Competency-based Credentialing: A New Model from the Massachusetts Board of Registration in Medicine Expert Panel on Credentialing

Keywords:

• Competency-based credentialing process

A decade has passed since the publication of the IOM report To Err Is Human.1 Yet the pressing question remains: are patients any safer? A recent report from the Agency for Healthcare Research and Quality (AHRQ) suggests that progress toward a safer environment is mixed. Overall, measures of patient safety have actually declined recently.2 There was a positive finding in that hospitals are responding with performance improvement initiatives, but unfortunately their effects will take some time to show up in the statistics.2,3 As the AHRQ report notes, progress has been slow with regard to optimizing health care quality, measurement of that quality and therefore patient safety. Safety initiatives stagnate unless there is active involvement of leadership and the medical staff.4,5 Missing from the discussion are any data concerning physician competence. Yet, successful implementation of these initiatives requires well-qualified, knowledgeable, currently competent physicians. The primary method for ensuring competence is the hospital credentialing process.

Concern about the adequacy of the credentialing process led the Massachusetts Board of Registration in Medicine (Board), in September 2006, to create the Expert Panel on Credentialing (Panel) through its Patient Care Assessment (PCA) division. The Board's PCA has statutory and regulatory authority over quality improvement, patient safety, medical error prevention, and credentialing activities at Massachusetts health care facilities. PCA monitors these processes through review of quarterly reports submitted by the facilities describing all serious, unexpected patient outcomes, results of their investigations, and corrective plans undertaken by the institution. Through examination of these reports and communication with health care facility leadership, PCA concluded that the credentialing process in many hospitals is weak and haphazard, making it difficult to achieve the purpose of ensuring that all physicians on the medical staff are providing safe and competent care.

Since there seemed to be no uniform or reproducible method common to all hospitals for the required biennial physician credentialing, the Panel was charged with creating a standardized framework that facilities could use for both the initial credentialing and the re-credentialing processes. The overall objective was to develop a mechanism whereby populations served could be assured that the hospitals' credentialed physicians remain competent throughout the entire duration of their careers. Optimally, this framework should include a broad array of methods, such as evaluation of patient outcomes through case reviews, analysis of data, review of accomplishments, complaints, certifications, and other competency assessments as recommended by specialty boards, professional societies, or regulatory agencies.

The Panel acknowledged at the outset that satisfactory completion of a training program does not ensure sustained competency. The Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialties (ABMS) recognized this reality several years ago. These organizations, together with the Federation of State Medical Boards (FSMB), are working to establish standardized, comprehensive, and continuing methods for assessing physician competencies, both for physicians in training, at the hospital level, and for physicians in practice.6–8 As part of this process, the ACGME identified six areas of core competencies, for which each specialty has developed its own specifics. The driving purpose of the Panel, as well as these organizations, is to assure the public that every licensed and certified physician is competent to provide current evidence-based care.

The Panel began its deliberations in September 2006. An initial survey of selected health care facilities in Massachusetts was conducted to understand the current spectrum of credentialing criteria. As evidenced in Table 1, while there were several common elements, considerable variation in criteria was observed. Based on this finding, the Panel reviewed the literature and developed the Core Credentialing Criteria listed in Table 2. Primary Criteria are those typically used by facilities to meet mandatory credentialing requirements, while Secondary Criteria are suggested as elective depending upon the needs of the specific facility. In addition to ensuring compliance with the basic essentials of credentialing, these criteria or guidelines, taken in the aggregate, provide a basis for assessing the six major areas embraced by the ACGME, ABMS, Joint Commission, and FSMB as defined in Table 4.6–9

On Oct. 17, 2007, the Board approved this report, including the proposed guidelines.10

The responsibility for measuring competency rests with the hospitals or health care facilities where physicians practice. The guidelines suggest several assessment measures for each of the six core competencies. As the science of measuring competency is in its early stages of development, the Panel did not believe that use of any specific measures should be mandated at this time. These metrics will undoubtedly be modified and expanded over time. However, the broad array of assessment methods currently available is more than adequate to permit more meaningful competency measurement than has been the case in the past.

To test the feasibility of implementing these core guidelines, the Panel asked four hospitals to use them in their credentialing processes. One was a large teaching hospital (735 beds). The others were community hospitals: two mid-sized (360 beds and 270 beds), and one a small hospital (78 beds).