Every New Year’s Eve I think about setting goals for the new year, both professional and personal. It seems that I don’t even get through the first month and I’m back to my old ways. What will make this 2009’s resolutions different from the other years? Perhaps it will be the changes that we all know are coming in 2009 and our country’s new motto, “Yes, we can!”

On January 20 President-Elect Obama will be sworn in as our 44th president. According to U.S. News and World Report, he will draw on the inspiration from past presidents (Abe Lincoln, F D Roosevelt and John Kennedy). Whether we voted for him or not, he is our new President and is offering a time for change. MSPs and others in healthcare will most likely be watching for changes affecting our industry.

This new year we can help each other with at least one resolution: Keep informed about changes and challenges in healthcare. This year I am making a resolution to bring useful information about new developments and new solutions that will help MSPs increase their knowledge base.

I wish you a very Happy New Year! Bring on the Challenges and Change … we’re ready!

Carole La Pine, MSA, CPMSM, CPCS

According to the Associated Press, more than half of the 82 hospitals that responded to a recent Tennessee Hospital Association survey said they had made cuts in staff due to tight finances.

Roughly the same breakdown of hospitals have either reduced services or are thinking of reducing them because of the recession and a spike in uncompensated care, said the association's chief executive, Craig Becker.

"Everybody is looking right now for places where they can save money and keep their core business going," Becker said Monday.

Todd Morrison
Managing Editor

2008 will soon be in our past but it isn’t too late to reflect on the events of this year. A quick review of my favorite web sites revealed that one of the top issues of this year was the continuing rising cost of health care. The article appearing in the Public Agenda for Citizens makes a very interesting read.

This is also a good time to remember healthcare pioneers who made significant contributions to this industry.

Carole La Pine, MSA, CPMSM, CPCS

Ok, so it's not Friday yet, but with the New Year holiday coming up, we just couldn't wait until the end of the week to share our new initiative with you.

Every Friday in January the Credentialing Resource Center blog will feature a free form for you to download. A Free Form Friday extravaganza - what could be better than that? Simply click on the link in Friday's edition of the Credentialing and Privileging Advisor to access the featured blog post. Or go straight to the source - the CRC blog - to access the form directly.

This week’s free form is a certified registered nurse anesthetist (CRNA) clinical privileges form. Click here to access it http://hcpro.com/supplemental/6517_Free%20Form%20Friday_1.02.09.doc.doc.

What free form would you like to see next week? Drop me a line at eberry@hcpro.com and let me know.

Cheers!

Emily Berry
Associate Editor

This is the time of year when medical staff services professionals usually see an increase in the number of “temporary” privileges that are required in order to cover critical patient care needs. I used to say, “If it’s Friday at 4 pm before a Holiday weekend, I’ll get a request for temp privs around 3 pm.” Sometime the request came in a little earlier, but it was certain that temporary privileges would be needed before the day ended.

There is considerable pressure on MSPs to process requests for temporary privileges as quickly as possible in order to meet patient care needs. Please keep in mind that our one key responsibility is to never short-change the patient. I’ve been in such situations where a thorough credentialing process could not be completed before the end of the day. In those instances, I had to deliver the bad news; the request could not be completed and temporary privileges would not be granted. This is certainly not a popular spot to be in and is one that doesn’t make friends. However, it does protect the patient which is our ultimate goal.

For MSPs, this is the most wonderful time of the year to be reminded of the vital role we have in ensuring competent patient care. Patients may never know the gift they have been given, but we’ll know.

Merry Christmas and Happy Holidays!

Carole  La Pine, MSA, CPMSM, CPCS

I’ve been considering signing up for the Proactive Disclosure Service (PDS) but thought it was too expensive. So I did a little homework and here’s what I discovered: The PDS meets the mandatory hospital query requirements of the Health Care Quality Improvement Action of 1986. It is acceptable to The Joint Commission, Healthcare Facilities Accreditation Program, National Committee for Quality Assurance, Centers for Medicare and Medicaid, and Commission on Accreditation of Rehabilitation Facilities as an alternative to direct querying the National Practitioner Data Bank (NPDB).

Several hospitals that I contacted that are using PDS are very pleased with the streamlined and efficient process. Those that are not using PDS indicate that they consider the service too expensive.

I created a scenario to look at actual costs. The number of practitioners at my make-believe hospital is 1,200.  I process 150 applications each year. My average reappointment number is 600.  Approximately 70 practitioners add new privileges each year. Based on the current PDS enrollment rate of $3.25 per practitioner, I calculated the following:

One of the benefits of PDS is the notification you receive when a report is filed on one of your enrolled practitioners.  You get notified immediately and do not have to wait for reappointment to learn about new actions.

What is not included in the calculation is staff time.  How much staff time does it take to query and retrieve reports?   Would staff time cost be less than $492.50/year? 

