Medical Staff Services: Through the Lens of the Patient Safety Program

1. Medical Staff Services: Through the Lens of the Patient Safety Program Susan Sherman, RN, PhD Director, Quality Programs Rex Healthcare

2. Do Not Lose Sight of What You Do Not See • A small evident part or aspect of something largely hidden: afraid that these few reported cases of this problem might only be the tip of the iceberg.

3. Think About Our “Customers”

4. What People Say About You: Administration • “You are the Human Resources Department for the Medical Staff” • Follow the organization’s Medical Staff Bylaws • Meet Conditions of Participation rules for CMS • Meet Joint Commission Standards • Assure physician satisfaction with hospital • Provide support services to physician department leaders • Get the best practitioners in the door that meet our needs

5. What People Say About You • “Medical Staff services staffs are the gatekeepers for patient safety.” • “Medical staff services get the right people in and keep the wrong people out when it comes to patient care.” • “Med Staff makes sure things are running smoothly when it comes to the physicians.”

6. What People Say About You-CMO, Dr. Linda Butler • “Medical Staff impacts both the quality and patient safety by setting the tone or expectations of the providers when they join the organization and again at re-appointment. The providers are considered leaders who can shape the culture of the organization. They also help orient the department chairs who follow up on the variances that are reported.”

7. CMO Paraphrase • You are setting the tone and the expectations for leaders in our hospital, in our organization. • You have an impact at the time these leaders 1) arrive (application and on-boarding), when they get evaluated (FPPE & OPPE), and when they get reappointed (pulling everything we have about this practitioner together so we can fully evaluate her/him).

8. How Do You See Yourself? • www.youtube.com/watch?v=Pk7yqlTMvp8

9. Patient Safety • To Err is Human from The Institute of Medicine (IOM) (1999) – focus on patient safety • Crossing the Quality Chasm from The Institute of Medicine (IOM) (2001) – broader approach in terms of the purpose/aims of healthcare • IOM est. 1970 – advises the federal government, identifies issues in medical care, research, education. • Redesign is required-not just organizations and professionals, but the actual structures and processes in the environment in which we function.

10. The Patient Safety Program • Assure that patients are safe & protected from unnecessary harm • Surveillance of environment of care risks • Analyze process flaws through Root Cause Analysis or Failure Mode Effects Analysis • Determine accountability for staff • Develop contingency plans for potential failures in the care delivery system • React to small problems before they become BIG!

11. Just Culture • Just Culture Core Beliefs: • To Err is Human • To Drift is Human • Risk is Everywhere • We Must Manage in Support of our Values • We Are All Accountable

12. Our Partners in Protecting Patients • First line of defense: • North Carolina Medical Board (NCMB)

13. NCMB • Prejudicial Actions Taken: • 2009 - 218 total (includes 22 licensure denials) • 2010 - 226 total (includes 6 licensure denials) • 2011- 213 total (includes 14 licensure denials) • “To err is human”

14. The Basics Medical Staff Services

15. Application Processes: Protecting the Patient • Recognize red flags during your application processes: • Gaps in practice • Frequent practice changes • Poor references • Incomplete application • Poor follow up to your requests • Excuses for anything and everything • “Risk is everywhere”

16. Application Processes: Protecting the Patient • Communicate profusely with those involved in the credentialing decision making • Share your concerns • Follow all of the rules outlined in your bylaws – do not deviate • Document everything for your Credentials Committee

17. Application Processes: Protecting the Patient • Consider communicating with physician office or hospitals’ Medical Staff professionals where your applicant has practiced • Be an active part of making the credentialing process work for safe care – • “We are all accountable”

18. Questions for Consideration: • When a physician is disrespectful, unprofessional with you or your staff, do you have a mechanism to report that so it can be addressed? Do you note this on the paperwork of an applicant? • Does your organization have a process to follow for reporting these events? And, do you use it? • When you report, is anything done to correct the problem?

19. Support Practice & Privileging • Processes have taken on greater complexity with the influx of midlevel providers: • Greater challenges r/t mobility of these providers • Those coming from other states may have difficulty making practice ‘rules’ transition • Look at application with same critical appraisal processes • Orientation may need to have more depth with this provider, especially if they are coming directly from educational program

20. Midlevel/Dependent Practitioners • Growing contingent • Modify our processes to meet their condition of practice/organization needs • Many challenges including competency assessment conferring privileges • How should our processes vary for these individuals? • Have we made any adjustments or will we wait until a critical event?

21. Physician/Midlevel Disciplinary Action or Removal from Staff • Is this a failure on the part of Med Staff Services (MSS)? Is this a different way of looking at MSS problems? • How do we identify factors that led to the negative outcome? • In the Patient Safety Program, we would utilize tools such as Root Cause Analysis to identify issues. • How do we integrate findings into our systems and processes to prevent this from happening in the future?

22. Recommendations for Medical Staff Services • Develop a strong orientation program: • Include your mission, vision, and values – talk about how that will guide practice • Assure that your physician, dependent practitioner knows the quality parameters they will be graded on for FPPE/OPPE and re-appointment • Share information about your patient safety program

23. Recommendations for MSS • If you do not do this now: • Make a close association with Risk Management: • Assure that events that are logged in by your coworkers are addressed quickly and thoroughly • Assure that coworkers know the processes that are used to address physician related events such as unprofessional behavior or clinical standards deviations

24. Recommendations for Medical Staff Services • Encourage the use of reporting tools that are available in the organization • At the very least, be aware of issues that have become trends as they relate to physician/midlevel (“To drift is human”) • Signing off on orders • Co-signatures • Professional behavior “We must manage in support of our values”

25. Recommendations for Medical Staff Services • Get to know your Patient Safety Officer • Have some familiarity with the issues across the organization – may give you guidance on things MSS can do to improve Patient Safety in your organization

26. Thank you for everything you do! • You help protect the people in your community and others who come to your organization for care through your work.