Medical staff competency: How much is enough? Part I
Departments develop numbers-based requirements
By Patrice Spath, ART
Brown-Spath Associates
Forest Grove, OR
New applicants for medical staff membership, as well as physicians being reappointed to the medical staff, must show evidence of current competence in performing the requested privileges. Joint Commission standards require that each clinical department develop its own criteria for determining how a physician’s competence will be measured. The standards do not, however, specify what those criteria must be.
Some medical staff departments rely solely on the recommendations of peer physicians or on the results of ongoing monitoring and evaluation. However, an increasing number of departments are also developing competency requirements based on the number of patients treated by the individual physician. These types of competency-based criteria usually are applied to procedure privileges. The clinical departments define the annual number of procedures that must be performed by a physician to maintain competency. For example, in one hospital, physicians who request bronchoscopy privileges must have performed 10 therapeutic and 12 diagnostic bronchoscopies each year to retain privileges for these procedures. In the case of bronchoscopy with transbronchial biopsy without fluoroscopy, a physician must perform 25 or more of these procedures each year to retain privileges.
The development of proficiency criteria for the varied types of procedures performed by the medical staff may seem an overwhelming task. To reduce the work involved, the clinical departments can implement the process in steps by continually defining and adding new competency criteria. 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. This month we will address the first four:
• What category(ies) of medical staff membership may be granted privileges for specific types of procedures?
The medical staff may recommend that only MDs or DOs be allowed procedure privileges in certain categories. Otherwise, the medical staff may choose to allow open procedure privileging as long as criteria are met.
• Have relevant medical professional societies recommended annual numbers of procedures required to maintain proficiency? Have any research studies been published on the relationship between volumes and outcomes?
Some professional societies have addressed procedure competency through the development of guidelines for credentialing and privileging of physicians in specific procedures. The American Society of Gastrointestinal Endoscopy (ASGE) was one of the first groups to formally recommend proficiency numbers for residency or fellowship training in gastroenterology or surgery.
Current medical literature also may be a source for performance requirements. Many studies in the past 10 years have evaluated the effect of surgical volume on patient outcome, with many studies showing that higher-volume providers tend to have better results. The medical staff ad hoc committees should evaluate the findings of these studies in setting their competency-based performance criteria. (Examples of relevant articles are listed in the resource section at the end of this article.)
• What are the number of procedures that should be performed prior to granting privileges to new medical staff applicants? How will the new applicant document performance of these procedures? If the desired number of procedures cannot be substantiated by a new medical staff applicant, will the privilege be allowed only after observation of the physician’s technique? How many procedures should be reviewed to ensure competency?
Identify the annual number of procedures that must be performed in order for the new applicant to be considered for privileges. If the new applicant has not performed the desired number of procedures, specify the number of procedures that must be observed by a physician with privileges during the new applicant’s provisional status. Get the new applicant’s permission to obtain records from his or her training program or previous hospital affiliations that document the applicant’s performance of specific types of procedures.
• What is the definition of a "formal training program"? Is this limited to a residency/fellowship training program, or do posteducation training programs qualify? What educational attributes should be present in a formal training program?
The physician requesting privileges to perform the procedure should be able to provide documentation that he or she received supervised training and hands-on experience. Residency and fellowship programs should be able to confirm in writing the number of cases for each procedure for which privileges are requested and the actual observed level of competency for the applicant.
Privilege decision predicaments arise when an established physician requests new procedure privileges after attending a "short course" training program outside of residency/fellowship education. Such short courses can be defined as an organized teaching program lasting less than several weeks and often only a few days. The clinical departments must determine what types of educational programs provide sufficient training and experience to qualify the applicant for full procedure privileges. Similar criteria can be designed for all posteducational training experiences. The decision regarding the adequacy of the training program rests with the medical staff credentials committee. The ad hoc committees should provide general evaluation guidelines.
Next month’s Quality-Co$t Connection will discuss how much time can elapse between a training program and the privilege, plus another set of considerations to be addressed by the group in the design of volume criteria.
Resources
Ellis SG, Weintraub W, Holmes D, et al. Relation of operator volume and experience to procedural outcome of percutaneous coronary revascularization at hospitals with high interventional volumes. Circulation 1997; 95:2,479-2,484.
Rogers DA, Regehr G, Yeh KA, et al. Computer-assisted learning vs. a lecture and feedback seminar for teaching a basic surgical technical skill. Am J Surg 1998; 175:508-510.
Cundiff GW. Analysis of the effectiveness of an endoscopy education program in improving residents’ laparoscopic skills. Obstet Gynecol 1997; 90:854-859.
Regan JJ, Guyer RD. Endoscopy techniques in spinal surgery. Clin Orthop 1997; 335:122-139.
Shwayder JM. The learning curve for laparoscopically assisted vaginal hysterectomy/laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc 1994; 1:S33.
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