MSPs, physicians, and hospital-owned clinics: No easy answers

More community practices are joining hospital systems because it makes economic sense for both parties. However, when hospitals acquire community practices and clinics, the medical staff services department (MSSD) faces credentialing and privileging questions. Will physicians in newly acquired clinics be considered members of the hospital medical staff? Will they be credentialed by the hospital’s medical staff office? Will they need two sets of privileges? For Joint Commission-accredited facilities, how will FPPE and OPPE be handled?

The answers to these questions vary by organization.

The fundamental question that must be answered first is whether hospital-owned practices will be included on a hospital’s license. Practices may be owned by a system without being on its license, but from a compliance perspective, it can be more complicated for a hospital if clinics are included. For example, if a practice is on the hospital’s license, Joint Commission– accredited hospitals must grant privileges and conduct OPPE and FPPE for the clinic’s practitioners just as they would for practitioners with hospital privileges, although the OPPE and FPPE must be appropriate for the physician’s practice setting.

For Barbara Stockton, director of medical staff at Katherine Shaw Bethea (KSB) Hospital, a not-for-profit, independent facility in Dixon, Illinois, the major challenges aren’t related to whether providers should be included in the hospital’s medical staff. “We acquired our medical group a long time ago, and all the providers we acquired are already on our medical staff,” she says. KSB is an 80-bed acute-care hospital. Its affiliated medical group of almost 80 physicians are employed by the hospital. KSB is CMS and state-certified.

The transition was a relatively easy process because it was done gradually and didn’t have a major effect on how the hospital operated. However, tracking issues with employed physicians is hard because more people get involved in the processes, says Stockton. For example, if the medical staff services department gets a peer review issue on an employed physician, if it’s a behavior issue, then HR and the vice president of the medical group want to be in the loop, because it’s an employment issue.

“A lot of times, the vice president of the medical group will want to have a conversation at the lowest level with the practitioner before it would ever go to a committee, so it’s gotten really difficult to do loop closure on an event,” she says.

As medical staff director, Stockton would go through the usual peer review process, but HR or the vice president of the medical group might have dealt with it another way. “Some cases would get to a higher level that had already been settled by HR. Or maybe the vice president settled it or the medical director, and it didn’t get to peer review at all. Without [resolution], we’re not getting it for OPPE,” she says. "Just a brief email or memo explaining the action taken and any followup indicated, communicated back to me, will close the concern or issue."

KSB is corralling that problem through better communication. Now when an issue is sent through the peer review process, Stockton sees to it that HR and the vice president of the medical group also know about it. "Then I’ll communicate with them [and say] I need the loop closed, because this needs to go into OPPE. That’s critical,” she says.

Privileges

Most of the KSB medical group uses hospital medicine, so they’re practicing primarily in the office. The medical staff saw a need for hospital medicine privileges, but the task of developing them wasn’t hard because most of the hospital medicine physicians practice internal medicine or family medicine.

“Now we’re building ambulatory privileges because we have practitioners coming on board, or who are scheduled for reappointment and have not provided care to in-house patients for up to two years, who practice only in the office. We have a couple of family medicine physicians who are helping us build ambulatory care privileges," she adds.

Then there’s OPPE: KSB is building its ambulatory OPPE, and will use patient experience scores and payor report cards. “We decided to incorporate [payor report cards] because all of this is preventative—that’s all you look at in the ambulatory world, immunizations, colonoscopies, routine tests. … Those are the kinds of things our payors are collecting,” says Stockton. The OPPE process may also use patient complaints. The hospital’s patient advocates are under the quality department, so when a complaint is received, it can be entered into OPPE, with the outcome.

However, no matter what the medical staff chooses to measure, data integrity is most critical and until they can trust the data, they will not buy into the process. “We finally have patient advocates, infection control, quality, and medical staff services, under one director, so now we can really get our arms around this,” she adds.

Who is ‘active staff’?

The changes at KSB over the years have led Stockton to seek a new way to define “active medical staff.”

The hospital has some physicians who primarily use hospital medicine, but are on the physician leadership groups of KSB’s clinics, and help with patient experience tactics, attend meetings and they participate in the quality projects. “They may not admit anybody; they’re in the clinic. ‘Active staff’ needs to be redefined to include them,” she says. “I think we have to take out the volume and [focus more on participation]. We have a lot of active providers that don’t admit anymore so their inpatient volume doesn’t matter. But they’re active because they’re clinic leaders.”

As KSB gets OPPE launched, it could mark the end of provisional status for physicians, according to Stockton. “I see provisional status going away with OPPE, because every provider will be monitored on an ongoing basis, all the time,” she says.

The hospital’s divisions themselves might change as well. The medical staff may recommend the addition of an ambulatory division to the current medical and surgical divisions. Currently the ambulatory physicians are coming to surgery and medicine, and although outpatient matters are discussed in these settings, the ambulatory group needs its own forum to deal with their specific issues, she says.

