solution to the challenges posed by a practitioner who has not practiced medicine for several years.

This week's letter concludes my four-part series offering practical strategies for dealing with low-volume providers. Until next time, be the best that you can be.

William K. Cors, MD, MMM, FACPE
Senior Consultant
The Greeley Company