CEDAR RAPIDS Medical Executive Committee Orientation December 9

CEDAR RAPIDS Medical Executive Committee Orientation December 9, 2014

Why Are You Here? CEDAR RAPIDS

CEDAR RAPIDS The Medical Staff is responsible for monitoring and improving the quality of care provided at Mercy Medical Center; primarily the performance of individuals granted privileges (LIP)

Medical Staff Organization CEDAR RAPIDS Board of Trustees Medical Staff Management

Medical Staff Organization Board of Trustees Medical Staff Executive Committee Departments Committees CEDAR RAPIDS

Medical Staff Departments • • • • Anesthesia CV Medicine Dental Emergency Medicine Family Medicine Internal Medicine OB/GYN Ophthalmology Orthopedics Pathology Pediatrics Podiatry Psychiatry Radiology Surgery Urology CEDAR RAPIDS Committees • • • Bylaws Credentials Nominating Physician Wellness Peer Review • • • Medical Education Medication Management Blood Management Institutional Review Committee Trauma Allied Health Practitioners Board of Trustees Quality Committee Medical Director Council Cancer

Medical Staff Organization CEDAR RAPIDS Board of Trustees Medical Executive Committee Department Chairs Management VPMA Medical Directors

CEDAR RAPIDS So how do we go about ensuring the quality of care provided by the providers at Mercy?

Quality Continuum © Greeley Company CEDAR RAPIDS

Poor Quality Continuum Corrective Action Credentialing CEDAR RAPIDS

Appoint Excellent Providers Credentialing and Privileging • Appointment • Reappointment • Development of privileging criteria CEDAR RAPIDS

Appointment • • • Application Primary Source Verification Review by Department Chair Credentials Committee MEC Board of Trustees CEDAR RAPIDS

Appointment CEDAR RAPIDS • Credentialing - Membership – Just being on the Staff – Same for all physicians, dentists, podiatrists – Categories of membership • Associate, Active, Courtesy, Affiliate, Honorary • Temporary, Locum Tenens, Disaster • Privileges – What allowed to do • Department Chair > Credentials Committee > MEC > Board

Appointment CEDAR RAPIDS • Credentialing – – – Education: professional school/residency/fellowship License, drug certificates, liability insurance References History at other institutions Background check Other factors: malpractice, NPDB, gaps in history, frequent movement, exclusion from federal payment programs • Any other information you need? • Interview?

Appointment CEDAR RAPIDS • Privileging – Training and experience – Case logs – References – “Universal” criteria when privileges overlap between specialties – Main focus for Department Chairs

Reappointment CEDAR RAPIDS • “Current competence” for privileges requested • Provider profile – OPPE/FPPE • Peer Reviews • License, drug certificates, CME, liability insurance • Dept Chair>Credentials>MEC>Board

Other Credentialing Issues • • Core privileges vs. Laundry lists Competency clusters Current competency Turf battles Low volume/No volume providers Telemedicine Burden is on the applicant CEDAR RAPIDS

Process at Mercy • • CEDAR RAPIDS Applications sent out by and returned to MSO Applications reviewed by MSO for completeness Compile all verifications, references, case logs For reappointments: OPPE/FPPE, PR, complaints, procedure volumes, CME • Generally flag any “bumps” • Department Chair called to review applications • Chair makes recommendations to Credentials

Ultimate Question CEDAR RAPIDS Would I feel comfortable having my parent/spouse/child seen by this physician?

Criteria Development • What is the training, experience, competency necessary to adequately perform a new procedure? • Formal or informal training? • Hands-on labs? • Proctoring? • Maintenance criteria-CME, numbers? CEDAR RAPIDS

Quality Continuum © Greeley Company CEDAR RAPIDS

Set Expectations CEDAR RAPIDS • • Medical Staff Bylaws Policies and Procedures Standardized order sets Quality of care Quality of service Specialty society guidelines External benchmarks

Provide Feedback CEDAR RAPIDS • Ongoing Physician Practice Evaluations (OPPE) – Metrics developed for each Department to provide members with feedback on their performance – Sent out to members semi-annually • Focused Physicians Practice Evaluations (FPPE) – For new members/privileges or to follow up identified concerns • Meetings with physicians

Why Have Feedback? • • • CEDAR RAPIDS To set expectations To recognize good performance To identify opportunities for improvement To allow physicians to self correct To initiate dialog on potential poor performance (Why are you different? )

Manage Poor Performance CEDAR RAPIDS • Chart Reviews – Universal and Department-specific triggers • Peer Review • Medical Staff Wellness Committee (Article XI) • Personal Conduct (Article VI)

Peer Review Process CEDAR RAPIDS Case referred for evaluation 1 Department Chair Rank 12 Rank 23 Rank 34 Peer Review Committee 5 MEC 6 BOT 7

Corrective Action CEDAR RAPIDS Article VII of the Medical Staff Bylaws

Health Law CEDAR RAPIDS

General Duties CEDAR RAPIDS • Attendance at MEC and Department meetings – agenda planning • Review of Credentials files for new applicants and reappointments • Chart reviews • Staff resource for clinical questions • Resource for Department members • Resource for development of new policies/procedures • Assistance with performance issues

Typical MEC Meeting CEDAR RAPIDS • 1 st Tues of month, 5: 30, Neuhaus Board Room • Agenda – – – – Approve prior minutes Review Department minutes Administrative report Committee reports-i. e. Credentials, Bylaws Quality, Safety, Clinical Outcomes Old Business New Business

Physician website CEDAR RAPIDS https: //p. mercycare. org (same user name and password as with Epic) – – – – News updates Agendas Minutes Bylaws/Policies Send comments References Links

Issues for 2015 • • CEDAR RAPIDS Refinement of OPPE/FPPE Development of Department metrics Rules and Regulations/Bylaws update The Joint Commission – due for survey late 2015 or early 2016 • Medical Staff leadership training • ICD-10 training • Continued progression towards P 4 P and population health management

Questions ? CEDAR RAPIDS