Module 1 Introduction to Credentialing. Course Overview. Day One. Day Two 2/27/2013. Carol Cairns, CPCS, CPMSM Maggie Palmer, CPCS, CPMSM

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1 Course Overview Carol Cairns, CPCS, CPMSM Maggie Palmer, CPCS, CPMSM Module 1 Introduction to Credentialing Module 2 Foundation for Credentialing Module 3 Phases of Credentialing Module 4 Initial Appointment Module 5 Basics of Privileging Module 6 Performance Monitoring/OPPE/FPPE Module 7 Reappointment, Reappraisal, and/or Renewal of Privileges Module 8 Credentialing Challenges 1 2 Day One Module 1 Introduction to Credentialing Module 2 Foundation for Credentialing Module 3 Phases of Credentialing Module 4 Initial Appointment Day Two Module 5 Basics of Privileging Module 6 Performance Monitoring/OPPE/FPPE Module 7 Reappointment, Reappraisal, and/or Renewal of Privileges Module 8 Credentialing Challenges 3 4 Module 1: Introduction to Credentialing Session 1: What Is Credentialing? At the end of this session, you will be able to: Define credentialing and privileging Differentiate credentialing from privileging Articulate the purpose of credentialing Session 1: What Is Credentialing? Session 2: In What Settings Do We Credential? 5 6 1

2 Session 1: What Is Credentialing? The process of obtaining, verifying and assessing the qualifications of a practitioner to provide care or services in or for a healthcare organization. Activity #1: Why Credential? Patient Hospital/MCO Federal and State Regulatory Bodies Accreditation TJC, NCQA, HFAP, AAAHC, URAC, DNV, etc. Financial Medicare/Medicaid Risk Management/Legal Accountability Bylaws/Rules & Regulations/Policies & Procedures 7 8 Case Study #1: Why We Credential Patient Safety Dr. Swango was dismissed from many jobs. He continued to find work at hospitals around the world. Dr. Swango is suspected of killing an estimated 60 patients Who Gets Credentialed in the Hospital Environment? Who Gets Credentialed in the Hospital Environment? Licensed Independent Practitioners (LIP) Allopathic Physicians (MD) Osteopathic Physicians (DO) Podiatrists (DPM) Dentists (DDS/DMD) Psychologists (PhD) Advanced Practice Nurses (APRN)* Advanced Practice Professionals Advanced Practice Nurses Certified Nurse Anesthetists (CRNA) Certified Nurse Midwives (CNM) Nurse Practitioners (NP) Clinical Nurse Specialists (CNS) Physician Assistants (PA) *In some states

3 Who Else Gets Credentialed in the Hospital Environment? Non LIPs Surgical Assistants Radiology Technicians Staff Nurses Nurses working for physicians Etc. Circumstances Requiring Credentialing by the Medical Staff Membership Membership is defined by medical staff bylaws Outlines individual s rights and responsibilities Circumstances Requiring Credentialing by the Medical Staff Privileging The process whereby the specific scope and content of patient care services (i.e., clinical privileges) are authorized for a healthcare practitioner by a healthcare organization, based on evaluation of the individual s credentials and performance. Privileging Components Facility specific Delineation of privileges system Criteria based Granted on demonstrated ability Membership and Privileges Session 2: In What Settings Do We Credential? Membership Privileges At the end of this session, you will be able to: Identify settings where credentialing is performed Membership & Privileges

4 Session 2: In What Settings Do We Credential? Long Term Care Credentials Verification Organizations Hospitals Managed Care Organizations Ambulatory Care Medical Practice Groups Academic Urban Rural Critical Access Specialty Hospitals Long Term Care Ambulatory Care Skilled nursing Rehabilitation Surgery center Clinics Specific disease management Urgent care Physician office surgical facilities Medical Practice Groups Managed Care Organizations 1. Single/Multi specialty Groups 2. Locum tenens Anesthesia Emergency medicine 3. Telemedicine Radiology Psychiatry E ICU Developed to reduce the cost of health care Three components Health insurance plan Delivery of care Plan administration MCOs may contract with a hospital or CVO to conduct credentialing

