Credentialing Critical Care Providers

Transcription

1 Credentialing Critical Care Providers Neal H. Cohen, MD, MPH, MS Professor and Vice Dean UCSF School of Medicine Chair, Risk Management Committee August 8, 2008 Credentials in Critical Care Medicine What is Critical Care Medicine? What are the expectations and how do they impact the credentials requirements? What do I need to maintain my credentials to practice critical care medicine?

2 What is Critical Care Medicine? You ll know it when you see it but, is it related to Patient specific skills? Diagnosis related capabilities? Management and coordination of care? so, it depends! What is the relationship to other providers? What is Critical Care Medicine? Clinical and diagnostic skills Procedural capabilities Airway management Access arterial lines, central lines Other procedures Hemodynamic monitoring Pharmacologic management Inotropic agents, vasopressors Sedatives, analgesics, deep sedation

3 What is Critical Care Medicine? but what about Circulatory assist devices ECMO Renal replacement therapies Percutaneous tracheotomies? What is Expectation of the Critical Care Medicine Provider? Can critical care medicine be differentiated from other specialties? Should it be? Are they expected to have the same skills? Do all critical care providers have/need the same credentials? Should the capabilities (and expectations) differ from one ICU to another? Should the credentials be based on specific expectations/roles of the critical care provider? Diagnostic Skills Knowledge and Cognitive Abilities Procedural Capabilities

4 Clinical Competence General Definition State or quality of being adequately or well qualified to perform a specific role Standardized requirement(s) for an individual to properly perform a specific task Knowledge, skills and behavior utilized to maintain and improve performance Assessing Clinical Competence The Crude Definition Training/Education Medical School Residency/Fellowship Continuing Medical Education Certification Board Certification Maintenance of Certification Public Reporting of Outcomes NPD, DPH Professional Liability History Other Publicly Reported Outcomes

5 Assessing Clinical Competence Zagat s Guide to Critical Care Medicine Physician Central Line Infections Ventilator Associated Pneumonia ICU Length of Stay Risk Adjusted Quality of Life A B C D Clinical Competence These crude measures are insufficient They do not take into account a number of critical issues Is there a standard by which to judge all providers? Should all critical care providers have the same credentials? When should competency be assessed?

6 Credentials and Competence What is the Link? The purpose of the credentialing process is to ensure competence Credentials are expected to reflect clinical capabilities Define specific clinical privileges To do so, requires increasing granularity Specific clinical activities Individual procedural skills Granularity is sometimes difficult to achieve, and often creates unintended consequences Credentials and Competence What is the Link? Assuming that the credentials reflect clinical competence, it is likely that they not be identical for all critical care providers, but Credential(s) must parallel the clinical expectations Patient population Clinical requirements Institutional needs, including call coverage

7 So, We Use the Credentialing Process to Ensure Competence What is a Credential? The privilege to perform the function Evidence concerning one's right to certain privileges Attestation of qualification, competence, or authority issued to an individual by a third party with assumed authority to do so Assumes a process for ongoing peer review How Does This Apply to Credentialing of Critical Care Medicine Providers? What are the privileges required to practice critical care medicine? Are there core privileges that every critical care provider must have? If critical care physicians come from diverse backgrounds, they are likely to have different competencies As a result, there must be a process to ensure that the privileges are appropriate? and, to define who decides

8 Critical Care Medicine Credentials Are there some credentials that are specific to critical care physicians? Does it matter if the ICU is open or closed? Is there any relationship between the credentials for the ICU physician and the credentials for the primary physician? Some Suggest That Training Matters? All intensivists are not created equal Surgeons should not abrogate the responsibility for the care of our patients to [non-surgeon] intensivists Glenn Whitman, Jefferson Medical College Only board certified internists can supervise medical residents in the medical ICU IM Residency Review Committee

9 Does the CCM Physician Matter? Intensivist Physician Staffing and 30-Day Mortality Daily rounds by a multidisciplinary team are associated with lower mortality for medical ICU patients Improved survival is in part explained by presence of multidisciplinary teams in high intensity physician-staffed units Kim, M. M. et al. Arch Intern Med 2010;170: Association Between Intensivist Physician Staffing and 30-Day Mortality Kim, M. M. et al. Arch Intern Med 2010;170:

10 Training Influences Practice Patterns and Perhaps Credentials? Calgary Comparative Study of ICU Care ICU mortality was significantly lower for patients admitted by pulmonary CC provider No difference in ICU length of stay or hospital mortality Significant variation in practice patterns Number of procedures Decisions to limit life-sustaining therapies Billington, et al. Critical Care, 2009 So, How Does This Impact the Credentialing Process? Credentials are now privilege specific No longer a blanket approval for all privileges Privileges must be more granular Credentialing and recredentialing must include a process for assessing clinical competence in each privilege Outcome measures are more important than process measures Is the care within the standard? What is the outcome of care? Assessment of procedures must be differentiated from assessment of other services (eg; consultations) Attribution of outcomes of care to an individual provider is often challenging, particularly in critical care

11 Credentials Validate Clinical Competence Credentials must be consistent with practice and documented capabilities Joint Commission standards incorporate the six core competencies to be addressed in the credentialing process Professionalism is becoming increasingly important Hospital must have a code of conduct that defines acceptable and disruptive and inappropriate behaviors Leaders must create and implement a process for managing disruptive and inappropriate behaviors ACGME Core Competencies Patient Care compassionate, appropriate, effective Medical Knowledge biomedical, clinical, cognate sciences, and their application Practice Based Learning and Improvement investigation and evaluation, appraisal and assimilation of evidence Interpersonal and Communication Skills effective information exchange, teaming with patients and families Professionalism carrying out professional responsibilities, ethics, sensitivity System Based Practice awareness and responsiveness to larger context and system of health care, use of system resources

12 Credentialing Process Focused Professional Practice Evaluation Initial Process requires Focused Professional Practice Evaluation TJC mandates for a period of focused review for each privilege No exemption for board certification, clinical experience, reputation Requires documentation of the monitoring plan and duration of monitoring specific to each requested privilege OPPE (Ongoing Professional Practice Evaluation) The process to ensure competence for ongoing privileging Numbers alone will be insufficient Outcomes must be documented OPPE Ongoing assessment of performance related to each privilege Goal is to improve performance on more timely basis It would not be acceptable to find at the two year reappointment that someone has not performed a privilege for two years. (TJC)

13 OPPE The Requirements Periodic Chart Review Direct Observation Use of Diagnostic Studies Evaluation of Treatment Techniques Use of Consultants, Discussions with Other Providers, Staff Decisionmaking about each credential Maintenance of privilege based on review Credentials no longer required (or used) will be revoked OPPE Can Simulation Replace Clinical Experience? Performance based metrics can be used to assess procedural skills Simulation based training and experience might both accelerate acquisition of skills and assure continued clinical competence Simulation also effective in team training Other roles for simulation warrant further evaluation, but may become standard operating procedure without validation Wahidi et al: Chest, 2010;137:

14 Assessing Critical Care Credentials The Clinical Competence Report Card Clinical Services Competence General Medicine General Surgery Patient Care Neuro Cardiac Vascular Medical Knowledge Practice-based Learning Interpersonal/ Communication Skills Professionalism System-based Practice Credentialing Critical Care Providers Where Do We Go From Here? Determine what credentials you need Ensure you can document competence in each requested credential Monitor outcomes associated with each credential Maintain skills Volume alone is inadequate Simulation, other methods may be required Revaluate clinical practice and skills regularly to ensure that your practice and your competencies are aligned