Medical staff competency: How much is enough?
How much time can elapse after formal training?
By Patrice Spath, ART
Brown-Spath Associates
Forest Grove, OR
An increasing number of hospital departments are developing competency-based criteria to apply to medical staffing procedure privileges. The competency requirements are based on the number of patients treated by the individual physician as defined by the clinical departments. Medical staff ad hoc committees, with membership representatives of the physicians performing different categories of procedures, can be formed to develop the criteria. There are eight major considerations to be addressed by the group in the design of volume criteria. Last month we addressed the first four. Following are four more considerations:
• What is the maximum number of years that may have elapsed between the formal training program and the privilege request in order for the training experience to count for competency purposes? What if the physician has performed no procedures since completing the training program?
The ad hoc committees should set limitations regarding the amount of time that can lapse between training and the privilege request. Does training over three years ago with no intervening opportunity for the clinician to maintain his or her skills qualify as continued competency? If the applicant has failed to practice his or her skills, does the mere existence of formal training several years prior to the clinician’s application for privileges still qualify the clinician for privileges? The ad hoc committee should address this question and provide definitive answers for the credentials committee.
• What is the number of procedures that should be performed by a physician during the time between reappointments in order to retain the privilege? If a sufficient number of procedures are not done at the primary hospital, how can procedures done at other facilities be documented?
In addition to defining the number of procedures or formal training necessary to receive initial privileges for a specific procedure, the ad hoc committee should define the yearly minimal number of procedures that must be performed in order to retain privileges.
Remember, a physician’s competency is being reviewed not only from a numeric performance standpoint but also through the medical staff’s quality measurement activities. Therefore, the annual number of required procedures may not need to be as high for reappointment purposes.
• If a physician reapplying for privileges has not performed the required number of procedures, can the physician still maintain privileges through a proctorship program?
If the physician applicant does not meet the minimal proficiency requirements for renewal of privileges, consideration may be given to the establishment of a provisional time period during which a minimum number of procedures will be observed by a physician proctor. Proctors should be chosen from medical staff members who already maintain the privileges or should be solicited from outside the hospital. The minimal number of observations may be suggested by the ad hoc committee.
This provisional status option may be appropriate for the newly established physician who lacks the patient referrals sufficient to performance of an annual number of procedures or for the physician who practices at other hospitals or in an independent clinic where documentation of the physician’s competency cannot be readily obtained.
• Is continuing education a requirement for continued competency in addition to completion of a specific number of annual procedures?
The ad hoc committee may wish to include continuing education requirements for physicians requesting renewal of specific procedure privileges. As technology evolves, maintenance of clinical decision making may be just as important as technical skills.
The medical staff may choose to limit the types of procedures that require annual proficiency criteria to those procedures that require maintenance of technical and clinical skills that cannot be obtained through continuing education alone. In some specialties, it may not be necessary to develop numeric procedure requirements for each specific type of procedure because performance of one type of procedure, such as cholecystectomy, may ensure the surgeon’s competency in other types of procedures, such as appendectomy. In these instances, numeric requirements by surgical category can be defined.
To identify those specific procedures requiring numeric annual performance criteria and those procedures that can be grouped into broader categories, the ad hoc committees may wish to survey the members of the clinical department.
Be sure to document all the decisions that the ad hoc committees make. The physicians charged with the credentialing function should be given clear and concise instructions for initial appointments, new privilege requests, and reappointment decisions. The objective competency criteria for each type of procedure or category of procedures should be included in the application form completed by new medical staff members and those applying for reappointment.
Whatever criteria are developed by the individual clinical departments, they must be applied uniformly to all medical staff members and new applicants requesting privileges to perform the procedure. Joint Commission standards very clearly state that any criteria used to measure medical staff competencies must be applied uniformly and consistently (MS.5.4.1: "Each clinical department makes recommendations to the medical staff regarding professional criteria for clinical privileges").
Potential problem areas are those procedures performed in more than one clinical department. For example, bronchoscopies might be performed by general surgeons as well as internal medicine physicians. Make sure competency criteria for bronchoscopies are jointly established by the surgery and medicine departments and applied equally to all physicians.
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