The Renewal of Infrequently Exercised Privileges for Family Physicians

In recent years, the Joint Commission (JC) and other regulatory agencies have increased their scrutiny of the credentialing reappointment process in hospitals. This activity is meant to be a periodic reappraisal of the privileges granted to each medical staff member to determine if the board should re-authorize these privileges for an additional two-year period. The JC has emphasized that this reappraisal should be data-driven. This is a departure from the historic practice of re-authorizing the privileges if the subjective opinion of a department chair is that there is no reason not to grant them. The demand for new rigor in this evaluation process is also driven by the rapid rise in lawsuits against hospitals for negligent credentialing. The plaintiff attorneys in these cases frequently challenge the hospital’s representatives to show what information they used to assure that a physician was warranted the privileges he was granted.

In the face of this demand for data-driven reappointment, hospital credentials committees have struggled with how to address the issue of low volume providers on staff. For family physicians, this is a concern not only over specific privileges, but also over membership. In many cases, a family physician wants to remain a member of a hospital staff, but not actively manage inpatients. This desire may be driven by a requirement of managed care payers that want family physicians to be on a hospital staff, or because the family physician wants access to his hospitalized patients to make social calls and to look at the chart. The family physician may also wish to partake in the continuing medical education (CME) and social activities of the medical staff, even if he or she doesn’t actively manage inpatients. Some hospitals are questioning whether they should allow this arrangement since the expense and burden of recredentialing these physicians is constantly growing. They are also concerned that they have no data on these physicians to inform the recredentialing/reappraisal process. However, since these physicians do not want specific privileges and are often granted a form of membership which just allows them to “refer and follow” but not manage patient care, the reappraisal can be fairly simple (e.g., letters of reference vouching that the family physician is a good outpatient physician and of good ethical and professional character).

Where specific privileges are requested, the challenge posed by low volume activity is raised a notch. A partial solution is to move family medicine departments to “core privileging”. This approach moves away from delineation of privileges forms that are extensive lists (often pages long) of the conditions treated by family physicians and the procedures they perform. Where this “laundry list” approach is utilized, the JC, among others, is asking for predefined criteria which establishes the qualifications for each item on the list. This is a daunting challenge and overly burdensome.

The preferred approach is to ‘bundle’ all of the items on the list commonly performed by family physicians and for which they are typically trained in accredited residency training programs. This bundle represents the ‘core’ of what family physicians do and is described in several prose sentences. For example:

Admit, evaluate, diagnose and treat newborns, children and adults for most illnesses and injuries. Privileges include but are not limited to; pre- and post-operative care, suture simple lacerations, I & D abscesses, perform simple skin biopsies or excisions, remove non-penetrating corneal foreign bodies, and manage uncomplicated minor closed fractures and uncomplicated dislocations.

The qualifications to hold this core are then articulated – e.g. completion of a three-year approved residency program - and there is no need to identify individual qualifications for the hundreds of conditions and procedures subsumed within this description. Because the skills in the core are generally not felt to diminish if one is in active and full family medicine, the reappointment criteria can typically just require evidence of such practice (e.g. active management of at least “x” inpatients and “x” outpatients over a two year period).

Some items are not so generic to all family physicians and family medicine training programs, and these are listed as special privileges granted outside of the core. An example might be colonoscopy or certain skinny needle biopsies. Other items might be specially listed outside of the core because there is a more rapid deterioration of the skill if not practiced with some frequency. An example might be cesarean deliveries. A physician could go five years without seeing a patient with pneumonia, but still be able to recognize and treat this condition at the end of that period. However, if someone has done no obstetrics for five years, there may be greater cause for concern about his or her ability to still perform a c-section with the requisite skill.

Setting the qualifications for maintenance of a specific privilege is often an area of concern for family physicians because competing high volume specialists often advocate performance of a minimum number as a threshold for reappointment. Since family physicians have less occasion to do many procedures in high volume, they are disadvantaged by the use of numeric reappointment criteria. How should family physicians respond?

First, where numeric criteria are used, credentials committees should allow experience from all locations to be utilized in tolling up experience with a procedure. If a physician does only three colonoscopies at the hospital but 15 in his or her office, or ten more at another hospital, the numbers from all sources should be totaled and used to determine compliance with any numeric re-privileging criteria.

Second, family physicians should also make clear to credentialing committees and medical staff leaders that “competency” in a procedure is what needs to be ascertained in order to grant the associated privilege. Only a relatively small volume requirement is necessary to establish that someone indeed does something they are requesting permission to do. High volume requirements do not equate with competency. Family physicians should argue that competency can be established by references – i.e. testimony from someone knowledgeable of the physician’s competence (typically in a letter of reference). Where such a reference is not available , then an alternative to denial of the privilege is to grant it contingent upon having the next one or two exercises of the procedure performed under the observation of a proctor who can then provide the necessary confirmation of competence.

This approach gives family physicians who do procedures three methods to demonstrate competency: 1) do the procedure in high enough volume that any quality trends might be detectable; 2) have references attesting to competency; and 3) have a proctor attest to competency. Regarding the first option, family physicians should insist that the number chosen is evidence-based, and where no supporting literature exists for a specific number, insist that the criteria is established by the consensus of a multidisciplinary group of physicians who do not have a self-interest in creating an artificially high volume requirement. However, any of the three options listed above should be available to provide a basis for determining competence.

Core privileging and a three option approach to demonstrating competence for selected privileges should get family physicians past the “low volume” challenge in most cases.