Archives April 2022

In this blog, I’ll be reviewing the purpose of medical staff hospital credentialing, identifying who is responsible for credentialing, comparing the roles and responsibilities of the medical staff, and the hospital Board, and reviewing criteria-based systems recommended for the credentialing process.  It’s important to have an understanding of the above concepts to ensure that hospital systems have an effective credentialing process that promotes patient safety, sustains a system that mitigates the risk of malpractice litigation, while also mitigating the risk of restraint of trade. 

Credentialing Purpose: The primary purpose of credentialing is to protect patients by ensuring quality patient care.  A credentialing process appropriately overseen by the hospital Board reduces patient exposure to poorly performing providers, ultimately, reducing the risk of preventable patient injury. 

secondary purposes:

• To ensure that only qualified providers are admitted and allowed to remain on medical staff.  Medical staff includes Physicians, Physician Assistants (PA), and Advanced Practice Registered Nurses (APRN): Certified Nurse Midwives (CNM), Nurse Practitioners (NP), and Certified Registered Nurse Anesthetists (CRNA).   
• To ensure that providers are practicing within their scope, consistent with quality standards of the hospital.
• The appointment, re-appointment into medical staff.
• The granting, and renewal of privileges (delineation of privileges) – what a provider is allowed, and not allowed to do, types of patients a provider is able to manage, types of diseases the provider is able to treat, procedures the provider is able to perform, or not perform based on privileging delineations, and clear credentialing criteria.  For example, CNM management of low-risk obstetrical patients; CNM collaborative management with Ob/Gyn for high-risk obstetrical patients.

Who is Responsible for Hospital Credentialing? Medical staff credentialing is the core responsibility of the hospital Board, and serves to be the most important responsibility of the Board secondary to the impact on patient safety, and the role credentialing has within the hospital’s quality improvement and patient safety system. 

The legal structure (as shown below) needs to be understood by the Board, medical staff, and management to ensure clear role delineation, and to ensure an effective credentialing system.

                              

Roles and Responsibilities: It’s important to have a clear understanding of role delineation to ensure that the hospital has an effective credentialing process that promotes safe work environments, while reducing the risk of patient injury. 

Board:

• Reviews recommendations received from the medical executive committee and compares the recommendations against established credentialing criteria
• Makes sure the credentialing criteria is consistently applied to all applicants: efforts need to be made to avoid loose criteria that could result in patient injury and increase the risk of malpractice litigation.  Contrary, efforts need to be made to avoid tight / biased criteria that could result in claims of negligent credentialing, and/or restraint of trade
• Makes sure the medical executive committee has a credentialing procedure in place
• Makes final decisions: grants privileges, grants admission into medical staff 

Medical Staff (Medical Executive Committee):

• Makes recommendations to the Board
• Identifies credentialing criteria for evaluating providers
• Evaluates performance
• Evaluates applicants

Credentialing is proven to be the most difficult governance function to perform effectively for the following reasons:

• Many Boards and medical staff do not accept the Boards role to oversee the medical staff
• Many lay Board members are not comfortable with the responsibility
• Neither the Board, nor the medical staff know how to do credentialing

The hospital Board maintains liability for inappropriate decisions made regarding (re)credentialing and delineation of privileges.  The Board cannot exclusively rely on the recommendations of the medical executive committee as a defense to justify a poor decision.

How To Do Hospital Credentialing – The Use of Criteria Based Systems for (Re)Credentialing and Privilege Delineation: It’s best practice to have a clear decision criterion for credentialing and delineation of privileges that sets the hospitals quality and safety bar high.  The criteria should be based on internal information sources.  Additionally, privilege delineation should be unique and specific to each provider.  The Joint Commission requires provider specific data to be collected continuously and reviewed at the time of re-credentialing.  It’s recommended that this provider specific data is compared to the aggregate data as a means to identify how each individual provider is performing in each performance measure in comparison to his/her provider colleagues.  Typically, the specific credentialing criteria are developed by the clinical department, and submitted to the medical executive committee (MEC) for approval.  MEC then makes the recommendation to the Board who makes the final decision. 

Examples of Criteria Based Credentialing:

               Frequency Criteria: A number of professional organizations suggest frequency criteria for (re)credentialing and privileging.  For example, Surgeon A is required to perform 20 laparoscopic cholecystectomies in a 2-year period (credentialing term per Joint Commission is 2-years).

               Minimum Volume Required Criteria: For example, Surgeon A is required to perform a minimum of 10 laparoscopic cholecystectomies in a 2-year period. 

               Clinical Outcomes: Internal data – individual provider specific data (outcome measures).  For example, Surgeon A’s specific data (outcomes): post-operative complications, morbidity and mortality rates, returns to the OR, wound infections.

               Behavior Criteria: Patient complaints, malpractice claims per individual provider

References:

American Hospital Association Trustee Service. 2017. The Role of the Board in Medical Staff Credentialing:https://trustees.aha.org/quality/the-boards-role-in-medical-staff-credentialing

Credentialing and Privileging – Requirements for Physician Assistants and Advanced Practice Registered Nurses:https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/medical-staff-ms/000002124/

JCAHO’s new credentialing, privileging standards require provider-specific data: https://www.reliasmedia.com/articles/122719-jcaho-s-new-credentialing-privileging-standards-require-provider-specific-data

P.S. Comment and share your experience with hospital credentialing.

