The Evolving Role of the Medical Staff

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The Evolving Role of the Medical Staff

• The Governance Institute
• January 20, 2008

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An Historical Perspective

• As physicians delegated the running of hospital
  infrastructure to a new category of professional
  managers, the organized Medical Staff emerged
  to assure that medical professionals would retain
  control of medical decisions.

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at a Time When

• Hospitals were the hub of tightly integrated
  physician communities
• Technology was vastly less complex
• Professional fees were adequate to support
  physician income
• Hospital / physician competition was relatively
  insignificant

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While the formal duties of the organized Medical
Staff have changed little, the context in which
these duties are exercised has changed profoundly.
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Changing context

• The Medical Staff is far less unitary
• And much less hospital-centric
• And more likely to be grumpy
• Competitive issues are huge in many communities
• Administrative teams have many more demands /
  requests of physicians.
• Professional physician leaders (VPMA, CMO) are
  more common.

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Changing context

• The Medical Staff is far less unitary
• And much less hospital-centric
• And more likely to be grumpy
• Competitive issues are huge in many communities
• Administrative teams have many more demands /
  requests of physicians.
• Professional physician leaders (VPMA, CMO) are
  more common.

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Our field has often attracted strong-willed,
tenaciously independent types, who show from an
early age a reluctance to accept external
authority
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Gathering in large groups only on the rarest
occasions
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But, for most physicians, this is not an easy
time
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Changing context

• The Medical Staff is far less unitary
• And much less hospital-centric
• And more likely to be grumpy
• Competitive issues are huge in many communities
• Administrative teams have many more demands /
  requests of physicians.
• Professional physician leaders (VPMA, CMO) are
  more common.

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Continued

• Professional physician leaders (VPMA, CMO) are
  more common.
• Exclusive contracts and Medical Director roles
  create accountabilities outside of the Medical
  Staff structure
• Technical innovations (Nighthawks, e-ICUs)
  broaden the clinical team beyond local geography.
• As the generations change, so do expectations and
  commitments.

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Three recurring characteristics of Generation X
professionals

• Desire for flexible schedules
• Preference for the latest technology
• Cynical about organizations
• Mark Shields, M.D., and Margaux Shields

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As we review best practices in Medical Staff
leadership, it will be enormously important to
have in these contextual issues in mind.
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Formal Duties of the Medical Staff

• Self-organizing functions
• Assuring the quality of licensed providers
  participating in overall efforts to improve
  quality
• Credentialing and granting privileges
• Peer review

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In this context, we encounter

• Issues of citizenship and behavior
• Issues of turf
• Issues of economics

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Continued

• In all of these tasks, there is a complex
  balancing act
• Setting and enforcing standards (the Professional
  task)
• Protecting the rights of its members (the Guild
  task)
• Maintaining cognizance of the hospitals concerns
  about viability ( the Stewardship task tending
  to interdependence)

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Informal Functions

• Representing the Medical Staff to the Board
• Representing the Medical Staff to Administration
  in setting organizational priorities, strategies
• ?? Assisting our colleagues in the creation of
  rewarding approaches to practice

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This issue relates to whether or not we feel a
responsibility to be our brothers keeper

• How many of your colleagues would admit to being
  burned out.
• How many more do you think are, but dont admit
  it?
• Can anything make a difference?
• What can / should physician leadership do?

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Self-organizing functions of the Medical Staff

• Determining a leadership structure
• Electing leaders
• Setting a meeting rhythm
• The issue of compensation for leaders
• Interface with the VPMA
• The Department Chair / Medical Director
  distinction
• Communication

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Assuring the quality of licensed providers
participating in overall efforts to improve
quality

• Credentialing and privileging
• Peer review
• Participation in hospital led activities

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On whose behalf do we credential?

• Community ?
• Board ?
• Administration ?
• Our colleagues ?
• Our own ?

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The Credentialing Process A Critical Moment

• Vetting candidates
• Induction into your culture
• Setting expectations
• Creating a psychological contract
• Executing a code of conduct

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Credentialing and granting privileges

• First Principles
• Second Policies
• Hugh Greeley
• Our Policy is to follow our Policy. In the
  absence of a Policy, our Policy is to create a
  Policy before we act.

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The cascade of credentialing activities

• Determining eligibility
• Offering applications
• Primary source verification and background checks
• Interviews / Observation ?
• References ?
• Data accumulation
• Review and recommendation

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Issues unique to recredentialing

• Measuring performance against expectations
• What data points do you gather, and how do you
  organize them?
• How can you change the rules?

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Peer Review

• A unique and critical component of a
  comprehensive quality program
• Here is where only physicians are qualified to
  make adjudicationsif we have the skills and
  courage to do so.

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But is it

• A disciplinary process
• An investigative process
• An educational process

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What about

• A surgeon discharges a post-op patient, who calls
  the next day with generalized dysphoria,
  heightened pain and redness around the wound
  site, and a high fever.
• The surgeon re-admits the patient, but to another
  hospital.
• Would this come onto your radar screen?

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• If yes, how would you catch it?
• If no, how do you feel about that?

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Components of a Comprehensive Peer Review
Program

• Screening clinical material
• Trending outcomes, complications
• Preliminary review
• Informing colleagues
• Committee review
• Adjudication
• Recommending action

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What about rule breaking?

• Delinquent charts
• Failure to respond
• Improper documentation

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What about complaints, incidents, etc.

• The clinical relevance of behavior and
  communication

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Profession or Guild

• Peer review, when done well, exemplifies
  professionalism.
• Fairness, objectivity, impartiality, and
  consistency offer protection for those reviewed.
• Guild dynamics represent an inevitable threat
• Protectionism on the one hand, persecution of
  economic competitors on the other hand

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Major Issues in Peer Review

• Centralized or decentralized
• External peer review (on site or off-site)
• Peer review collaboratives
• When is specialty-specific review essential?
• Sharing findings with colleagues

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Quality data and the re-credentialing process

• The essence of re-credentialing lies in the
  reference to quality measures, in the context of
  explicit expectations
• What data points do you gather, and how do you
  organize them?
• How can you change the rules?

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Linking physician peer review with hospital
quality efforts

• Data flow in and out of the peer review system
• The flow of recommendations
• Peer review as a method for uncovering process
  issues
• Reporting to the Board

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As the entire healthcare enterprise is under
increasing pressure to deliver quality, value,
service, and transparency, the ability of the
organized Medical Staff to deliver on these
fronts will be critical. With tomorrows
plenary, I will take a different tack, and locate
this presentation in the broader context of what
is euphemistically called hospital / physician
relations.