5 Credentialing in Managed Care Hospital Managed Care Patients Members Practitioner Provider or Clinician Credentials Verification Organization (CVO) Medical societies Health system based Independent (for profit) Privileges Provider Panel Centralizing the Credentialing Verification Process Potential Benefits Standardization of processes and forms Knowledgeable, dedicated staff Allows MSP more time for other responsibilities Potential staff reduction in facilities served Reduction in time spent by practitioners and office staff (completing multiple applications, etc.) Centralizing the Credentialing Verification Process Reduction in risk Increased efficiency Source of information and resource to individual entity Improved outcomes Better information available to all Turnaround times (TAT) reduced Centralizing the Credentialing Verification Process Potential Challenges Loss of control at facility level System decides processes, forms, TAT Uniformity vs. individuality Reduction in comprehensiveness of credentialing (best practices) Reduction in scope of services provided in MSSD Centralization may require added steps and/or processes

6 Activity #2 Quiz Module 2: Foundation for Credentialing Session 1: Legal Aspects of Credentialing Session 2: Regulatory and Accreditation Organizations Session 3: Federal Regulations Impacting Healthcare Session 4: Organization Specific Requirements Session 1: Legal Aspects of Credentialing Development of the law regarding hospitals At the end of this session, you will be able to: Define the legal term negligent credentialing Explain how landmark cases have influenced credentialing Session 1: Legal Aspects of Credentialing Development of the law regarding hospitals Case Study #2 Prior to 1960s Doctrine of Charitable Immunity 1965 Darling vs. Charleston Community Hospital Respondeat Superior Negligent Credentialing Let the master answer Employer is responsible for the legal consequences of the acts of the employees Failure to act as an ordinary prudent person or conduct contrary to that of a reasonable person under specific circumstances

7 Negligent Credentialing Hospital can be directly liable for failure to credential properly Hospital must conduct appropriate due diligence How Does This Affect You? The healthcare organization needs to have a well defined credentialing process and follow the process to protect the patient and the organization. If problems would have been revealed by credentialing, the hospital may be liable for any patient harm caused by the substandard clinician Case Study # 3: Johnson vs. Misericordia (1981) Key Issues Negligent credentialing Failure of initial credentialing process Fact Summary Hospital is liable for patient injury Physician failed to disclose malpractice history Physician lied about privileges at other hospitals Activity #3: Case Study Case Study #4: Gomez vs. West Historic Case (1973) Gonzales vs. Nork Key Finding: Hospital knew or should have known and taken steps to protect other patients If the organization knew or should have known that a practitioner is not qualified and the practitioner injures a patient through an act of negligence, the organization can be found separately liable for the negligent credentialing of this practitioner. Session 2: Regulatory and Accreditation Organizations At the end of this session, you will be able to: Identify the regulatory and accreditation organizations and the health care facilities they impact

8 Regulatory Agencies Centers for Medicare and Medicaid Services (CMS) CMS State Licensing Bodies Administers: Medicare Medicaid State Children s Health Insurance (SCHIP) Health Insurance Portability and Accountability Act (HIPAA) Clinical Laboratory Improvement Amendments (CLIA) Centers for Medicare and Medicaid Services (CMS) Accrediting Organizations CMS administers the regulations contained in the CoPs. CMS also grants deeming authority to other organizations to accredit hospitals and health plans for Medicare/Medicaid reimbursement without additional state and/or federal surveys. TJC DNV HFAP AAAHC URAC NCQA The Joint Commission (TJC) The Joint Commission (TJC) Independent, not for profit organization Granted deeming authority in 1965 Activities include: Public policy initiatives Standards development Accreditation and Certification programs Accredits approximately 88% of hospitals Accreditation Programs Ambulatory Care Behavioral Health Care Critical Access Hospitals Home Care Hospitals Laboratory Services Long Term Care Office Based Surgery

9 Healthcare Facilities Accreditation Program (HFAP) Det Norske Veritas (DNV) Created in 1945 to review osteopathic hospitals and educational programs Granted deeming authority in 1965 Accredits Hospitals Critical access hospitals Ambulatory care/surgical facilities Mental health facilities Physical rehabilitation facilities Clinical laboratories Primary stroke centers 1864 Established in Oslo, Norway to regulate ship building industry 1898 Began U.S. Operations 2008 Granted deeming authority for hospitals 2010 Granted deeming authority for critical access hospitals Det Norske Veritas (DNV) National Integrated Accreditation for Healthcare Organizations (NIAHO ) ISO 9001 Quality Management System CMS CoPs Accreditation Association for Ambulatory Healthcare (AAAHC) Formed in 1979 to advance and promote patient safety in ambulatory healthcare Accredits approximately 5,000 organizations Ambulatory and surgery centers Community health centers Medical and dental group practices Medical home Managed care organizations Indian and student health centers National Committee for Quality Assurance (NCQA) Accreditation Programs Health Plan Accreditation (HPA) Wellness & Health Promotion (WHP) Managed Behavioral Healthcare Organizations (MBHO) New Health Plans (NHP) Disease Management (DM) Quality Plus URAC Established late 1980s to create uniformity in standards for utilization review services Mission expanded to cover various health care settings Integrated health systems Health plans CVOs More than 22 additional accreditation and certification programs