                                                    

In this blog I’ll be reviewing the difference between rotational and non-rotational maneuvers in the management of a shoulder dystocia.  I’ll also discuss the efficacy in relieving the shoulder dystocia, and the risk of brachial plexus injury, comparing both types of maneuvers.   

Non-rotational maneuvers: pose the least risk on the degree of stretch on the brachial plexus nerve.  Examples include: McRoberts maneuver, suprapubic pressure, and delivery of the poster arm. 

According to ACOG, in cases where the McRoberts maneuver and suprapubic pressure are unsuccessful, delivery of the posterior arm can be considered as the next maneuver to manage shoulder dystocia. Recent evidence has shown that delivery of the posterior arm has a high degree of success in accomplishing delivery.  In a computer-generated model, delivery of the posterior arm required the least amount of force to effect delivery and resulted in the lowest amount of brachial plexus stretch.  The use of the above maneuvers will relieve 95% of cases of shoulder dystocia within 4 minutes. 

Below Image (delivery of the posterior arm) requires the delivering provider to insert a hand into the vagina and deliver the posterior arm by sweeping it across the fetal chest

Rotational maneuvers: Examples include: The Rubin maneuver,  the Woods Screw maneuver

• The Rubin maneuver requires the delivering provider to insert a hand into the vagina and on the back surface of the posterior fetal shoulder.  The provider then rotates the fetal shoulder anteriorly towards the fetal face with his/her hand.
• The Woods Screw maneuver requires the delivering provider to rotate the fetus by exerting pressure on the anterior, collar bone region of the posterior shoulder to turn the fetus until the anterior shoulder emerges from behind the maternal symphysis (pubic bone).

Below Image (Rubin Maneuver)

References:

The American College of Obstetricians and Gynecologists. (2014). Neonatal brachial plexus palsy. ACOG Task Force on Brachial Plexus Palsy

The American College of Obstetricians and Gynecologists. (2017). Shoulder dystocia [Clinical Practice Bulletin #178]

 P.S. Comment and Share: What has been your experience in a brachial plexus case involving a shoulder dystocia?  How did the standards of care, specific to type of maneuvers, and type of traction employed, impact the outcome of the case?  

In this blog, I’ll be reviewing the U.S. maternal morbidity statistics associated with hypertensive disorders of pregnancy. Additionally, I’ll be highlighting the elements of performance, specific to severe hypertension and preeclampsia, Joint Commission accredited hospitals are required to be in compliance with. Lastly, I will offer risk mitigation strategies specific to care delivery, risk assessment, prevention, documentation, consultation, and referral.

Statistics: Hypertensive disorders of pregnancy (chronic hypertension, gestational hypertension, severe hypertensive crisis, preeclampsia, eclampsia, HELLP Syndrome) continue to be the leading cause of maternal and infant death.  Preeclampsia specifically, complicates 8% of pregnancies globally.  It is estimated that 60% of maternal deaths from preeclampsia may be preventable.  In the U.S., hypertensive disorders of pregnancy account for 6.8% of pregnancy related deaths.  For women who had a hypertensive disorder of pregnancy cause of death, 12.2% had a stillbirth (fetal demise).  Almost all (96.8%) pregnancy related deaths occurred by 42 days postpartum (CDC, 2018).

The Joint Commissions Perinatal Safety Standards: In response to the worsening maternal morbidity and mortality in the U.S. associated with severe hypertension and preeclampsia,  The Joint Commission has identified clinical areas of greatest potential impact based on review of maternal mortality reports, and evidence-based practice recommendations.  

The literature review performed revealed that prevention, early recognition of signs and symptoms, and timely treatment for severe hypertension, and preeclampsia had the highest impact on maternal, fetal, and neonatal outcomes.

Joint Commission accredited hospitals are now required to conform to the six new elements of performance (EPs) as identified below:

GOAL: PC.06.03.01 – Reduce the likelihood of harm related to maternal severe hypertension/preeclampsia

Requirement EP 1: Develop written evidence-based procedures for measuring and remeasuring blood pressure. These procedures include criteria that identify patients with severely elevated blood pressure.

Rationale:  Procedures should address appropriate blood pressure measurement, including cuff size, proper patient positioning, and frequency of measurement. Inaccurate measurement can lead to a mother not receiving proper treatment and being discharged with elevated blood pressure. Untreated hypertension can lead to morbidities or even death. Criteria for what constitutes a severely elevated blood pressure should be established by the organization utilizing current recommendations from national organizations.

