When and How Should Case Logs be Used to Document Competency

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.

What are case logs?

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.

When should case logs be used with credentialing/privileging?

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.

Requesting case logs: who and where?

Logs can come from the provider's training program, a healthcare facility, or personal data collection by the provider.

• Training Programs: The Accreditation Council for Graduate Medical Education (ACGME) sets and monitors the professional educational standards for its approved training programs. To meet ACGME requirements, the program needs to ensure that each student (provider) sees enough patients in addition to an appropriate mix of patients during their clinical terms. As such, training programs develop patient encounter and procedure log policies requiring trainees to enter procedures into a tracking system following each procedure. When a provider comes to your facility after a recent training program, the provider's procedure log should be requested from the training program. If the applicant is currently in the training program, they will be able to access the program's tracking system and print procedure logs as needed.
• Healthcare Facilities: Hospitals, ambulatory care facilities, and other healthcare institutions can provide a list of procedures performed and patient encounters for a provider, as requested. When making a request for logs, a time period must be specified, for example, within the past two years.
• Personal Data Collection by Provider: Providers may also opt to keep a list of procedures performed and/or patient encounters to document competency. These types of lists can be generated from the billing system used in the provider's office, though it's important to note that procedures performed in the office may not reflect the complexity of procedures that would otherwise be performed in an inpatient or outpatient surgery setting. Some specialty organizations offer providers options to track procedures online, giving the provider the ability to provide case logs utilizing the online tracker listing.

Do accreditors require the collection of case/procedure logs?

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.

Sharing Data: Rules

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.

What happens if a provider has not performed the required number of procedures?

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:

• Not recommending the requested privilege due to failure to meet minimum criteria.
• A recommendation to grant the requested privilege with a provision that it may be granted under a focused review or proctorship.
• This will vary depending on the actual procedure requested and the number of cases that have to be documented for the procedure. For example, if it is required to document 50 colonoscopy procedures a year in order to maintain privileges, and the provider can only document 49, the medical staff may feel that the provider is competent and may make a recommendation for approval of privileges with a retrospective review of a couple of cases.
• If the provider has not performed any procedures in question, then it may be appropriate for the medical staff to recommend that privileges are not approved for that specific procedure.

What happens with low-volume providers who do not admit patients to our facility and do not have privileges at any other facility?

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.

Why is documenting case logs important?

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.

How does CredentialStream support the collection and reporting of case/procedure logs?

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.

• For new applicants, Apply can be configured to allow the provider to upload their case/procedure logs directly into the Hub as part of their application. Those case/procedure logs can then be pulled into the documentation available for the reviewers in Appoint.
• At reappointment, Performance Privileges provides procedure count reports that are automatically integrated into Appoint documentation.
• The Performance Privilege report will display:
• The provider' granted privileges
• The minimum required
• The number performed within a specified period



To learn more, be sure to visit CredentialStream's Evaluate web page. And if you have any questions or want to schedule a demo, we're always here to help, simply reach out!