Evidence-based management provides the opportunity for clinical leaders to make decisions based on the best objective knowledge available, and avoid the pitfall of setting operational requirements based on personal experience.1 In pediatric oncology, treatment decisions are based on clinical evidence, trials, and protocols. The Institute of Medicine (IOM) calls for patient care that is safe, effective, efficient, timely, patient-centered, and affordable.2 Pediatric oncology patients undergo many procedures and rely on physicians and advanced practice providers (APPs) to perform the procedures safely, efficiently, and effectively.
The APP director is responsible for the oversight of training and documentation of provider competency in the cancer center. A management decision made by the APP director with the input of another senior nurse practitioner (NP) was to document competency after performing 10 lumbar punctures (LPs), 10 bone marrow aspirates (BMAs), and 10 biopsies (BMXs). Leadership has asked for evidence of the minimum volume standard for establishing competency for procedures. The questioning of this management decision provided an opportunity to explore evidence regarding minimum number of procedures for establishing competency.
Description of Management Practice
BMAs and BMXs are performed to diagnose malignancies or determine response to treatment for diseases such as leukemia, lymphoma, or bone marrow dysplasia.3 LPs are performed to diagnose central nervous system (CNS) leukemia, other CNS malignancies, or infection. These procedures are performed by physicians and APPs in this large pediatric cancer center. In 2018, 1339 procedures were performed in the postanesthesia care unit (PACU) [P. Wills Bagnato, Annual report on APP productivity to physician leadership. October 11, 2018]. All bone marrow (BM) procedures are conducted in the PACU treatment room where patients are sedated with propofol or anesthesia gas. This facility employs 8 APPs and 3 physicians who are trained to perform procedures and staff the PACU treatment room each month.
The APP director is responsible for oversight of training and competency assessments. Literature on BM and LP procedures, a PowerPoint module with instructions on sampling, a copy of the facility’s policy on provider responsibility, and procedure checklists are provided to the trainee in advance of the practicum. Trainees are assigned to an experienced APP provider 1 day a week to begin training to perform BM procedures and LPs. Trainees must successfully complete 10 of each procedure — BMAs, BMXs, and LPs — and document pathology reports for the BMA and BMX procedures.
The minimum requirement of 10 procedures was based on the recommendation of 2 senior NPs with more than 10 years of experience performing procedures and was approved by the section physician leadership. Even after the minimum number of procedures is performed, the APP trainee continues to train under direct supervision until fully credentialed as a billing provider. Before independent privileges are requested and granted by Medical Staff Services, the APP trainee must also be able to demonstrate the ability to run the show: coordinate the day’s procedures with the preoperative staff, conduct the intraprocedural process, and facilitate a smooth hand-off to the postoperative recovery team. This procedure training program may take up to 4 months for the APP trainee to obtain billing privileges, during which time the APP trainee continues to perform procedures weekly with supervision by a credentialed billing provider. Once billing privileges are granted and the APP is credentialed by Medical Staff Services to perform the designated procedures independently, the APP assumes an individual procedure clinical schedule of at least 1 day a month.
The minimum requirement of performing 10 BMAs and 10 BMXs was recently questioned. This question necessitated a review of the evidence for required minimum volume of procedures to infer competency. Pfeffer and Sutton discuss the need for managers to make decisions based on evidence as opposed to experience.1 The evidence for a minimum requirement for procedures would either confirm the appropriateness of this policy, or redirect leadership to adopt a more evidence-based training plan.