Ask the expert: How can our facility determine the competence of a practitioner who is active at ambulatory surgery center?

If a physician doesn’t have much activity in your hospital but is active at an ambulatory clinic or surgery center, current clinical competence can be determined using the following mechanisms:

• The organized medical staff can require the applicant to produce a specified number of patient records that reflect his or her clinical work and are comparable to the privileges requested at your facility.
• Your credentials committee can appoint a member of the medical staff to review the patient records the applicant provides. A review of these records will show whether the physician ordered the right ancillary services, made appropriate and timely consultations, and documented care legibly.
• The hospital may require the applicant to compensate the physician who conducts the review. However, many hospitals share this expense equally with the physician. 
• The hospital may appoint an outside expert to review the physician’s patient records. Hospitals typically choose this option when the applicant directly competes with a current member of the medical staff who would normally be responsible for reviewing the applicant’s practice.

This week’s question and answer are fromAssessing the Competency of Low-Volume Practitioners: Tools and Strategies for OPPE and FPPE Compliance, published by HCPro, Inc.