Michael Carrese: Welcome to the ASHRM podcast made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. Visit ASHRM.org/membership to learn more and become an ASHRM member. I'm Michael Carrese.

Well, the healthcare workforce in the US is older on average than that of other major industries and nurses are one good example. As of last year, nearly half of all registered nurses were 65 years old. This leaves employers managing a complex set of issues as they attempt to assess competency in the late career practitioner. We're going to explore those complexities today, talk about why this is a concern to providers and administrators and learn what positions professional organizations have taken and how risk management strategies support assessment.

Our guide is Mary Steffany, an independent healthcare risk consultant. Mary has over 30 years of experience in healthcare risk management, most recently as senior healthcare risk consultant for Zurich North America, where she reviewed and assessed healthcare facilities throughout the United States.

Her career also included positions at NYU Hospital for Joint Diseases and Lenox Hill Hospital. And she started as a registered nurse herself at what was then known as NewYork-Presbyterian/Cornell Medical Center.

Since 2008, Mary has been an active board member of the Association of Healthcare Risk Management of New York. And Mary, welcome to the ASHRM podcast.

Mary Steffany: Thank you.

Michael Carrese: So let's start with a general definition here. How do you define a late career practitioner?

Mary Steffany: Well, strictly speaking, there's no definition of a late career practitioner. However, most of us know that age 65 is considered the age for retirement. And according to the Association of American Medical Colleges, about one-third of practicing physicians are 65 or older.

Now, unlike other professions, such as commercial airline pilots, FBI agents, and air traffic controllers who have mandatory retirement ages, that does not exist in healthcare. There is no mandatory retirement age for physicians. And in researching this topic, I learned of a pediatrician, age 92, who is partially retired now, but he covers for other pediatricians when they go on vacation; a pulmonologist who's 80 and an oncology surgeon, age 72. The list goes on and on. So physicians and surgeons practice their craft well beyond normal retirement age.

Michael Carrese: You mentioned surgeons there. And I'm wondering if there is a sense of priority about what particular kinds of practitioners should be required to undergo assessments of their competency more than others. For instance, surgeons, because perhaps you could make the case that more is at stake than with somebody handling routine dermatology appointments or somebody doing primary care.

Mary Steffany: Well, that's a very good question. Actually, a lot of data is collected on surgery and surgical cases. And in order to be a surgeon, there's a lot of skills that need to be in place really simultaneously. First of all, usually you start in the OR very early in the morning. And you have to be ready to go. There's production pressures. So if you have your block time, let's say for Tuesday or Thursday morning, you have to be ready to roll probably at 7:00. And if you don't live near the hospital, that means getting there and getting ready, having scrubbed and being prepped and ready to go into the OR. So there's a lot of things that need to be in order. You have to be able to work throughout that caseload. And if you're an academic medical center, perhaps you are teaching residents or medical students.

But getting back to your question, there's many statistics kept on cases that surgeons do. A dermatologist may never come to the hospital. They only see patients probably in their private office setting. And I recall a situation where a dermatologist who saw a patient with an enlarged lymph node thought that it was perhaps an infection, gave the gentleman antibiotics, he didn't respond. And as it kept getting larger, the dermatologist suggested that they excise it. They did, and they struck a nerve and the person suffered, you know, a very poor outcome, had to have other procedures done. And this shines the light on how can you assess competency, not only in the acute care setting, but the outpatient setting. And here, sometimes people don't even realize what's going on in the office because we don't reach beyond the four walls of the hospital.

Michael Carrese: Right. So what kind of assessment processes are in place and is there any uniformity at all across states or localities?

Mary Steffany: Well, in order to answer that question, I want to set the stage here with some basic information. CMS, which is the Centers for Medicare and Medicaid Services, reimburses hospitals for services rendered to their beneficiaries. In order to be reimbursed for those services, hospitals have to be accredited and the accreditation process entails looking at an organization's credentialing process. That process is in order to see if providers are competent. If they are competent, privileges are granted for whatever their particular specialty is. The Joint Commission is one of the agencies that provides accreditation services.

And in 2007, so we're talking back 14 years ago, they incorporated two processes. One is called the Ongoing Professional Practice Evaluation, OPPE, and the Focus Professional Practice Evaluation, FPPE, into medical standards. The medical standards is something that the Joint Commission looks at when they're doing an accreditation of the hospital. What are you doing to ensure that your medical staff is competent?

