Book excerpt: Putting the Competency Assessment to Work

All accrediting agencies require medical staffs to perform global assessment of practitioner competence. Not only is this assessment required, ensuring the quality of care provided by those privileged through the medical staff is also the right thing to do.

In 2007, The Joint Commission gave the field a structure by which to assess practitioner competence when it introduced what it called three new concepts in its revised credentialing and privileging standards. The first concept created a framework to measure practitioner competency and is modeled after the Accreditation Council for Graduate Medical Education and American Board of Medical Specialties joint initiative. This concept is known as the six areas of “general competencies,” which are:

·         Patient care

·         Medical/clinical knowledge

·         Practice-based learning and improvement

·         Interpersonal and communication skills

·         Professionalism

·         Systems-based practice

Medical staffs should assess present and future practitioners using this framework or any other framework that assesses practitioner performance globally. If your hospital is Joint Commission-accredited, this framework does not need to be identical, but it must be comparable to the six general competencies.

The second concept that The Joint Commission introduced in 2007 replaced the old “proctoring” with a more vigorous requirement called focused professional practice evaluation (FPPE). There are two types of FPPE. One type evaluates the competence of all new practitioners to ensure initial competence. Initial FPPE is a defined period that is required for any initially requested privilege, whether from a new applicant or from an existing privileged practitioner seeking a new privilege.

The other type evaluates the performance of all practitioners who have been identified through an ongoing professional practice evaluation (OPPE) as needing further proctoring. Medical staffs must establish FPPE criteria (akin to the old “focused review”) to determine when to further evaluate practitioners if questions arise regarding their ability to provide safe, high-quality patient care during the course of OPPE.

Traditionally, the credentialing and privileging process has been a procedural, cyclical process in which practitioners are evaluated when they are initially granted privileges and every two years thereafter.

The third concept, OPPE, is a process designed to continuously evaluate a practitioner’s performance in the hope that the medical staff will identify and resolve potential problems as soon as possible. Although The Joint Commission does not use the term “peer review,” OPPE is an attempt to improve the overall value of the peer review process.

If your organization is Joint Commission-accredited, it should enumerate all three of these concepts in the medical staff bylaws to ensure not only that the medical staff performs thorough peer review, but also that the medical staff has a solid defense if it is brought into litigation. If your organization is not Joint Commission-accredited, evaluating practitioner performance using a framework of performance criteria, initial review, ongoing review, and focused review (if necessary) are best practices and comply with the competency assessment required by all regulators.

This week's book excerpt is from The Greeley Guide to Medical Staff Bylaws, Third Edition by Mary J. Hoppa, MD, MBA, CMSL, a senior consultant with The Greeley Company, a division of HCPro, Inc., in Danvers, MA.