Book excerpt: Procedures for evaluating performance of APPs

The medical staff should evaluate the performance of all advanced practice professionals (APP) as part of its routine performance improvement processes. APPs’ performance should be consistent with the medical staff policies and procedures regarding competency assessment (FPPE and OPPE, if your hospital is Joint Commission-accredited). Any concerns regarding the quality or appropriateness of care provided by an APP identified during this review processes should be brought to the attention of the appropriate medical staff review committee.

If an individual has concerns regarding a physician’s supervision of an APP, he or she should report those concerns to the appropriate medical staff department/clinical service or review committee. In addition, the hospital likely evaluates the quality of care provided by the APPs that it employs on an ongoing basis through its employment performance evaluation process.

Automatic Relinquishment of Privileges

The board should not grant APPs the right to dispute automatic relinquishment of privileges. Automatic relinquishment would occur if the license or other legal credential of the APP expired or was revoked, or if the APP was excluded from Medicare/Medicaid, etc. Automatic termination would occur if the APP failed to meet his or her eligibility criteria.

The board should terminate an APP’s privileges and status immediately, without right to a fair hearing, in the event that the APP’s employment with the hospital is terminated for any reason, or if the APP’s employment, contract, or sponsorship with a member of the medical staff organization is terminated for any reason.

Corrective Action

Whenever the activities or professional conduct of an APP adversely affects, or is likely to adversely affect, patient safety or the delivery of quality patient care, or if the APP’s professional conduct is disruptive to the organization’s operations, the matter should be referred to the credentials committee or MEC for consideration of corrective action. The credentials committee should review the matter or designate an ad hoc or existing peer review body to evaluate the matter.

In addition to being referred to the credentials committee, the matter may be referred to the employing organization as described in organization-specific policies and procedures (applicable to hospital-employed APPs only). The credentials committee may use external third parties to conduct all or part of the investigation or to provide information to the investigating body. The investigation may involve an interview with the APP involved, his or her supervising/collaborating/sponsoring medical staff member, and/or other individuals or groups who can potentially provide valuable information regarding the APP’s performance.

Fair Hearing and Appeal Process

The hospital and/or medical staff should allow APPs the right to dispute any action that revokes, suspends, terminates, restricts, or reduces the clinical privileges that they have been given permission to provide at the hospital, unless the action revokes, suspends, terminates, restricts, or reduces the clinical privileges of an entire classification of APPs rather than being focused on an individual.

Organizations must consider the section of the bylaws that relates to hearing and appeals for APPs carefully. There are several issues that need to be considered, including the following:

    -- The Joint Commission’s medical staff standards permit a different right of hearing and appeal for individuals who are members of the medical staff versus those who are not members but are privileged by the medical staff. However, medical staffs must give practitioners the right to a hearing and appeal. Although some medical staff organizations provide the same right of hearing and appeal to APPs, others choose to provide a less extensive process. The following are factors to consider when making this determination:

          -- Will the outcome be reported to the NPDB? If the answer is yes, the hearing must meet the requirements stated in the Health Care Quality Improvement Act. Most likely, the APP would receive the same hearing and appeal rights as members of the medical staff.

          -- Are there state-specific laws or regulations affecting the right to a hearing and appeal?

          --  Will employees of the hospital be provided the employee grievance process and an additional hearing/appeal through the medical staff?

          -- Are there employment contracts, union contracts, or other agreements that affect these rights?

The Greeley Company recommends carefully weighing and discussing these factors with the hospital’s legal counsel to determine the best course for the organization.

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