The evolution of medicine toward greater and greater levels of sub-specialization has resulted in the complementary trend of physicians crossing traditional specialty lines and laying claim to procedures previously within the purview of another specialty. Although not new—neurosurgeons and orthopedic surgeons have long shared spinal surgery privileges—overlapping claims and emergent turf battles are creating new challenges for healthcare executives.

Leadership at St. Clair Hospital in Pittsburgh, an independent community hospital serving residents of Southwestern Pennsylvania, recognized the potential negative impact of physicians crossing specialty boundaries. “Healthcare’s continual evolution impacts both the roles and scopes of traditional physician practice . . . Often, progress creates increased demand for specialization and innovation in care delivery across all fields of medicine,” says Alan Yeasted, MD, St. Clair’s vice president of Medical Affairs.

A structured process is necessary in order to explore the hospital/physician dynamics of cross-specialization and develop strategies that minimize disputes and ensure that patients receive the best possible care.  

Corazon, a Pittsburgh-based heart and vascular consulting and recruitment firm with an office in south Florida, has developed the following proven steps for such an initiative:

1. Recognizing the Problem
As is often the case, the first step is to recognize the potential problem, which includes encouraging physicians from the various specialties to formally share their viewpoints. St. Clair, which worked with Corazon to develop expanded cardiovascular services and ongoing strategic plans for the specialty, takes an active role in bringing issues out in the open and serving as mediators.

2. Understanding Why the Problem Exists
Evolving technology creates new treatment options, opening up opportunities as well as creating pressures. Particularly if younger physicians in a specialty have been trained in a procedure, they are not willing to be bound by traditional privileging rules that may be outdated. All parties involved need to understand the evolving roles and capabilities of various specialties, and the dynamics of change caused by technological innovation.

3. Considering the Relevant Factors
Issues of privileges and scope of practice should be based on relevant and credible data, including quality measures, national and regional standards of practice and financial data. Among the types of questions to be considered in assessing cross-specialization practices are the following:

• What privileges are typically associated with a given specialty in the community?
• What is the standard of care? Is it changing as technology evolves?
• Does the organization have the variable resources that might be needed by each specialty undertaking a procedure? Will there be an impact on resource efficiency?
• Will spreading volume across specialties lead to quality or proficiency issues?
• Are their legal implications to a dispute about privileges among specialties?
• Do the payors have an established policy related to privileging for the procedure?

4. Bringing All Key Players to One Table
Hospitals that are most successful in managing competing claims among specialties are able to bring all stakeholders together as a working group exploring solutions. “Physicians and executives need to address the situation together at the same table so they know their opinions matter. . . You have to think positively that you can move forward and create something together from this discussion,” says Karen Hartman, president, Corazon. It is important to foster data-based discussions, bringing the results of preliminary investigations to the table, while also engaging physicians from the various specialties in evaluating the data and moving forward.

5. Determining the Best Solution
“Good decisions revolve around the business of patient care,” says Susan N. Heck, vice president, Corazon. “It is about trust and building a platform that everyone can work together on,” says Heck. For instance, at St. Clair, a physician champion helps guide the group, initiating discussions to focus on what is best for the patient. For a productive session, the champion will ensure physicians and executives acknowledge history, but leave baggage at the door. The goal is to bring specialties together based on patient care first—and then align not only individual interests, but the financial interest of the organization.

6. Gaining Endorsement
The final step before implementation is to gain endorsement. Agreement with the solution needs to last beyond acquiescence while around the table and progress to endorsement once out the door. In some cases, the endorsement process may include considering pilot projects to bring along those who are not ready to support the decision.

Physicians and hospitals have different perspectives and needs, but each has overlapping skills they can share. They can gather specific information on patient outcomes to compare the hospital versus national best practice. The members in the meeting can then begin to develop a form of standardization. The team can consider requiring credentialing guidelines that are uniform and based on national approved joint guidelines.

7. Implementing the Solution
Documenting an implementation and operational plan will help the group make the tough decisions needed to forge ahead. The plan should include detail on how credentials and privileges will be evaluated and monitored. Ideally, the relationships developed in solving cross-privileging issues also may foster greater medical staff collaboration along clinical service lines. For ongoing success, it is also important that medical staff leadership, as well as the chief medical officer, have clearly defined roles and job descriptions related to mediating physician cross-specialty issues.

8. Following Up to Assess Outcomes
As the process unfolds, those involved in the cross-specialization discussions should continue to monitor progress, comprising an ongoing steering committee. “The primary goals should be providing quality patient care and attaining trust from all parties,” says Heck. “To be a success, this also needs to be in alignment with the organization’s overall mission.” This process serves as a way for physicians and executives to collaborate across disciplines to build consensus and trust for better patient care.