10 Accreditors Change in accreditors? TJC DNV or HFAP TJC CMS HFAP TJC Session 3: Federal Healthcare Regulations At the end of this session, you will be able to: Explain how specific federal regulations dictate some credentialing processes Session 3: Federal Healthcare Regulations Healthcare Quality Improvement Act (HCQIA) National Practitioner Data Bank/Healthcare Integrity and Protection Data Bank (NPDB/HIPDB) Americans with Disabilities Act (ADA) Health Portability and Accountability Act (HIPAA) Case Study #5: Patrick vs. Burget (1988) HCQIA HCQIA Immunity coverage available to: Professional review bodies Members/staff of those bodies Those under contract with the bodies Anyone who participates or assists the bodies with respect to action Those who provide information regarding competence/conduct unless the information is false and the person giving the information knew it was false (whistleblowers) Exceptions to immunity coverage: Healthcare entities failing to meet the standards for immunity Healthcare entities failing to report information to the National Practitioner Data Bank

11 HCQIA Standards for immunity: Only good faith peer review qualifies for HCQIA protection HCQIA sets standards for good faith peer review Includes right of fair hearing and appeal HCQIA of immunity: The HCQIA has been successfully applied in cases brought by physicians challenging the peer review action taken by hospitals, to protect the hospital and the physicians who conducted the review NPDB NPDB Established because: Increased occurrence of medical malpractice litigation Need to improve quality of medical care Congress sought to provide incentive and protection for physicians and dentists engaged in peer review Hospitals/health care entity must report on physicians and dentists. May report on other healthcare practitioners. Each entity is responsible for determining which categories of licensed healthcare practitioners to report NPDB Who Queries? NPDB Who Queries? Hospitals must: Initial application for membership or clinical privileges Every two (2) years re: physicians, dentists, and other healthcare practitioners on the medical staff or who have clinical privileges Requests for temporary privileges or additional privileges Other healthcare entities may at initial appointment or granting clinical privileges State licensing boards may query at anytime Plaintiff s attorney may query under certain circumstances Healthcare practitioners may self query anytime Authorized agent CVO

12 NPDB Who Reports? NPDB Who Reports? Hospitals and other healthcare entities who take action against a practitioner based on professional review Medical malpractice payers: Payment resulting from all written claims or judgments on physicians, dentists and other healthcare practitioners State Licensing Boards Prior to March 2010, reporting was limited to disciplinary actions for reasons related to professional competence or conduct on physicians and dentists As of March 2010, Section 1921 expanded reporting of all state licensure actions to include all types of health care professionals Professional societies on physicians and dentists Reporting is limited to disciplinary actions for reasons related to professional competence or conduct on physicians and dentists if it adversely affects membership NPDB What is Reported? NPDB Malpractice payments from written claim or judgment Licensure disciplinary actions for professional competence or conduct (as of March 2010, all licensure actions per section 1921) Professional review actions for reasons relating to professional competence or conduct adversely affecting membership Clinical privilege actions longer than 30 days or voluntary surrender or restriction of clinical privileges while under, or to avoid investigation Quiz Question #1: Who must report actions to the NPDB but has no authority to query? NPDB Quiz Question #2: At what three times, must a hospital query the NPDB? Healthcare Integrity and Protection Data Bank (HIPDB) Integrated NPDB website: hipdb.com Designed to combat fraud and abuse in health insurance and health care delivery Available to federal and state government agencies; health plans and self queries by providers, suppliers and practitioners Query and reporting process integrated with NPDB via website

