Risk Management



Competency Reviews and Discussions

Anne M. Menke, RN, PhD, OMIC Risk Manager

Digest, Spring 2010

Physicians in group practices and those who are owners of ambulatory surgery centers are often interested in monitoring outcomes as part of credentialing processes. Here are some questions our policyholders have posed.

Q  My group would like to begin tracking outcomes. How do we begin?

A  There are guiding principles that may help to allay concerns and ensure a sense of fairness. First, it is best to discuss the planned review process with all stakeholders. Sufficient time needs to be allotted to achieve consensus on what objective criteria will be used. Clinical material from the American Academy of Ophthalmology, such as Preferred Practice Patterns, will be helpful. Ask the medical staff office at the hospital where you have privileges what criteria it uses and how it conducts and documents evaluations. Medical staff bylaws contain a fair hearing process that is usually based upon state law, vetted by the hospital’s general counsel, and indicates if any reports must be made to the state medical board. Obtaining these policies and procedures saves time and money, but you will still want to determine if the laws pertaining to groups or surgery centers are the same as those governing hospitals. Ensure that the same evaluation process is applied to all physicians. Develop clearly stated, written objectives geared toward patient safety and continuous quality improvement. use multiple tools, such as a chart audit based upon a checklist form, patient complaints, feedback from staff and colleagues (see the lead article for signs of issues), and outcome data. If the group is small or there are obvious conflicts, enlist an outside ophthalmologist’s assistance.

We have been tracking performance in our surgery center and have concerns about a colleague. How do we prepare to talk to him?

A  Assess your motives, check for any possible conflict of interest, and develop a plan to disclose and manage any conflicts that are present. Determine who is the best person to lead the discussion. Factors to consider include personality issues and who has the best access to information, rapport with the physician, and communication skills. Plan on a face- to-face meeting, in a neutral location, as close in time as possible to when the problem or complaint surfaces. Schedule the meeting for a time free of patient care and other obligations.

Q  I dread having this conversation. What can I do to make it as painless as possible for both of us?

A  Remind yourself that physicians have a right and a need to know if there are concerns about their care, and that your goal is patient safety. Think of how you would like to be approached if a colleague had questions about your competency. Begin by expressing your respect and explain that the conversation may be difficult: “Joe, I need to talk to you and am a little nervous about having this conversation. I’ve enjoyed having you as my colleague and have learned a lot from you. Because I respect you, I want to share some concerns I have.” Or, “As you know, I am in charge of reporting back to physicians when there is a complaint. This might be awkward but you deserve to know the feedback we have gotten about your care.” Arrange comfortable seating, and maintain a relaxed posture. Emphasize the physician’s value to the ASC and the patients, and that you want to help. Provide the objective data. Allow the physician time to respond and explain.

Q  I am a subspecialist. Often, I have concerns about physicians who refer patients to me. What feedback can I give?

A  If your concerns center on the diagnosis, explain your own diagnostic process in detail in your consultation report, or consider sending an article on the topic along with the report. It may be worthwhile to explain when and why you like to be contacted if you feel the ophthalmologist has waited too long to refer. Focus on how an earlier referral will benefit the patient. If you feel the referring physician is attempting to treat conditions beyond his expertise, ask about his or her skill set: “Most comprehensive ophthalmologists who refer to me don’t provide this treatment. Tell me about your experience in this technique.” Determine if the patient was reticent to see another physician or if there are logistical or payment barriers.

Q  My patient needs subspecialty care. The last few patients I have referred to this ophthalmologist have suffered serious complications that seem to be due to negligence. Could I be liable if I continue to refer patients to this physician?

A  Yes. under a legal theory known as “negligent referral,” you may be held liable for substandard care provided by a physician who you knew, or should have known, was incompetent. Addressing quality of care concerns at the earliest opportunity reduces your own possible liability exposure in addition to promoting patient safety.

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An ophthalmologist pays nearly half a million dollars in premiums over the course of a career. Premium paid is directly related to your carrier’s claims experience. OMIC has a higher win rate taking tough cases to trial, full consent to settle (no hammer) clause, and access to the best experts. OMIC pays 25% less per claim than other carriers. As a result, OMIC’s base rates have consistently averaged approximately 15% lower than multispecialty carriers in the U.S.

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