Carole  La Pine, MSA, CPMSM, CPCS

I’ve never been a big fan of clowns; not on television, not at the circus, and not in movies. The only clown that ever made an impression on me was the lady who transformed from Lovely Lady to a white-faced clown in a religious presentation called “Clowning for Christ’s Sake.” And I love the song, “Send in the Clowns”. However, all other clowns always made be suspicious of who was actually hiding behind the false nose, white face, red hair and baggy clothes.

Although I enjoyed watching the movie “Patch Adams” when it first came out, I discovered that I was not reacting in the same way to the real Patch Adams (Adams was a keynote speaker at the National Association Medical Staff Services Conference held in Milwaukee this year). Instead of making me feel “happy”, I found myself getting a little uncomfortable with the message and behaviors. But now, as The New York Times reports, a new kind of clown is coming to light -- The Nurse Clown.

New York University's College of Nursing called in performers from the Big Apple Circus to teach 132 nursing students on the application of clown techniques in the clinical setting. It was reported that the main purpose of the workshop was to make the students aware of their surroundings and to sharpen their powers of observation. Ms. Betty L. Leef, a nursing instructor, admitted to having a fondness for clowns but acknowledged that the workshop was to make it easier for the nurses to put their patients at ease and not necessarily turn young nurses into clowns.

I understand and appreciate the intention of this technique to better relate to patients by reading their facial expressions, especially when verbal communication is not possible. For me, however, please “don’t’ send it the clowns.”

Carole La Pine, MSA, CPMSM, CPCS

Not as early as some might like, according to this report.  Although there are those like Sen. Ted Kennedy (D-MA) who will likely push for tackling this in 2009, others are saying that the economy will take precedence, at least for a while:

Votes on legislation to enact comprehensive national health reform might have to wait until early 2010, the Democratic chairman of a powerful House subcommittee said Wednesday.

Rep. Pete Stark (D-Calif.), who chairs the Ways and Means Committee’s health subcommittee, said Congress is likely to take a slower approach on healthcare reform. He said lawmakers have too many pressing priorities on the economy and other smaller-scale healthcare issues to move quickly on a large healthcare bill next year, as reform activists have advocated.

“I don’t think we’ll do it in the first 100 days,” Stark said during a conference call with reporters, which was hosted by the Institute for America’s Future, an arm of the liberal grassroots organizing group Campaign for America’s Future.

Todd Morrison
Managing editor

A question arose recently about the role of the credentials  committee in the reappointment process.  Unlike initial application processing, the practitioner going through the reappointment process is a known entity (or should be if he/she has membership and/or privileges). 

Accreditation standards, facility-specific medical staff bylaws, and/or credentialing policies and procedures may contain detailed instruction as to what is collected, reviewed and approved.  MSPs know that The Joint Commission Standards relate to the medical staff making recommendations to the governing body and the governing body takes final action. 

How does the recommendation for reappointment reach the “medical staff”?  What is the role of the credentials committee?  Do committee members have to review entire files that have already been reviewed by the department chair?

The reappointment process goes like this:

1. Application and collected required documentation is collated by the MSPs
2. The department chair is provided a copy of the reappointment file including a request for privileges (as appropriate).
3. The department chair recommendation is presented to the credentials committee on a “consent agenda”.
4. Following the credentials committee review, the recommendation is sent to the medical executive committee and finally to the governing board.

In this case, the credentials committee members did not review every document collected in the reappointment process.  However, committee members and the department chair would be notified of any “unusual” finding.

The role of the credentials committee?  Make sure that every step in the reappointment process is followed consistently and that all questions regarding clinical competency, ethical conduct, and ability to perform requested privileges are answered.

How would this process work in your organization?

Carole  La Pine, MSA, CPMSM, CPCS

Now that science fiction has once again morphed into reality, you might end up creating criteria for face transplant procedures sooner than you once thought:

On Wednesday, Dr. Maria Siemionow, the head of plastic surgery research at the Cleveland Clinic, is expected to announce the completion of another complex surgery -- a near-total face transplant.

The face transplant surgery done two weeks ago by a team of eight surgeons at the Cleveland, Ohio hospital, is the first of its kind conducted in the United States.
…

In such a transplant, the facial flap from the donor's face is attached to the recipient. Veins, nerves and arteries are connected, but the recipient's body could reject the graft.

The transplant recipient has to take immune-suppressing drugs for the rest of his or her life to prevent rejection of the donated tissue. 

Todd Morrison
Managing editor

I missed this recent piece by the New York Times on the connection between disruptive physician behavior and medical mistakes. It begins with a doozy of an example, one fueled by outright arrogance:

It was the middle of the night, and Laura Silverthorn, a nurse at a hospital in Washington, knew her patient was in danger.

The boy had a shunt in his brain to drain fluid, but he was vomiting and had an extreme headache, two signs that the shunt was blocked and fluid was building up. When she paged the on-call resident, who was asleep in the hospital, he told her not to worry.