Requirement EP 2: Develop written evidence-based procedures for managing pregnant and postpartum patients with severe hypertension/preeclampsia that includes the following:

• The use of an evidence-based set of emergency response medications that are stocked and immediately available on the obstetric unit

• The use of seizure prophylaxis

• Guidance on when to consult additional experts and consider transfer to a higher level of care • Guidance on when to use continuous fetal monitoring

 • Guidance on when to consider emergent delivery

• Criteria for when a team debrief is required

Note: The written procedures should be developed by a multidisciplinary team that includes representation from obstetrics, emergency department, anesthesiology, nursing, laboratory, and pharmacy.

Rationale: Studies have shown that delays in the diagnosis and treatment of severe hypertension/preeclampsia and receipt of suboptimal treatment of severe hypertension/preeclampsia are linked with adverse maternal outcomes. Having clear procedures in place and educating staff around these procedures should decrease failures to recognize and treat severe hypertension/preeclampsia

Requirement EP 3: Provide role-specific education to all staff and providers who treat pregnant/ postpartum patients about the hospital’s evidence-based severe hypertension/preeclampsia procedure. At a minimum, education occurs at orientation, whenever changes to the procedure occur, or every two years.

Note: The emergency department is often where patients with symptoms or signs of severe hypertension present for care after delivery. For this reason, education should be provided to staff and providers in emergency departments regardless of the hospital’s ability to provide labor and delivery services.

Rationale: Decreasing the blood pressure through rapid recognition and treatment has been shown to decrease maternal morbidity and mortality. It is imperative to provide education for staff and providers on how to measure accurate blood pressures, recognize severe hypertension/ preeclampsia, and provide evidence-based treatments to lower blood pressure in a safe and timely manner. Although not required, in situ simulations that allow staff to practice organizational procedures in actual clinical settings are encouraged.

Requirement EP 4: Conduct drills at least annually to determine system issues as part of ongoing quality improvement efforts. Severe hypertension/preeclampsia drills include a team debrief.

Rationale: Multidisciplinary drills give an organization the opportunity to practice skills and identify system issues in a controlled environment. It is crucial to have members from as many disciplines as possible available during drills to truly be able to test each level of the emergency and identify areas of improvement. Organizations should assess their level of proficiency to determine the frequency drills should be performed; organizations that have reached a high level of mastery may need less frequent drills.

Requirement EP 5: Review severe hypertension/preeclampsia cases that meet criteria established by the hospital to evaluate the effectiveness of the care, treatment, and services provided to the patient during the event.

Rationale: Continuous feedback loops are imperative for organizations to find errors and improve skills to ensure that patients are receiving the highest level of care. Root cause analysis, apparent-cause analysis, or similar tools to review the care in a rigorous, psychologically safe environment is critical to identify successes and opportunities for improvement in a way that creates a culture of safety and empowers staff to design safe and effective procedures and processes.

Requirement EP 6: Provide printed education to patients (and their families including the designated support person whenever possible). At a minimum, education includes:

• Signs and symptoms of severe hypertension/preeclampsia during hospitalization that alert the patient to seek immediate care

• Signs and symptoms of severe hypertension/preeclampsia after discharge that alert the patient to seek immediate care

• When to schedule a post-discharge follow-up appointment

Rationale: Maternal mortality reviews have shown that some patients with severe hypertension/ preeclampsia due after discharge because they were unaware of which symptoms to watch for and when to seek care urgently. Women should understand their severe hypertension/ preeclampsia diagnosis and inform healthcare providers of their pregnancy history when the seek care after discharge to ensure correct diagnosis and treatment.

How to Mitigate Medicolegal Risk & Increase Defensibility:

1. Confirm that your organization is conforming to the six elements of performance (EPs) that is now required for Joint Commission accredited hospitals.  Become an active provider leader in implementing and educating staff/providers on the above (EPs). Render care according to the above (EPs). Consider implementing re-credentialing requirements to support required simulation drills and debriefings.
2. Identify women at risk: first pregnancy, new genetic makeup, pregnancy of artificial reproductive technology, multiple pregnancy, gestational diabetes, preexisting medical history: diabetes, chronic hypertension, renal disease, lupus, older maternal age, African American race, obesity, personal or family history of preeclampsia (list is not inclusive)
3. Document risks, and plan of care for surveillance and prevention strategies in pregnancy within the medical record.
4. Implement prevention strategies in plan of care, and document in medical record: exercise, low dose aspirin therapy, dietary supplementation
5. Diagnose and initiate timely management according to evidence-based practice criteria, and organizational policy: document diagnosis and management plan in the medical record.
6. Consider referral to Maternal Fetal Medicine, or higher level of care delivery based on organizational level of care, and maternal consultation and transfer agreement with Regional Perinatal Center. 
7. Consultation/collaboration: ensure patient assessment is complete within the time frame designated within organizational by-laws, rules and regulations.  Ensure timely entry of consultation / progress note as the consulting, or collaborating provider.

References:

Association of Women’s Health, Obstetric, and Neonatal Nurses. 2021.

CDC. 2018. Pregnancy mortality surveillance system

The Joint Commission. 2019. Provision of care, treatment, and services standards for maternal safety. Issue 24

P.S. Comment and Share: Do you have experience with a maternal hypertensive case that resulted in a maternal death.  Did this case impact policy, procedure, process, or system changes as a result?