So when hospitals prepare for these surveys, they make sure that they have systems to align with the OPPE requirements, to monitor provider's clinical competence on a regular basis. And then if they deem that somebody needs a little bit more structured or focused supervision, they will have the FPPE in place.

Now, these processes are in place throughout any hospital that is accredited and getting reimbursed by CMS. And we know that's virtually every hospital. So those are the things that they would be looking at on a regular basis.

Michael Carrese: So that's why this matters so much because your accreditation could depend on it.

Mary Steffany: Exactly.

Michael Carrese: So in situations where hospitals and health systems have initiated these assessments, what's the reaction been from the late career practitioners themselves?

Mary Steffany: Just in the ordinary course of business, hospitals, physicians, providers, allied health professionals go through the accreditation process every two years. It's an application and there's also a statement as to your health. It's pretty much you know, pro forma. But when you are getting towards the later part of your career, and I'm talking now about those providers who are age 70 and older that has pretty much been red line, if you will, in terms of when we're talking about late career providers, they will go through the accreditation process. But in certain facilities, policies have been implemented requiring them to undergo additional evaluation. In other words, having their mental acuity tested in addition to their reflexes. And there has been mixed reaction to that. Some see it as important for patient safety and quality and others balk at it. They just feel they went through medical school. They completed a residency. They're board certified. They have years of experience. Their patients love them. They admit patients in the hospital, so they're generating revenue. They resent it.

Michael Carrese: Have there been cases of, you know, age discrimination complaints?

Mary Steffany: Actually, there is one right now that has been brought involving Yale New Haven Health System. And in this particular case, it was a pathologist who had been on the staff, I think over 40 years. And he went through all the testing, but he filed a complaint with the EEOC. And he felt that, you know, he was being discriminated against.

Now in 2016, Yale had implemented a policy that required neuropsychological and ophthalmologic testing of all medical staff age 70 and over. So essentially, you know, they wanted to screen these providers to see if they were competent. A hundred and forty-five physicians were evaluated and they ranged in age from 70 to 84. Now, the pathologist who brought this complaint, actually he passed all the tests. But of that group, I just mentioned, the 145, 80 of them passed, 30 qualified passed, 14 were borderline deficient and 1 was deficient, 7 failed. So some of them just decided to retire. Others underwent retesting and were placed under additional supervision. And then the results were presented to the Credentials Committee, which then made their determination.

Now as of 2020, the EEOC, which has the Equal Employment Opportunity Commission had charged the health system with violating the law because it required employees to complete cognitive and eye examinations in order to maintain their privileges. And they said that they had singled out these people and they were singled out because of their age.

Interestingly, Yale medical school had entered into an agreement with the hospital to fully integrate operations. So the faculty with clinical department appointments are required to obtain medical staff privilege at the hospital, but they're not employees of the hospital. So, as of last August 2020, the EEOC had not yet been required to prove the basis of its claims. And we just have to stay tuned to see what's going to happen.

Michael Carrese: Boy, you can see how complicated this can get and how touchy it is. Emotions can get involved.

Mary Steffany: Yes, very much so.

Michael Carrese: So what do professional associations say regarding these kinds of assessments?

Mary Steffany: Well, actually there have been position papers published by three of the organizations. The American College of Surgeons, they understand that surgery is a very demanding specialty area. It requires dexterity as well as obviously mental acuity and they recommend that surgeons age 65 to 70 voluntarily undergo a physical exam and visual testing by their personal physician. And then assuming that there's no deficits, they can just undergo a regular reevaluation.

Another specialty board, Obstetrics and Gynecology published a committee opinion on late career obstetrician-gynecologists. And we know with this specialty, you're on call. The baby doesn't necessarily make an appointment when they're going to arrive. A woman could be in labor a long time. And so this requires a tremendous amount of, not only the experience, the intellectual acumen, but also physically to be able to stay with a woman in labor.

So they made three recommendations. They suggested systems-based competency assessment to address the physician's health and the effect age has on their performance and care outcomes. They also support an adoption of a workplace recommendations to assist OB-GYNs to age well for the duration of their career. So that's really emotional support. And they also feel that hospitals should equitably apply these age assessments to all physicians. Once again, I think the thread here is that so far nobody has suggested or embraced, when I say nobody, none of these organizations has embraced mandatory retirement.

Michael Carrese: Right.

