Thursday, March 31, 2005

Hospital Credentials

It is interesting to watch the discussions on mail-lists and blogs regarding credentialing in hospitals.

When I was a FP resident, we took for granted that we would be allowed to perform the procedures for which we where training. I trained in the Navy and all of the Navy FP programs at that time were at community hospitals and were the only residency training programs in those hospitals. We did endoscopies, treadmills, fracture care and a full spectrum of OB care, included instrumented and operative deliveries. I left my program credentialled to do flex-sigs, treadmills, appendectomies, adult circumcisions, vasectomies and vacuum-assist and forceps deliveries.

My first hospital as a full-fledged FP was also in a Navy hospital, where I was granted all the credentials I left my residency with.

What a surprise it was at the first civilian hospital I went to. Initially, it seemed the Credentials Committee just rubber stamped my application, without reviewing it, because I was given all the credentials for which I applied, including instrumented deliveries. I did not apply for c-sxn or appy privileges.

However, I soon found out that anything I tried to do that was "not the norm" for the other FP's in the hospital was either scrutinized with a microscope or simply refused. Especially if it seemed it might take money away from a more established physician in the hospital.

For example, treadmills. I had done about fifty as a resident and more at my first hospital. I was current in my procedure list. The norm at this hospital was that the internists did all the treadmills. I asked around and found out how to schedule my own patients for me to do. The routine at that hospital was for the docs in town to refer to a general scheduling list and these would be assigned to the docs who did treadmills (at the time, the two internists in town.) I asked to be part of that rotation. I asked to be allowed to read and bill for my own inpatient EKG's and to be added to the reading rotation. After all, I was trained and credentialled to do these activities. I soon got a visit from the head of the respiratory department who informed me that I was not allowed to do treadmills or bill for EKG's, that this was the purview of the internists and the "FP's don't know how to do these. After all, all the other FP's in town refer to the internists."

The next issue was flex-sigs. One of the internists in town had done part of a GI fellowship. I am unclear why he didn't finish it. Anyway, he dominated the GI lab. One of the general surgeons (of two in town) fought to get one start time a week for her colonoscopies and she was soon pressured to leave, and did. I asked for one day every other month to do my own patients and got a visit from the hospital administrator. He told me that my credentials to do flex-sigs were cancelled. I argued that he didn't have the authority to pull my credentials, only to suspend them on an emergency basis and that he had to have cause and that I should be formally notified and have access to due process.

Well, what do you know? I was successful in that argument. He replied that my credentials were intact, but that the nurse who ran the GI lab worked for him and would be instructed not to schedule any more of my procedures. And, oh by the way, the director of the treadmill lab won't be scheduling any of those for you either.

I wasn't allowed to bill for my EKG's or to be on the unassigned call list for pediatrics in the ER or from the newborn nursery either.

The position of the American Academy of Family Practice (see Tips for Avoiding Privileging Disputes) is that credentials should be based on the demonstrated compentency of the individual and not generally on the residency completed. In other words, if you require an FP to have done 15 supervised flex-sigs with at least 5 of those at your institution, you should require the same of an internist. You should not grant an internist blanket credentials for a procedure and then require additional documentation of compentency from an FP.

On the AAFP website, there is a document titled, Procedural Privileges Legal Opinion which should be helpful to any physician, regardless of specialty, who is in a credentialing dispute. The section on The Grant or Denial of Privileges notes:
Accrediting organizations and professional associations uniformly acknowledge that credentialing decisions must be based on the demonstrated competency and experience of the physician in question. Decisions which are based upon competitive factors, personal biases, or other similar grounds are not consistent with the obligations of hospitals and physicians involved in the peer review process.
This same page quotes JCAHO:
The mutual objective of both the governing board and the medical staff is to improve the quality and efficiency of patient care in the hospital. Decisions regarding hospital privileges should be based upon the training, experience and demonstrated competence of candidates, taking into consideration the availability of facilities and the overall medical needs of the community, the hospital and especially patients. Personal friendships, antagonisms, jurisdictional disputes or fear of competition should be disregarded in making these decisions. Physicians who are involved in the granting, denying or termination of hospital privileges have an ethical responsibility to be guided primarily by concern for the welfare and best interests of patients in discharging this responsibility.

and a joint statement of the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists. The AAFP-ACOG Joint Statement on Cooperative Practice and Hospital Privileges provides in part:

The assignment of hospital privileges is a local responsibility and privileges should be granted on the basis of training, experience and demonstrated current competence. All physicians should be held to the same standards for granting of privileges, regardless of specialty, in order to assure the provision of high-quality patient care. Prearranged, collaborative relationships should be established to ensure ongoing consultations, as well as consultations needed for emergencies.

The standard of training should allow any physician who receives training in cognitive or surgical skill to meet the criteria for privileges in that area of practice.
Also from this page:
Courts prefer credentialing decisions to be made primarily on the basis of competency and quality of care. The courts have frequently invalidated restrictions on privileges when the restrictions were based upon factors other than the demonstrated capabilities of the physician in question. See, e.g., Desai v. St. Barnabas Medical Center, 510 A.2d 662 (N.J. 1986) (restriction based upon years of practice invalidated); Berman v. Valley Hospital, 510 A.2d 673 (N.J. 1986) (restriction based upon years of practice invalidated); Berman v. Valley Hospital, 510 A.2d 673 (N.J. 1986) (restriction based upon affiliation with another physician invalidated) Armstrong v. Board of Directors of Fayette County General Hospital, 553 S.W.2d 77 (Tenn. Ct. App. 1976) (restriction based upon specialty certification found unreasonable).
As you can infer from the list of my jobs above, I am no longer in practice at this hospital. I did contact an attorney, but he advised that, although I would likely win a lawsuit, I would spend a lot of money to do it and the actual financial damages were small. I mean, heck, I was only asking to do about 20 or so procedures a year. The internist who stirred up this trouble was doing about 20 colonoscopies a week! And there was no way I would have wanted to work in this community after a lawsuit.

I am much happier where I am now, anyway. But hopefully this info can help someone out there.


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