The Society of Rural Physicians of Canada (SRPC) released a position statement regarding minimum volume credentialing in the latest issue of the Canadian Journal of Rural Medicine.
Authored by Ms. Hester Soles, JD , and Dr. Trina Larsen Soles, past president of the SRPC and President-elect of Doctors of BC, the statement addresses the “fatal flaws” in the Provincial Privileging Process (PPP) and the need for improved physician accountability procedures that are rooted in evidence relevant to the Canadian context. It also makes four recommendations to help Canadians move towards more meaningful and impactful physician review and requalification.
RCCbc interviewed Ms. Soles and Dr. Larsen Soles to learn more about why the SRPC felt it was important to release a position statement, now that the PPP (recently renamed the BC Medical Quality Initiative or BCMQI) has been operational for a year.
Why did the SRPC release this position statement on the PPP in 2016?
Larsen Soles: The SRPC tends be responsive because it’s a small grassroots organization run by volunteers. When the privileging dictionaries were being developed for the PPP, there was a lot of discussion about the unintended consequences [of minimum volume credentialing] which led the SRPC to develop this position statement.
Ms. Soles conducted the literature research and put together a statement that frames the issue in a robust manner. The statement was approved by the SRPC in November 2015, but underwent peer review before being accepted for publication.
In the position statement, it’s recommended that BC put in place a comprehensive physician review and revalidation process that’s rooted in evidence relevant to the Canadian context. Why is this so important to develop, post-PPP?
Larsen Soles: There are currently two processes at play here: College revalidation that is based on CME/CPD, and the PPP which is done by the health authorities to review annual hospital privileges. The two systems don’t communicate with each other very well. All the literature referenced in the statement, including Dr. Cochrane’s report, say that improving physician competency needs to involve communication and continuous quality improvement. Neither of these programs really satisfy those benchmarks – they’re surrogates for competency.
Soles: All of the systems discussed in the SRPC position statement address individual physician performance – the papers didn’t look at how communities, groups, or assortments of people perform together.
Larsen Soles: MOREOB, is a Canadian prototype of a really successful initiative that examines how a team provides a range of services in the hospital. It involves nurses, administrators and physicians. My community hospital is entering Year 4 with MOREOB – we have ongoing case reviews, we continually look at how we can improve communication within the obstetrics program. That’s the prototype we should be aiming for [with the PPP].
Why isn’t a program like MOREOB being used as a template for the PPP?
Larsen Soles: The health authorities were handed a specific time constraint to implement a peer review process. Developing a program for every physician in your health authority and examining their function is hugely expensive and time consuming.
MOREOB works because obstetrics has always been “a team sport” that requires well established communication. Not all of the specialties have that infrastructure in place yet.
One of the issues of applying the PPP in a rural context is that frequently teams, rather than individuals, provide treatment. When we have a big trauma in my community, we call in people and say “who’s going to do the IV, who’s going to do the chest tube” and we play to our strengths. You have a combined powerful skill set that none of us have as individual physicians. That is not measured by a process like the PPP which only measures individual performance.
The reason for implementing the PPP is to ensure patients are safe and physicians are competent. To achieve these goals, we need to look at the whole healthcare system and how we can integrate all of the different quality improvement programs. Dr. Martin Wale and the BCMQI group are currently working on this, but in the meanwhile, we’re using a system that is potentially having a negative impact in specific areas.
By releasing this position paper, will the SRPC be able to persuade people to take the need for CQI into consideration as this [PPP] process continues?
Larsen Soles: I hope so.
Soles: In this case, the PPP has a broader impact than what its stated goals are. We are drawing attention to what we perceive the issues to be so at least the larger audience will think about those issues.
Larsen Soles: Let’s look at the example of rural anesthesia. The rural anesthesia privileging dictionary was modified to try to make it reasonable, but in a low volume hospital, if you strictly look at the operating room, you will never get enough hours. You then are forced to develop other solutions which may or may not be useful, such as traveling out of town to perform procedures elsewhere to meet the minimum volumes – this can then destabilize your rural community.
On the other hand, rural anesthetists may be doing a lot of work in the emergency room that involves their anesthesia skills: putting in PICC lines, tube and IVs, using the ultrasound for nerve blocks. These procedures don’t necessarily count towards your anesthesia volumes. Rural practice uses a different model and framework that can’t necessarily be well measured by the PPP.
I don’t think that anything can’t be changed. Yes, we’ve invested in the PPP – a lot of work and money. If it’s not working for everyone, we have to change it and make our system functional. This may be modifiable into something useful. We need all physicians to document what’s working and what isn’t.
What specifically should be documented?
Larsen Soles: Practitioners should let the BCMQI group know how the PPP has impacted their service provision. Have they decided to not renew their privileges, and if so, how has that impacted their practice and the community?
I can give you a personal example: I’ve done D&Cs for years. It’s not a common procedure in my community now because a lot of cases that used to require it can be addressed by an office-based endometrial biopsy. When my privileging was being established for the PPP, D&Cs were a non-core service for me. I would have had to go through the process of applying for non-core privileging to maintain that particular procedure. When I looked at what would be required for me to maintain that privilege, I didn’t bother because the probability that I’d be the only person in town to provide that service is relatively slim.
If there is a rare situation where a patient has an incomplete miscarriage with bleeding and needs a D&C, and I happen to be the only available physician, if it’s a bad enough emergency, I can do it regardless. But not having the procedure on my privileging list would make me hesitant to provide that service in an emergency.
We need to track and document the consequences of the PPP in our communities. When we find out what the impacts are, we can then figure out how to modify it to make it rural friendly.
 A Canadian initiative created by the Society of Obstetricians and Gynecologists of Canada