Stockton sums up some of the challenges this way: “It’s not easy to sit down and reorganize the medical staff when you’re not a physician. … When I propose [changes] to the medical executive committee, I’m getting the physicians leaders on board. When I do the ambulatory privileges, I get a couple of family medicine physicians helping me, so when I take the final draft to the credentials committee, I’m going to have those physicians behind me. When I propose the new definition of active staff status, I need to have the president of the medical staff and the division chairs behind me. Physician to physician is much easier than me trying to explain to them that we have to do this.

“Those are really big challenges. The thing for me, as a medical staff director, is just getting them to buy into these changes. That’s where we really have to lean on our leaders, to get that part done.

“This is challenging for everybody,” Stockton adds.

30-plus clinics, one medical staff

More than 30 outpatient clinics are associated with Ventura County Medical Center, a county medical system based in Ventura, California. All credentialing and management of physicians is done within the medical staff office, says Tracy Chapman, manager of Ventura County Medical Center’s medical staff office.

The organization has a medical staff of more than 730; of those, about 90 are midlevel practitioners.

The rest are physicians; the majority of them work in outpatient settings and have hospital privileges and call responsibilities. In addition, a good portion are community providers not specifically contracted with the county, but are privileged to see patients at Ventura County Medical Center. The majority of practitioners are active, Chapman adds.

Many of the physicians are contracted, and a few hold administrative positions, but they also see patients. For example, the medical director also sees patients at one of the outpatient clinics on a part-time basis, she says.

“We are delegated with several health plans, so we are held to [National Committee for Quality Assurance (NCQA)] standards for credentialing as well. We are audited annually by the health plans for NCQA, so we’re doing that dance between the [The Joint Commission and the NCQA], trying to find practices that work with both sets of standards,” says Chapman.

All credentialing of practitioners is done in-house through the medical staff office.

Some of the system’s clinics are owned by Ventura County Health Care Agency and some are affiliated clinics and considered independent businesses, but all medical staff are credentialed through the medical center’s medical staff office. “I’m still getting up to speed on which clinics are owned by the Health Care Agency versus which ones are affiliated clinics,” she says.

When the associated clinics hire physicians, they come to the Ventura County Medical Center office for credentialing. The medical director is involved in a portion of the interviews, according to Chapman. “All physicians have gone through the same credentialing process and are held to the same OPPE, regardless of whether they’re contracted with the county or with a specific clinic,” she says.

Revisiting OPPE

Ventura County Medical Center is in the process of revising its OPPE process because in the past, “OPPE indicators were minimal and didn’t specifically include the midlevel practitioners or the ambulatory care practitioners in the measurements,” says Chapman.

Each medical department in the organization is selecting new data indicators for associated specialties that can be monitored for both inpatient and outpatient practitioners, she says. Indicator data will be presented to the departments on a six-month basis via a dashboard report with the specific physician identifiers removed. Each practitioner will have his or her own report as well that will show quarterly results based on the two-year appointment cycle.

The organization is moving to dashboard reports because some department chairs previously reported that they weren’t comfortable assessing peers with whom they hadn’t worked directly, and welcomed the opportunity to see comparative data for the whole department, spotting trends and data that may fall outside the norm. If outlier information is identified, the department chair could access that specific practitioner’s individual data to determine if further review is required. Quarterly data will be reviewed at the time of reappointment as well, she says.

Some departments are moving ahead faster than others for a variety of reasons. There are fewer practitioners in some departments, which have had less difficulty selecting performance indicators that apply to both inpatient and outpatient facilities.

‘How do you measure outpatient psychology?’

It’s more of a challenge for other departments. For example, Ventura County Medical Center has an inpatient psychiatric unit next to the hospital along with outpatient behavioral health clinics that are under its licensure and are accredited under the hospital manual. However, they are on a different electronic system, and identifying meaningful indicators that encompass adult, adolescent, inpatient, and outpatient psychiatrists has been a challenge.

“We also had to figure out, ‘How do you measure outpatient psychology?’ ” Chapman says. The department added items to the peer review process and will do chart audits every six months to ensure that all clinicians are “on the same page” with treatment plans. OPPE measures selected by the psychiatry department will also apply to psychiatrists working in outpatient clinics, she says.

The OPPE revision process has been underway since the beginning of the year as part of ongoing quality improvement projects. The revisions have meant a lot of documentation and input in the MSSD in part because it doesn’t have an OPPE or quality-specific software program.

“We’re creating our own and working with the EHR coders and representatives that are building the reports that will come to the MSSD. We’ll compile the data and we’ll have individual sheets for practitioners at the time of reappointment that have the cumulative data for the four quarters within the two two-year reappointment cycle that they can sign off on, instead of coming into our office and signing off on a large amount of individual documents at one time,” Chapman says. “We’re getting there and the physicians are pleased to be looking at outpatient information as well.”