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Overwhelmed by laundry lists? Core privileging might be your answer.

If you are still using “laundry list” privileging as opposed to core privileging, you are likely struggling to perform meaningful OPPE and FPPE. If a laundry list for a typical specialist includes 60-80 privileges, how do you determine current competence for each?

In order to prove current competence, you need data.  And performance on only a small number of privileges can be evaluated by the types of data typically collected, such as core measure compliance and Apgar scores. Other measures, such as patient satisfaction, medical records completion, blood usage, and drug usage, do not provide privilege-specific competence measurement for individual privileges on the list. That leaves you with individual case reviews as the primary mechanism for assessing competence for most privileges on the list.

Everyone who works with peer review programs in the real world will recognize the major flaws in this approach. Case reviews may be triggered by cases “falling out” because they meet predetermined criteria, such as unplanned return to the operating room or unexpected death, or through the hospital’s incident reporting system. The only meaningful way to link the peer review of individual cases found through either of these mechanisms to privilege-specific competence assessment is the logic of “no news is good news.” In other words, for each line on the laundry list, an absence of adverse events is used as the basis for current competence. Everyone who works with peer review programs in the real world will recognize the major flaws in this approach.

A numbers game
A hospital must be able to measure and report the number of procedures performed or cases managed that fall under each line on the laundry list, something most hospitals cannot do with adequate accuracy. So, even if there is an adverse event, is it one of two (1:2, or 50%) or once in a Blue Moon (1:300, or 0. 3%)? Without a denominator for the equation, how can a “fall out” case say anything meaningful about the presence, absence, or cadence of errors?

Conflict and trust “issues”
Any attempt to label a physician as incompetent or to threaten nonrenewal of a particular privilege based on one or a few cases often meets great resistance, including charges of bias. In a time when medical staff conflict is high and trust is low, taking the right action is a rough road, especially when data proofs are imperfect.

A culture of protectionism
Physicians are notoriously reluctant to score the care of a fellow physician as not meeting the standard of care. That leaves the vast majority of items on the laundry list with zero cases scored and very few privilege-specific data to inform the reappointment process.

La-La Land about EP 10
There are a surprising number of hospitals that, because of challenges related to laundry lists, routinely ignore the lack of “sufficient clinical performance information to make a decision to grant, limit, or deny the requested privilege” on a laundry list. If they attempted to do so, it would paralyze their process.

Retreat to EP3
Once a medical staff recognizes the limitation of available data for line-item consideration, the usual fallback position is found in MS.07.01.03, EP 3, which states, “Upon renewal of privileges, when insufficient practitioner-specific data are available, the medical staff obtains and evaluates peer recommendations.” This brings us full circle back to the time when decisions about privileges were primarily based on references, which are far from “objective and evidence-based.”
OK, so we’ve covered OPPE challenges, so what about FPPE?

Laundry lists create perhaps even greater challenges for implementing FPPE. MS.08.01.01, EP 1 states, “A period of focused professional practice evaluation is implemented for all initially requested privileges.”

Perpetual proctoring?
Simply stated, it is impossible to proctor cases for FPPE for every line on the laundry list. Given the limited resources realistically available for FPPE, only a small sample of procedures or conditions can be proctored or otherwise measured. So we are back to the limited data, look for “fall out” status.

The Joint Commission (TJC) gives a little bit of help here: “While the EP would require an evaluation of each new privilege it could be possible to group very similar activities together and then evaluate a set number of any mix of the privileges, for example, any ten from the group will be evaluated to determine competence for the whole group, but you cannot just look at one privilege from the group.” (FAQs, October 2008)  In other words, TJC is implicitly recognizing the difficulties laundry lists create for complying with FPPE and is saying it is acceptable to cluster privileges together when assessing competence. This is, in essence, admitting that the only way to meet this standard in the real world is to apply some type of clustering methodology. This is the logic that underpins core privileges.

With all of the challenges inherent in OPPE and FPPE programs and laundry list privileging, what’s stopping your hospital from moving to core privileges and getting to an objective and evidence-based process?  Let’s start the conversation.

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