After a second page, Ms. Silverthorn said, “he became arrogant and said, ‘You don’t know what to look for — you’re not a doctor.’ ”

He ignored her third page, and after another harrowing hour she called the attending physician at home. The child was rushed into surgery.

How much of a connection is there between the two? Quite a bit, according to the following studies cited in the article:

A survey of health care workers at 102 nonprofit hospitals from 2004 to 2007 found that 67 percent of respondents said they thought there was a link between disruptive behavior and medical mistakes, and 18 percent said they knew of a mistake that occurred because of an obnoxious doctor.

Another survey by the Institute for Safe Medication Practices, a nonprofit organization, found that 40 percent of hospital staff members reported having been so intimidated by a doctor that they did not share their concerns about orders for medication that appeared to be incorrect. As a result, 7 percent said they contributed to a medication error.

Fortunately, progress is being made:

There are signs, however, that such abusive behavior is less likely to be tolerated. Physicians and nurses say they have seen less of it in the past 5 or 10 years, though it is still a major problem, and the Joint Commission is requiring hospitals to have a written code of conduct and a process for enforcing it. 

Todd Morrison
Managing editor

I did not see the 2007 movie, Sicko, by American filmmaker Michael Moore which investigated the US health care system and compared the US to health care systems of Canada, the United Kingdon, France and Cuba. It was also reported that the movie was made on a budget of approximately $9 million and grossed $24.5 million. I wonder if any of that revenue found its way into the healthcare stream.

Two years later the health care system has not recovered and in fact seems even sicker than it was. In a very short time President Elect Obama will have to face this situation and honor his campaign promise to trim the health care bill for families by $2,500/year.

An issue that concerns me today is that the US is the world’s most expensive health care system with expenditures exceeding $2 trillion annually. (I’m not even sure I know how many zeros there are in that number!). The Washington Post quotes Gary Kaplan, chair of Virginia Mason Medical Center, Seattle, as saying that as much as half of the $2.3 trillion spent today does nothing to improve health. It is projected that by 2015, the US will spend $4 trillion on health care.

For those of us who work to credential and privilege practitioners this is a hard pill to swallow. Surely our efforts to streamline our processes and eliminate time delays contribute somewhat to a more efficient health care system! We often say that we work to ensure that patients get competent health care and I know how diligently we work to fulfill our responsibilities.

Are we doing anything to help improve the health care in this nation? What more can we do?

Carole La Pine, MSA, CPMSM, CPCS

Here in Massachusetts, critics are complaining that new disclosure laws concerning doctors and drug companies still leave much to be desired.

According to the Boston Herald:

If the new rules are approved, Massachusetts physicians will be prohibited from accepting drug companies’ free meals and vacations. They will also be required to report any money drug companies give them to promote products.

But if doctors are paid to provide research or test drugs for the drug maker, they don’t have to disclose those payments.

Tufts University professor Jerome Kassirer, whose book, “On The Take: How Medicine’s Complicity with Big Business Can Endanger Your Health,” portrays America’s health-care system as a commercial enterprise, called the glaring exemption “unfortunate.”

“We shouldn’t be hiding any kind of personal relationships between pharmaceutical companies and physicians, because of the possibility that any kind of money that goes to physicians could produce some sort of bias,” he said.

Under the proposed rules, patients won’t know if their doctors are profiting when they recommend certain drugs or treatments.

What are the laws like in your state? 

Todd Morrison
Managing editor 

I found the article in Medscape on the limits of apology laws a note worthy topic. Imagine physicians on your hospitals staff apologizing to patients!

Thirty-six states have enacted laws protecting physicians from liability when they have extended expressions of sympathy to patients. In 28 states, investigators found that apology laws prevent the use of expressions of sympathy, regret and condolence -- but not admissions of fault -- against the physician in subsequent litigation. In eight other states, however, they found that apology laws protect expressions of sympathy as well as admissions of fault. It is anticipated that such laws will reduce the number of malpractice cases against physicians when they disclose to patients and families any medical errors that occurred during their care.

Rebecca Dresser of The Hastings Center stated that physicians perform their fiduciary responsibilities when they inform patients and families about deficiencies in patient care. Such disclosure provides patients and families with information to make decisions about follow-up care and to receive a fair compensation as appropriate.

The Joint Commission’s accreditation standards require hospitals to inform patients of any unanticipated outcomes. The challenge is getting physicians to take the first step in talking with patients and families to apologize and admit responsibility for medical errors. What will encourage physicians to take this step? Perhaps education on the correlation between apology and reduced malpractice suits and information that such admissions are protected by law.

This would be an excellent teaching opportunity for MSPs and risk managers to jointly implement.

Ready for the challenge?

Carole La Pine, MSA, CPMSM, CPCS