The Medical Staff's Guide to Overcoming Competence Assessment Challenges

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The Medical Staff's Guide to Overcoming Competence Assessment Challenges

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The Medical Staff's Guide to Overcoming Competence Assessment Challenges

Carol S. Cairns, CPMSM, CPCS; Sally Pelletier, CPMSM, CPCS; Frances M. Ponsioen, CPMSM, CPCS; Anne Roberts, CPMSM, CPCS    

Identify and overcome common medical staff assessment challenges with this new resource!

From advanced practice professionals to telemedicine providers, The Medical Staff’s Guide to Overcoming Competence Assessment Challenges will walk you through every step of collecting performance data to ensure quality of care and comply with accreditors’ standards. Our expert MSPs, including Sally Pelletier, Carol Cairns, Anne Roberts, and Frances Ponsioen, address many of the common challenges that medical services professionals face when collecting performance data. Never again wonder whether your organization has covered all its bases—ensure compliance and practitioner competence with this new book. 

This resource will help you:

  • Create strategies to collect performance data for telemedicine providers, advanced practice professionals, low- and no-volume providers, practitioners in the ambulatory setting, and single practitioners in a specialty
  • Differentiate between medical staff membership and privileges
  • Attribute performance data to the correct practitioner
  • Determine when new technology, procedures, or techniques are appropriate for your facility and successfully assess the competence of the practitioners who will be using them
  • Update your medical staff bylaws, policies, and procedures to reflect changes to competency assessment requirements


Take a look at the table of contents:

Chapter 1: Competence Assessment for Initial Appointment

  • Establishing minimum threshold criteria
  • Evaluating competence
  • Cross privileges and turf wars
  • Determining initial competence for low- and no-volume providers
  • Clinical evaluations
  • Evergreen or “forevermore” evaluations
  • Competence confirmation through FPPE after granting clinical privileges
  • Common missteps during initial credentialing

Chapter 2: Assessing Competence in the Ambulatory Setting

  • Understanding healthcare delivery in ambulatory settings
  • Requirements of accreditors and regulation agencies
  • Scope of privileges at the ambulatory site
  • Responsibility for privileging in an ambulatory setting
  • Medical staff category versus privileges
  • Competence assessment in the ambulatory setting
  • Assessing the competence of APPs in the ambulatory setting

Chapter 3: Temporary Privileges for Patient Care Needs

  • What does ‘immediate patient care need’ mean?
  • Developing a temporary privilege policy
  • Pendency of an application/committee approval
  • Temporary privileges for locum tenens
  • Assessing the competence of proctors
  • Visiting professors

Chapter 4: Attribution Challenges

  • Patient handoffs
  • Teaching services
  • Group practices
  • Advanced practice professionals

Chapter 5: Ongoing Competence Challenges and Validation at Reappointment

  • After initial appointment, what are the next steps in assessing competence?
  • Developing indicators for ongoing competence assessment
  • Implementing OPPE and addressing competence concerns
  • Addressing competence concerns identified during the ongoing review process
  • FPPE for cause, including OPPE and peer review findings and leave of absence reinstatement
  • Competence assessment at reappointment
  • Allied health annual competence reviews

Chapter 6: Assessing the Competence of APPs

  • Collecting data on APP performance

Chapter 7: How to Manage the Expanding Role of APPs

  • Training up

Chapter 8: Assessing the Competence of Telemedicine Providers

  • Introducing a telemedicine service at your facility
  • Defining telemedicine
  • Who provides telemedicine services?
  • Requirements of regulators and accreditation agencies
  • Effect of telemedicine regulations
  • Privileging telemedicine practitioners
  • Competence assessment unique to telemedicine
  • Evaluation of telemedicine specialty by specialty

Chapter 9: Assessing a Single Practitioner in a Specialty Area

  • Determining competence with no reference point
  • Conducting ongoing evaluation of the specialist
  • External reviews

Chapter 10: New Technology, Services, and Procedures

  • New technology, equipment, and procedures
  • New techniques

Chapter 11: Low- and No-Volume Practitioners

  • Introduction to low- and no-volume practitioners
  • Assessing the competence of the practitioner who is active at another facility
  • Dr. Rose and Dr. Cares-A-Lot: Two solutions to the low- and no-volume challenge
  • Matching privileges to current competence
  • Avoid denying privileges

Chapter 12: Selective Practice Affecting Competence, Privileges, and Call Coverage

  • Add EMTALA-based language to privileging forms
  • ED call coverage for practitioners who are not competent to assess, stabilize, and determine the disposition of patients
  • Burden on the applicant
  • Revisiting Specialized Medical Center


About the Authors

Anne Roberts, CPMSM, CPCS
Anne Roberts is the senior director of medical affairs at Children’s Medical Center of Dallas where she oversees eight departments, with her primary focus being on medical staff services and medical staff quality. Additionally, she is a consultant and speaker with The Greeley Company, a division of HCPro, Inc., in Danvers, Mass. As a recognized expert in the field, she presents frequently for National Association Medical Staff Services (NAMSS) and other healthcare entities on topics such as medical staff credentialing and legal strategies for MSPs and medical staff leaders; she has numerous guidebooks published by HCPro. 

Sally Pelletier, CPMSM, CPCS

Sally Pelletier is an advisory consultant and the chief credentialing officer for The Greeley Company. She brings more than 20 years of credentialing and privileging experience to her work with medical staff leaders and medical services professionals across the nation. Pelletier advises clients in the areas of accreditation, regulatory compliance, credentialing and privileging process simplification and redesign, and medical staff services department operations; she also provides leadership and development training for medical staff leaders and medical services professionals. Pelletier serves as an expert witness and presents at state and national seminars on a variety of topics related to medical staff leadership training, leading practices in credentialing and privileging, and physician competency management. She has coauthored several HCPro/Greeley books.

Frances M. Ponsioen, CPMSM, CPCS

Frances M. Ponsioen is Credence site director for The Greeley Company. She has over 20 years of experience in medical staff services, most recently serving 10 years as the director of medical staff services for the five-hospital Baptist Health System in San Antonio. In her roles, she has worked directly with medical staff leaders and hospital executives to ensure continued compliance with all regulatory standards related to medical staff and credentialing responsibilities; implemented a credentialing software system while transitioning the primary source verification process in-house for the healthcare system; developed and implemented core privilege forms for medical staff and allied health staff; and fully reorganized all medical staff governance documents. She also developed a successful plan for the full upgrade and implementation of the credentialing software system, bringing the initial application and reappointment process online.

Carol S. Cairns, CPMSM, CPCS
Carol Cairns has participated in the development of the medical staff services profession for more than 35 years. She is a senior consultant and frequent presenter with The Greeley Company. A recognized expert in the field, Cairns has been a faculty member with NAMSS since 1990. She presents frequently for NAMSS and other healthcare entities at state and national seminars on subjects such as basic and advanced credentialing and privileging, core privileging, AHP credentialing, CMS’ Conditions of Participation, and the standards of—and survey preparation for—The Joint Commission, the National Committee for Quality Assurance, and the Healthcare Facilities Accreditation Program.

Published: August 2013