Assessing ongoing competence

After a practitioner completes his or her initial focused professional practice evaluation, the medical staff is responsible for monitoring his or her competence on an ongoing basis. The following excerpt from The Medical Staff’s Guide to Overcoming Competence Assessment Challenges describes what data needs to be tracked to ensure a practitioner’s competence.

Often, negligent credentialing claims are based on allegations that the organization failed to ensure that a practitioner was competent to provide specified care, treatment, or services. Organizations should ensure that they have done their due diligence to not only verify initial competence but to also establish a comprehensive process to monitor and review practitioners’ ongoing competence.

Monitoring a practitioner’s overall performance is a comprehensive, data-driven process. Most organizations collate these data into a central department for tracking and trending and/or use commercially available databases to help streamline the process. Performance data that should be monitored on an ongoing basis include but are not limited to the following:

• Department-specific quality metrics
• Quality metrics identified by the organization that can be tracked and measured for each practitioner (e.g., average length of patient stay as noted in the example above, unplanned returns to the emergency department or ICU, timely patient discharge, etc.)
• Compliance with medical record documentation requirements (e.g., countersignatures; appropriate documentation of verbal orders; thorough, accurate, and timely documentation; etc.)
• Medication reconciliation compliance (e.g., review any discrepancies noted by the pharmacy or error rates attributed to the practitioner)
• Complaints or grievances reported from patients/families
• Performance concerns documented by the department chair (e.g., collegiality, meeting attendance, feedback from medical students/residents, etc.)
• Peer review data (e.g., clinical or behavioral concerns, policy or compliance violations, etc.)
• Maintenance of current credentials (e.g., number of times practitioner allowed license, Drug Enforcement Administration, insurance, or other credentials to expire, resulting in automatic suspension)
• Ongoing monitoring of state medical board investigations/sanctions, National Practitioner Data Bank (NPDB) updates, and Office of Inspector General (OIG) queries to ensure the practitioner is not on the excluded parties list
• Complaints or concerns reported from employees, the compliance department, or peers
• Overall compliance with hospital policies, code of conduct, medical staff bylaws, and rules and regulations
• Data from patient/family satisfaction surveys
• Any other data identified by the organization as being meaningful and measurable performance data

Source: The Medical Staff’s Guide to Overcoming Competence Assessment Challenges