A. 1. The intent of the standard is that organizations are looking at data on performance for all practitioners with privileges on an ongoing basis rather than at the two year reappointment process, to allow them to take steps to improve performance on a more timely basis.
2. A clearly defined process would include but not be limited to:
- who will be responsible for reviewing performance data. For example, in smaller organizations the department chair or the department as a whole at their department meetings might be able to review all department members. In larger organizations it could be the responsibility of the credentials committee, the MEC, or a special committee of the organized medical staff.
- how often the data will be reviewed. The frequency of such evaluation can be defined by the organized medical staff, e.g., three months, six months, nine, months, etc. However, as noted in the teleconferences during 2007, twelve months would be periodic rather than ongoing.
- the process to be implemented to use the data to make decision as to whether to continue, limit or revoke privileges. This could include defining who can make and approve a recommendation for action, e.g., the department chair when no action is required, the MEC and governing body for limitation or revocations.
- how data will be incorporated into the credentials files. There needs to be a defined process for the data to be in the record and for the review to occur. This can include storing the data out of the record and making it available with the record at the time of the review. There is no requirement that the data be continuously stored in the credentials file.
The decision resulting from the review, whether it be to take an action or to continue the privilege would need to be documented along with the supporting data.
3. The type of data to be collected would need to be defined by individual medical staff departments and approved by the organized medical staff. The standards require an evaluation for all practitioners not just those with performance issues. The departments will know best what type of data will reflect both good and problem performance for the various practitioners in their departments. The organized medical staff will then determine if the correct type and amount of data is being collected.
The standard's rationale outlines suggested data that the organization may choose to collect along with the following suggestions for methodologies for collecting information:
- periodic chart review
- direct observation
- monitoring of diagnostic and treatment techniques
- discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, nursing, and administrative personnel.
While some types of data apply to all practitioner, since performance is different for different practitioner, e.g., cardiologist vs orthopedists, vs obstetricians, there may need to be specific data.
In addition since most practitioners perform well, there would need to be data on their actual performance as well as those with performance issues. The fact that a practitioner doesn't fall out on pre-defined screening criteria, is not sufficient to meet the requirement for performance data on every practitioner.
It is also important to remember that zero data is in fact data. Zero data can actually be evidence of good performance, e.g., no returns to the OR, no complications, no complaints, no infections, etc.
It is also important to know when someone is not performing certain privileges over a given period of time.
4. The information resulting from the evaluation needs to be used to determine whether to continue, limit, or revoke any existing privilege(s) at the time the information is analyzed. Based on analysis, several possible actions could occur, including but not limited to:
- determining that the practitioner is performing well or within desired expectations and that no further action is warranted
- determining that issue exist that require a focused evaluation
- revoking the privilege because it is no longer required
- suspending the privilege, which suspends the data collection, and notifying the practitioner that if they wish to reactivate it they must request a reactivation
- determining that the zero performance should trigger a focused review (MS.4.30 EP 5) whenever the practitioner actually performs the privilege.
- determining that the privilege should be continued because the organization's mission is to be able to provide the privilege to its patients.
Evidence of these determinations would need to be included in each practitioner's credentials files at the time of each review of the data.