Mary Steffany: Anesthesiology is another group. And they are very cognizant that the percentage of active members of this society are 65 years of age and that's just growing. And they are aware of the unique challenges. You know, an anesthesiologist, depending upon what type of patients you anesthetize, if it's same day surgery, maybe you'r in the OR for a few hours, but there's a lot of case turnover, it's a short time and you're dealing with a patient population that's younger, doesn't have a lot of health issues. So I don't want to say it's easier, but perhaps less stressful, but if you're going to be the anesthesiologist for somebody undergoing a transplant or open-heart surgery or complicated neurological procedure, you could be in the OR a long time. Once again, they don't support blanket mandatory retirement, and they just feel that there should be modifications in the call schedule and that the organization should just work to support them in their current role. So that's where they stand.

Michael Carrese: Obviously, people are really trying to sort this through in different ways. So for risk managers, what strategies would support these kinds of assessments of late career practitioners?

Mary Steffany: I think from a risk management standpoint, the first thing you have to do is to understand the culture of the organization. If leadership has adopted a just culture, then you are working from the premise where everybody in the organization understands that they're accountable for their behavior. And if you have a chief medical officer who is engaging and well-respected, they very well could be your champion for addressing this very complicated issue.

Assuming those things are in place, then I would suggest that you create a multidisciplinary committee, including representatives from several clinical specialties, your medical exec committee, the credentials committee, risk management, human resources, to discuss the rationale for why you need this competency assessment. You also need to be familiar with the hospital bylaws and medical staff rules and regulations. You need to know about OPPE and FPPE policies.

Then I would suggest reaching out to other healthcare organizations to find out how have they addressed this. And make no mistake, you need to consult with counsel to draft a late career practitioner policy so that you don't get into trouble with the ADA requirements and the ADEA requirements.

And then another helpful thing is having a physician wellness committee. You know, a multidisciplinary committee that can look and see if any of your physician population is having issues and doing some kinds of review and analysis so that you kind of have the lay of the land in terms of your staff.

Moving on, you have all these things in place, but you need to communicate to the staff in an open forum about why the organization wants to look into having this type of policy. You have to anticipate the need for ongoing discussions and be prepared for pushback and have your facts ready. And then explain how the process will work and set a target date for rollout and organize resources for physicians who, if they are unfit for a really stressful job that they may have, that they can transition into a mentorship role and still be a very valuable resource to the organization and to their patients.

Yeah.

Michael Carrese: Because I would think part of it for organizations is, you know, these are very valuable employees. Even if, you know, say a surgeon is not going to be in the OR, there's a lot of other values that they can bring to their work.

Mary Steffany: Absolutely. And I think there is no substitute for the wisdom, the experience, and just the example that they will have shown to the new people who are joining the staff. And I remember distinctly when I was in the Hospital for Joint Diseases, we were doing a root cause analysis to try and figure out what had happened with a bad outcome. And one of the physicians who was participating in the conversation, he shared an example. And he said, "I remember distinctly when I was a resident" and he gave an example of something that happened to the case and the way the patient was managed. And he attributed that successful management to the physician who was his supervisor at that time. So there's no question they're invaluable.

I think the important thing is to be respectful obviously of this physician population, but to engage them in the conversation and have them understand that this is a topic for safety and quality, and they're not being singled out just because they've reached a particular age.

Michael Carrese: So Mary, as we wrap up, what's your message to healthcare risk management professionals about how importantly they should be taking this? And do you have a sense that it's a priority out there or should be more of a priority?

Mary Steffany: I think it should be more of a priority simply because the facts are clear. The providers are aging. The population is aging and people are coming into the hospital with more complex problems. So it's more challenging to manage their care. So instead of having organizations come and force hospitals to have some sort of policy, it's much better to do your own review, your own analysis, engage your group so they can be part of the solution, if you will, understanding how this policy will be crafted and how they can be part of making sure that patient care is safe and that they are the resources that will contribute to the safe patient care, be it in an active way or in a mentorship role.

Michael Carrese: Well, there's certainly a lot of wisdom in that, and I think it's a good place to leave things. I want to thank my guest, Mary Steffany for being with us today. She's an independent healthcare risk consultant. We appreciate your time, Mary, and for sharing all of your wisdom with us.

Mary Steffany: Thank you. It was my pleasure.

Michael Carrese: This podcast is made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit ASHRM.org/membership to learn more and become an ASHRM member. I'm Michael Carrese. Thanks for listening.