Documenting the competency of providers is one of the main tasks that medical staff is responsible for, and one way to accomplish this is through the collection and review of case logs, otherwise known as procedure logs. In fact, many organizations have incorporated requirements for the review of case/procedure logs into their credentialing policies and privileging criteria. And while the collection of case logs is not always a requirement, some hospitals and health systems require documentation of a certain number of admissions or consultations prior to granting privileges. So, when and how should case logs be used to document competency? Let's dig in.
Case logs are a list detailing the number of patients treated and/or procedures performed by a provider. They include information on patient load, the type of case, as well as the number of cases. This can cover a specific period of time or may cover the entire practice of the provider. Case logs can be obtained from a variety of sources, like a training program, a healthcare facility, or personal data collection by the provider.
In many cases, hospitals require at least 4 months of case logs for new applicants. In other cases, an organization's medical staff will determine a minimum number of procedures necessary to maintain competency for surgical and other procedures, which is why the collection of these logs is essential. These requirements are not arbitrarily selected, but rather are established after much deliberation and discussion by the medical staff, including the decision of how many procedures are necessary to both obtain and maintain competency.
Logs can come from the provider's training program, a healthcare facility, or personal data collection by the provider.
As is the case with most accreditation and regulatory agencies, there are varied requirements depending on the institution. The Accreditation Commission for Health Care (ACHC) requires that hospitals collect clinical activity, including procedure logs with outcomes, to support privilege requests for procedures not attested to in postgraduate references. The ACHC is the only hospital accreditor with this specific requirement.
The Centers for Medicare and Medicaid Services (CMS) sets regulations and interpretive guidelines for hospitals. Hospitals are required to be in compliance with the federal requirements set forth in the Medicare Conditions of Participation (CoPs) in order to receive Medicare/Medicaid payment. According to the CMS, the medical staff's appraisal procedure must evaluate each individual provider's qualifications and demonstrated competencies to perform each task or activity for which they have been granted privileges, including an evaluation of current work practice. The CMS also requires documented experience to examine credentials.
All hospital accreditors include similar language in their accreditation standards. This is why proper documentation of procedure logs is critical to helping providers meet requirements to demonstrate competency.
As more of our world moves into the digital so grows the concern for sharing data in a secure fashion. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law created to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. HIPAA's main goal is to ensure that an individual's health information is properly protected while allowing the flow of health information needed to provide high-quality health care. Its main function is to ensure that patient-specific information is properly protected. This is why patient-identifying data should not be included in any case/procedure logs.
Most hospitals and health systems have a process in place when it comes to sharing procedural and patient data with other facilities in the same health system. Regardless of the policy put in place, they should be developed with the help of an attorney so that appropriate language is included in your consent and release forms, in addition to medical staff bylaws. This will allow for sharing between facilities without needing the consent and release form each time information needs to be shared.
When a provider cannot document the required number of procedures necessary in order to request or maintain privileges, the medical staff has a few options to choose from. They are:
Some hospitals require a specific number of patient encounters in order to maintain a particular staff category or to remain on the medical staff. If you have a provider that has a low volume due to working only in an office clinic associated with the hospital, there is no way of documenting hospital patient contacts or procedures. In this case, consider moving the provider to another staff status that does not require inpatient treatment or giving them medical staff appointments without clinical privileges.
Patient safety will almost always be the impetus for documentation. It's essential to verify a provider has the skills needed to provide the best in care. Some hospitals or health care systems request case logs for procedures completed in the past year to show that a provider has the least minimum required experience in a specialty or within specific procedures or types of cases. This helps demonstrate the provider's qualifications for the position being considered, supporting the decision to grant privileges. These logs are especially important for hospitals that have a set minimum number of procedures to maintain competency.
This also helps hospitals remain compliant with different organizations, like The Accreditation Commission for Health Care (ACHC). They require that hospitals collect case logs to support privilege requests for procedures not attested to in postgraduate references. And while CMS doesn't have language specifically requiring case logs, hospitals are required to be in compliance with the federal requirements set forth in the Medicare Conditions of Participation (CoP) in order to receive Medicare/Medicaid payment.
Privileges granted to a provider should be based upon approved criteria. This typically includes the completion of a specific type of training and documented experience. These criteria often include documentation of a specific number of procedures that must be performed within a determined time period in order to request and maintain privileges. It's important for organizations that are considering establishing or revising requirements for minimum numbers of procedures necessary to request/maintain privileges to consider any recommendations of specialty organizations to ensure compliance.
CredentialStream includes everything you need to request, gather, and validate information about a provider. CredentialStream makes it easy to document competency with several features that facilitate the gathering of case logs.