13 The Americans with Disabilities Act (ADA) Designed to eliminate discrimination on the basis of disability Prohibits employment discrimination against the disabled Only covers discrimination between employers and employees or potential employees Quiz: Health Status Information Questions 1. Do you have a mental or physical condition that in any way may impair or limit your ability to practice medicine with reasonable skill and safety with or without reasonable accommodation? Is this question permitted under the standards of the ADA? Quiz: Health Status Information Questions 2. Are you currently engaged in the illegal use of controlled substances? Is this question permitted under the standards of the ADA? Quiz: Health Status Information Questions 3. Have you been hospitalized in the past two years? If so, for what reason(s)? 4. What prescription medications do you take? Are these questions permitted under the standards of the ADA? Quiz: Health Status Information Questions 5. Are you currently using any chemical substance(s) that in any way may impair or limit your ability to practice medicine with reasonable skill and safety? Is this question permitted under the standards of the ADA? The Health Portability and Accountability Act of 1996 (HIPAA) Requires hospitals, doctors, and other providers to obtain a patient s written consent before disclosure of identifiable health information Providers must inform patients how their health data will be used or disclosed and obtain written permission Federal civil and criminal penalties for improper use or disclosure of protected health information

14 Session 4: Organization Specific Requirements At the end of this session, you will be able to: Explain the differences between bylaws, policies and procedures, and rules and regulations Explain how medical staff bylaws, policies, and rules and regulations provide the framework for credentialing and privileging processes Medical Staff Governance Documents Bylaws address self governance and accountability of the medical staff to the governing body Policies and procedures focus on specific functions and processes Rules and regulations narrowly focus on specific requirements Bylaws CoPs require bylaws to: Define the composition of the medical staff Describe the medical staff organization and accountability Duties and responsibilities of MEC Include duties and privileges of each category Bylaws Bylaws CoPs require bylaws to: Describe the qualifications for appointment/reappointment Include criteria for privileges Outline requirements for an H & P Be approved by the governing body TJC requires the bylaws to: Define the structure of the medical staff Voting members Describe the medical staff organization and accountability Medical Executive Committee (MEC) Department and department chair Selection/election/removal of officers and MEC members

15 Bylaws TJC require bylaws to (continued): Include duties and privileges of each category Describe the qualifications for appointment Describe process for: Privileging and reprivileging practitioners Credentialing and recredentialing practitioners Appointment and reappointment Hearing and appeal Bylaws TJC require bylaws to (continued): Define indications and processes for automatic and summary suspension Indications for termination or suspension of membership or privileges Outline requirements for an H & P Define process for adopting and amending bylaws, rules & regulations, and policies Be approved by the governing body Bylaws TJC requires that bylaws specifically outline the previously listed items. However, associated details, which may provide the procedures involved in these processes, can be placed in the policies. Policies & Procedures Examples of medical staff policies and procedures include: Credentials procedure manual Hearing and appeal procedure manual Performance improvement/peer review policy Disruptive behavior policy Impaired physician policy Rules & Regulations Examples of medical staff rules and regulations General Required professional liability coverage Medical record completion obligations Payment of dues Department or specialty specific Required consultations for patient management Surgical scheduling requirements Activity #4 Policies and Procedures, Rules and Regulations & Bylaws

16 Module 3: Phases of Credentialing At the end of this module, you will be able to: Describe the activities characteristic of each of the four phases of credentialing Identify the tasks associated with each of the four phases of credentialing Differentiate the roles and responsibilities related to each of the four phases of credentialing Four Phases of Credentialing Phase 1: Develop Structure Develop Structure Gather & Verify Information Assess and Recommend Action Act Upon Medical Staff Recommendation Process: Create bylaws, rules & regulations, policies Create documents /reapplication Delineation of privileges (DOP) Professional Reference Questionnaire Phase 1: Develop Structure Phase 2: Gather & Verify Information Responsible Party: Medical staff leaders Governing body Process: Obtain a completed application Verify education, training, experience, competence, etc. Follow up red flags

17 Phase 2: Gather & Verify Information Responsible party: Credentialing professional Medical staff leaders Phase 3: Assess and Recommend Action Process: Compare information provided by the applicant against data gathered and identify inconsistencies Assess applicant s qualifications against predetermined criteria Determine follow up required to resolve inconsistencies Recommend action Phase 3: Assess and Recommend Action Responsible Party: Medical staff leaders Phase 4: Act Upon Medical Staff Recommendation Process: Approve Grant Modify Deny Responsible Party: Governing body Reapplication Privileges Requested Group Activity #5: Roles & Responsibilities

