EMBRACING CHANGE FOR PROGRESS

Inspiring Physicians to Embrace the Change that Defines Success in Health Care is the topic for Hugh’s Credentialing Digest. He itemizes processes that have roots in the past and then outlines optimal remedies to the traditional conventions that no longer have relevance in the way health care is administered today.

By Hugh Greeley, author of Hugh’s Credentialing Digest

“The greatest barrier to a paradigm shift is the reality and incredible inertia of paradigm paralysis. A paradigm paralysis can be defined as the inability or refusal to see beyond current models of thinking.”   –Gilbert Mercier

TAKING STOCK FOR PERIODICAL COURSE CORRECTION IN THE CREDENTIALING PROCESS

My grandfather, Hugh P. Greeley, MD, an internist from Boston, Madison, and Pilley’s Island, wrote the following in a 1917 issue of the Wisconsin Medical Journal: “Professions should pause periodically for stock taking.”

In medicine, that means reviewing the changes that have taken place and acting accordingly. If he were now chair of a modern credentials committee, he might begin a process designed to rethink and reform medical staff credentialing activity as we know it.

Why might this be a good idea for nearly all hospitals today? Nearly everything defining the relationship between physicians and hospitals, and among physicians themselves, has changed over the past 20 years or so. Yet the systems and processes used to vet new physicians and grant them permission to practice in health care facilities have remained rooted in concepts born in the late 1960s and early 1970s (years before many physicians on staff were born and before nearly all of them finished their medical educations). Consider a few of the more significant changes we are now navigating.

SUMMARY OF EVOLUTION IN HEALTH CARE AND THE CREDENTIALING PROCESS

• In many hospitals today, most physicians are employed or contracted.
• Many hospitals now derive the majority of their inpatient and outpatient revenues from employed or contracted practitioners.
• The legal issues surrounding credentialing are becoming more complex and costly.
• Increasingly, dedicated hospital-based doctors provide the majority of medical care delivered in the hospital.
• Physicians and other professionals are far more mobile today than in the past; few will begin and end their practices in one location (or with one employer).
• Advanced practice registered nurses (APRNs) and physician assistants (PAs) are now commonly providing care in collaboration with or under the supervision of a distracted medical staff.
• The majority of primary care physicians now practice exclusively in the ambulatory arena, yet most are still assigned to traditional hospital medical staff departments.
• Telemedicine’s role and practice have spiked with the current Coronavirus pandemic and will only continue to grow. The different forms of telemedicine and telehealth require policies, procedures, and skills that are significantly different than those used in traditional credentialing activities and license requirements.
• Focused and Ongoing Professional Practice Evaluation (F and OPPE) requirements (for those accredited by The Joint Commission) require far more attention than can be expected from practicing physicians.
• Hospitals have morphed into systems with vastly greater complexity at the governance level.
• Many hospitals have a plethora of employed physician leaders (directors, vice presidents of medical affairs, heads of the employed group, etc).
• Encouraging voluntary commitment to assist with credentialing activities is becoming difficult as physicians are pulled in many directions.
• Medical staffs and the requirements they must meet have not kept up with the evolution of the health care system and they perpetuate a paper-based, hospital-centric model.
• The technology available today to gather and verify a practitioner’s background bears no resemblance to that used only years ago, yet most hospitals fail to capitalize on its availability.
• The new generation of employees who assist in the credentialing process has become more sophisticated and better able to identify potential credentialing issues.
• The entire process of background checking and due diligence is moving beyond confirmation of competence and now includes many additional factors that might bear upon the employment or appointment of a practitioner.

3 DESIGN FACTORS FOR PROVIDER CREDENTIALING PROCESS IMPROVEMENT

1. Today’s available digital technology, real-time access to primary source data and identity verification science, must be used when gathering information about applicants and also with continuous monitoring of staff.
2. Health systems must have processes that allow completed applications to move rapidly through the review and approval processes. No delays due to a “scheduled” committee or board meeting should be allowed when virtual meetings and digital review can move the process along.
3. Facility-specific duplication of effort must be avoided. To the extent permitted by law or regulation, single applications should be used for both employment and appointment to all related facilities within a system. A single point source of verification and data collection should be used with nearly complete sharing of information among the various departments charged with review or decision making. This assures quality and consistency of data and verification as well as reducing administrative burden.

3 DESIRED OUTCOMES FROM AN UPDATED APPROACH TO PROVIDER CREDENTIALING

1. Qualified and competent practitioners should be allowed to apply for both appointment and employment without unnecessary steps, and decisions should be made as rapidly as possible considering patient and institutional needs as well as practitioner schedules.
2. Discontinue the review and evaluation process for unqualified practitioners or those with questionable professional backgrounds.
3. Medical staff hearings and appeals should be relics of a distant past.

IN SUMMARY

In summary, the delivery of health care is changing daily, especially in the case of remote health care known as telemedicine and telehealth. New state and federal requirements continuously evolve in order to mitigate fraud, waste, abuse, and patient endangerment. Compliance organizations that offer formal certification such as The Joint Commission, and quality assurance organizations like NCQA align requirements to level the many new forms of risk facing health care today.

The screening, credentialing, enrollment, privileging, and monitoring processes used to be paper-based with great limitations to acquiring primary source data at all or in a timely manner. Today, it is easy to check critical data sources in real-time digitally with secure access to a cloud or a server holding current and historical data on providers, administration, and other staff.

Verisys has the most extensive database of health care provider data in the industry. FACIS® is the gold standard of provider sanction and exclusion data.

Written by Hugh Greeley Credentialing and Healthcare Industry Expert HG Healthcare Consultant