How key members of leadership formulate the backup system to assign on-call physicians for all levels of medical staff
Making sure all bases are covered in the event a surgeon, specialist, or general practitioner is unavailable for patient care is the topic of this edition of Hugh Greeley’s Hugh’s Credentialing Digest.
Hugh discusses the topic of how close to the skills and experience an on-call physician must have to the physician he or she is covering for. He also discusses who of the hospital staff or medical executive committee (MEC) should be responsible to make certain all bases are indeed covered.
In the case of private practice in a practice group, physicians can often cover for one another. In the case of hospitals, the backup physician can come from within the ranks, or receive temporary privileges as a locum tenens, a hospitalist, or a traveling practitioner.
Emergency Departments Have a Requirement of Care
Emergency departments face a different set of requirements. The Emergency Medical Treatment and Labor Act (EMTALA) enacted in 1986 requires that an emergency department provide an on-call panel of backup physicians that match specialty capabilities so that patient needs are met regardless of the patient’s ability to pay.
Thinking ahead of the provisions that assure the highest quality of healthcare for all patients is part of a healthcare delivery organization’s responsibility. Backup plans range from no plan to inclusion in the processes and procedures. The no plan approach requires medical staff services or committee members to scramble every time a backup physician is needed. A voluntary backup system is where physicians or physician assistants volunteer their services through a scheduling system. The mandatory system engages most of the medical staff to participate on a rotating basis.
The following is contributed by Hugh Greeley, author of Hugh’s Credentialing Digest
My colleague and partner Al Fritz recently referred a question about “backup” physicians to me. The question revolved around three issues:
1. A gastrointestinal (GI) physician wanted to name a general surgeon (who performs endoscopies) as her backup. Other GI physicians declined to back up this doctor.
2. A medical executive committee (MEC) believed that the backup physician must be in the same specialty, though not have exactly the same privileges.
3. Hospital management believed that the MEC should have nothing to do with the issue of backup physicians and that this was a management matter.
Determine a Policy for Backup Physicians
Here is my edited response:
“You are quite correct in that the MEC should have a role in assisting the hospital in determining the rules and procedures for backup physicians. This should not become a board issue unless the MEC and administration cannot resolve any dispute they have concerning it. You have a provision in your medical staff bylaws that addresses dispute or conflict resolution. Hopefully, an issue such as this will not require its use.”
“You are also correct that it is generally recognized that physicians on staff with admitting or surgical privileges should be required to identify a willing ‘alternate’ in case they are needed but unavailable. Your suggestion that the alternate need not have identical clinical privileges is also correct. Indeed, many physicians nationwide identify a physician outside their specialty or clinical area as their alternate, to the satisfaction of the MEC.”
Putting Patients First without Creating a Log Jam for Hospital Leadership
“The primary issue is, of course, patient protection. The second issue is that it should not become the hospital’s or the MEC’s responsibility to quickly find a physician willing to manage the care needed by a patient when the attending is unavailable.”
“The reason the alternate need not have the same clinical privileges is fairly obvious. The role of the alternate is not necessarily to provide all care that may be necessary, but to assess the patient’s needs and either provide care or arrange for its provision.”
Are the Same Level of Privileges Required for Back-up Physicians or Hospitalists?
“This is generally why internists or pediatricians are able to sign out to family practitioners, or why it is acceptable to MECs for vascular, plastic, breast, or other specializing surgeons to sign out to a general surgeon. I often find that cardiologists, infectious disease specialists, general internists, and many other sub-specialists now sign out to the hospitalists’ group in the event they are unavailable.”
“The example you identified is similar. For all GIs to be required to sign out to another GI is in many cases impossible and probably unnecessary. In many hospitals, there is only one GI specialist, and he or she regularly signs out to an internist or to a general surgeon. The responsibilities of this alternate are to assess, provide, or arrange for the provision of care as needed by the patient.”
“You suggested that the issue is not simply procedural, but involves the care of the whole patient. Again, I have to agree. Alternates are only rarely called upon to respond to a potential surgical complication, reaction to a medication, or continued deterioration of the patient’s condition. Most often they are called in as a result of the lack of availability of the attending, or they see the patient for daily rounds due to the attending’s absence.”
“It would be perfectly appropriate for the MEC to agree that a general surgeon may serve as an alternate for a GI. It’s even better if the surgeon performs endoscopies himself or herself. This clinician clearly has the requisite knowledge, skill, and ability to give orders, provide care, or call in other consultants as needed, depending upon the circumstances.”
“There are no applicable rules or standards governing this issue issued by either The Joint Commission or the Centers for Medicare and Medicaid Services [CMS (in the Conditions of Participation)], nor will your state licensing regulations address this specific issue. Therefore, it remains the job of the MEC to assist management in formulating rules and procedures that best serve the patient, physician and hospital.”
Making Do in a Pinch—Backup by a Physician in a Different Specialty
“Historically, the issue of ‘designated backup’ has caused medical staff problems. Occasionally a physician will attempt to designate a backup who is not a member of the staff. Some MDs have tried to sign out to oral surgeons, or podiatrists; in other cases, a single group has determined that they do not have either the time or the inclination to ‘cover’ for a new solo practitioner. It is often under these circumstances that the MEC must step in and agree that a physician in another specialty may safely be designated as the backup doctor. This circumstance recently occurred when a solo general surgeon who restricted her practice to breast work was unable to find a general surgeon to serve as her alternate. The MEC permitted a well-qualified obstetrician and gynecologist (OB/GYN) to serve in that capacity.”
No Alternate Choices for a Cardiac Surgeon
“In another situation, an orthopedic ‘foot surgeon’ was unable to gain agreement from another general orthopedic physician to cover, so the MEC permitted a board-certified, fellowship-trained podiatrist to cover for his partner and vice versa. Alternately, the MEC in a relatively rural, but large, hospital was within its rights when it insisted that a cardiac surgeon must designate another cardiac surgeon as alternate for any patient upon whom he had recently performed cardiac surgery.”
“The MEC first must always look out for the patient and, second, it must make sure that cronyism or competition is not permitted to prevent or limit the practice of another. I also have often suggested that the MEC should never attempt to compel any practitioner to consult or cover for another, except in an emergency.”
“I have heard that physicians also are under an ethical responsibility not to refer or delegate care to another practitioner who does not have the necessary ability to provide care safely and effectively.”
The Bottom Line is to Assure Quality Care by Qualified and Compliant Providers
In conclusion, as Hugh explains, it is wise to have a plan in place to assure patients receive the care they need by a qualified provider. Exclusion screening is a best practice when granting temporary privileges.
FACIS® for Exclusion Screening
FACIS® by Verisys is the gold standard for exclusion screening as well as checking for debarments, sanctions, and disciplinary actions. With real-time records updates in combination with historical records back to 1992, searching FACIS® gives organizations and patients the peace of mind that backup providers are compliant to regulatory and quality standards requirements.
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Written by Hugh Greeley Credentialing and Healthcare Industry Expert HG Healthcare Consultant |