18 Module 4: Initial Appointment Session 1: Phase 1 Develop Structure Session 2: Phase 2 Gather & Verify Information Session 3: Phase 3 Assess and Recommend Action Session 4: Phase 4 Act Upon Medical Staff Recommendation Session 5: Other Processes Related to Initial Appointment Case Study #6: Dr. John Anderson King Privileges suspended for falsifying records Terminated from other hospitals for poor performance Hired at Putnam General Hospital in West Virginia Named in 125 malpractice suits Credentialing Process Initial Appointment Initial Privileges Reappointment Reappraisal or Renewal of Privileges Session 1: Phase 1: Develop Structure At the end of this session, you will be able to: Structure the initial appointment process in accordance with medical staff documents Evaluate the current medical staff application for compliance with CMS and TJC standards Use TJC standards to assess the adequacy of their specific organization s professional reference questionnaire Session 1: Phase 1: Develop Structure What would be considered a Phase 1 activity for an initial appointment? Process: Bylaws, Rules & Regulations, Policies Documents Delineation of Privileges (DOP) Professional Reference Questionnaire Session 1: Phase 1: Develop Structure Responsible Party: Medical staff leaders Develop bylaws, rules, policies Create applicable forms Governing body Act upon documents recommended by medical staff

19 Phase 1: Develop Structure: The 1. Personal/demographic information 2. Education/training 3. Licensure(s), registration(s), and certificate(s) 4. Board certification(s) 5. Current and past healthcare affiliations 6. References 7. Ability to perform 8. Academic appointments 9. Chronological work history 10. Professional sanctions 11. Malpractice history, current and past malpractice carriers 109 Phase 1: Develop Structure: The Red Flag Questions Specific information required by the regulator or accreditor For example, TJC requires information on: Challenges to licensure/registration Voluntary/involuntary relinquishment of any license/registration Voluntary/involuntary termination of MS membership 110 Phase 1: Develop Structure: The Red Flag Questions Voluntary/involuntary limitation, reduction or loss of clinical privileges Evidence of unusual pattern or excessive number of professional liability actions resulting in a final judgment Documentation of the applicant s health status Relevant practitioner specific data as compared to aggregate data, when available Morbidity and mortality data, when available 111 The 112 Activity #6: Dr. McDreamy XYZ Hospital has received an initial application from Dr. McDreamy. Is this application complete? If not, what needs to be done? Privileges Organization specific Based on demonstrated competence Procedure logs Peer recommendations Documentation of recent (current) experience Ability to perform privileges requested

20 Professional References (PR): Who are they and why are they important? Who Are They? Program directors Department chairs/clinical service chiefs/physician leaders Current/future partners? Other physicians/practitioners Other ancillary personnel Like specialty/same discipline 116 Why Are They Important? PR provides confirmation of: Education Training Character Professionalism Current clinical competency Ability to perform What do the regulatory and accreditation bodies require relative to professional references? Centers for Medicare/Medicaid Services Conditions of Participation The medical staff examines credentials of individual prospective members (new appointments or reappointments) including supporting references of competence. The Joint Commission Peer recommendations must address current information regarding the applicant s: Medical/clinical knowledge Technical and clinical skills Clinical judgment Interpersonal skills Communication skills Professionalism

21 Best Practice: Professional Reference Policy Sample Professional Reference Questionnaire Session 2: Phase 2: Gather & Verify Information At the end of this session, you will be able to: List the CMS and TJC requirements for credentials verification for the initial applicant Distinguish between required verification elements and industry best practices 123 Session 2: Phase 2: Gather & Verify Information What would be considered a Phase 2 activity for an initial appointment? Process: Obtain and evaluate application for completeness Verify education, training, experience, competence, etc. Identify discrepancies between information provided and data gathered Compare applicant s qualifications with applicable established criteria Follow up red flags 124 Session 2: Phase 2: Gather & Verify Information What would be considered a Phase 2 activity for an initial appointment? Responsible Party: Credentialing professional Medical staff leaders Initial Supporting Documentation Curriculum vitae DEA and state narcotics registrations Professional liability insurance face sheet Photograph Clinical privileges request Copies of: Diploma, training, license, board certification only if required

22 Obtain and Evaluate for Completeness fee Assure the application is complete Government ID (TJC) DEA certificate Professional Liability Insurance Certificate Releases and forms are signed Privilege forms are completed Education and training documentation supports each privilege requested Verification Sources Primary Source Designated Equivalent or Approved Source Secondary Source Primary Source Verification (PSV) Directly from issuing source Letter, fax, e mail or telephone Approved primary source websites Document copies from applicant don t count, but may be helpful 129 Designated Equivalent Source Primary Source Credentials Equivalent Source Credentials Examples: American Medical Association for verification of completion of U.S. education and training for a physician Federation of State Medical Boards data file for verification of licensure disciplinary actions 130 Secondary Source NAMSS Comparison of Accreditation Standards

23 Activity #7: Verification Verification Problems Licensure DEA Registration/Controlled Substance Education Training Experience (current and past healthcare affiliations) Specialty Board Certification Federal and State Sanctions NPDB/HIPDB Current Competency Peer references Ability to perform privileges requested Academic appointments Professional liability coverage Malpractice history Criminal background check Substance abuse screening Other? Paper trail of documentation Confidentiality Define peer references Confirmation of health status Hearsay Information Primary source no longer exists or has merged Crossing state line re licensing issues Temporary status Red Flags Gaps/missing dates Moving frequently Training Group practice Hospitals Discrepancies between information on application and response from written/oral verifications Healthcare employment and/or contract termination 135 Red Flags Suspended, revoked, reduced: Hospital privileges License DEA Insurance cancelled/excessive claims, trends of complaints Felony conviction 136 Red Flags Reference letters: From relative or associate Never worked with individual No reference to skills, performance Confirmation of dates only Removal from managed care panel for reasons of quality of care or professional conduct The burden of a complete application is on the applicant. The burden of proof is also on the applicant

24 Case Study #7: Hospital XYZ Medical Center has received an initial application from Dr. McDreamy. A professional reference has indicated that Dr. McDreamy becomes a nightmare when requested to provide emergency department call coverage. Is the hospital required to appoint the practitioner if all other information is positive? Yes No Case Study #8: CVO In response to an affiliation request, a hospital supplies a form letter stating that Dr. C. Section was a member of the medical staff with OB/GYN privileges from mm/yy to mm/yy. This hospital affiliation is where the doctor spent the last two years of practice. What should the CVO do? Case Study #9: Hospital Dr. Happycut has requested privileges for general surgery and special privileges for bariatric surgery at St. Elsewhere Hospital. The reference provided by his program director confirms his competence in general surgery, but does not support the request for bariatric surgery. Case Study #9: Test Your Knowledge A. Deny all requested privileges. B. Deny the request for bariatric surgery privileges only. C. Ask Dr. Happycut to withdraw his request for bariatric surgery. D. Ask Dr. Happycut for other evidence of training in bariatric surgery Review/Findings MSSD In a Medical Staff Services Department, the credentialer would: Review file and checklist for completeness Follow up of issues, concerns Identify red flags for medical staff leadership Review/Findings CVO CVO manager or designee will review the credential for completeness prior to releasing to the client Conduct periodic file review audits to assure quality performance

25 Session 3: Phase 3: Assess and Recommend Action At the end of this session, you will be able to: Describe the medical staff s leadership role in the credentialing process Distinguish between the medical staff s role and the Board s role in the credentialing process Session 3: Phase 3: Assess and Recommend Action What would be considered a Phase 3 activity for an initial appointment? Process: Compare information provided by the applicant against data gathered and identify inconsistencies Assess applicant s qualifications against predetermined criteria Interview applicant (optional) Determine follow up required to resolve inconsistencies Recommend action Session 3: Phase 3: Assess and Recommend Action Responsible Party: Medical staff leaders Evaluation by Medical Staff Leadership Is the application complete? Are there any discrepancies? Have all aspects of the application been verified satisfactorily? Are all defined criteria met? Are there any issues related to current competence for the privileges requested? Review/Recommendation Medical Staff Department Chair/Service Chief (as applicable) Credentials Committee (as applicable) Medical Executive Committee (required)

26 Session 4: Phase 4: Act Upon Medical Staff Recommendation At the end of this session, you will be able to: Describe the board s role in the credentialing process Distinguish between the board s role and the medical staff s role in the credentialing process Session 4: Phase 4: Act Upon Medical Staff Recommendation What would be considered a Phase 4 activity for an initial appointment? Process: Approve Grant Reapplication Modify Privileges Requested Deny Responsible Party: Governing body Credentials Committee of the Board 153 Adverse Recommendation Applicant may be entitled to a hearing and/or an appeal Due process is defined in bylaws Negative decisions must be reported to state and federal bodies 154 Notification of Final Action Applicant Organizational departments Key stakeholders Department chairs VPMA/CMO Expedited Approval Process Governing body may provide for an expedited process May delegate the authority to render decisions to a committee of at least two voting members of the governing body

27 Expedited Approval Process Governing body may provide for an expedited process for initial appointment, reappointment, and granting privileges Applicants must meet established criteria Applicant ineligible if application is incomplete Applicant ineligible if MEC makes a recommendation that is adverse or has limitations Applicant evaluated on a case by case basis dependent on history of challenges to license, medical staff membership, privileges, and malpractice history Session 5: Other Processes Related to Initial Appointment At the end of this session, you will be able to: Identify the circumstances under which the pre application process may be useful Identify onboarding activities appropriate to your facility Pre application Onboarding Related Processes Pre Screen applicants not meeting minimal requirements Avoids completion of an application No verification process No recommendation/action No required reporting 161 Onboarding Organizations vary. Onboarding may include: Assisting practitioner in applying for licensure, DEA, CDS Enrolling practitioner in applicable health plans Orienting practitioner Facility Medical record methodologies FPPE Pertinent rules and responsibilities, etc. Communicating practitioner demographics and privileges to appropriate individuals

28 Activity #8: Quiz Day Two Day 2 Module 5 Basics of Privileging Module 6 Performance Monitoring/OPPE/FPPE Module 7 Reappointment, Reappraisal, and/or Renewal of Privileges Module 8 Credentialing Challenges Module 5: Basics of Privileging Session 1: Develop Structure Session 2: Gather & Verify Information Session 3: Assess and Recommend Action Session 4: Act Upon Recommendation Session 5: Other Issues Session 1: Develop Structure At the end of this session, you will be able to: Describe CMS and TJC requirements related to clinical privileging Describe differences between privileging delineation systems Describe clinical criteria applicable to a specialty and/or procedure to recommend privileges

29 Session 1: Develop Structure What would be considered a Phase 1 activity for privileging? Process: Bylaws, Rules & Regulations, Policies Documents Delineation of Privileges (DOP) Responsible Party: Medical staff leaders Governing body 169 Delineation of Privileges System Three main users of the DOPs: Medical staff leadership Design and implement Applicant/reapplicant Nursing and ancillary staff Operating room Emergency room Labor and delivery Cardiac catheterization laboratory Radiology special procedures room 170 Delineation of Privileges System Should be: Based on services provided (or soon to be provided) at the facility/location Based on defined criteria Training Experience Demonstrated current competence Methodology varies (core privileging vs. laundry list) Please see Appendix F. Delineation of Privileges System CMS Regulations Criteria should include at least: Individual character Individual competence Individual training Individual experience Individual judgment Ability to perform privileges requested Delineation of Privileges System TJC Regulations Criteria should include at least evaluation of: PSV for current licensure or certification PSV of relevant training Evidence of ability to perform requested privilege Data from previous professional practice review from other organizations Recommendations from peers/faculty Review of performance within the hospital (applicable at renewal of privileges) Additional Considerations Approval of Forms Privilege Form Maintenance

30 Development of New Criteria New technology or procedure New clinical service New specialist New Privileges & Criteria First, determine if there is a policy in place outlining a medical staff process for considering new privileges New Privileges & Criteria Suggested policy components: What training/experience is required? Does this privilege cross specialty lines? Are there any other requirements? CME, board certification, specialized training course, peer recommendations What monitoring will be required? Resources for Criteria ACGME Residency Program Requirements ( See Appendix G Activity #9: Case Study Case Study #10 Dr. Arrhythmia

31 Session 2: Gather & Verify Information At the end of this session, participants will be able to: List the verification elements necessary to evaluate clinical competence Session 2: Gather & Verify Information What would be considered a Phase 2 activity for privileging? Process: Verify education, training, experience, current clinical activity, competence, etc. Compare applicant s qualifications with applicable established criteria Identify variance between applicant s stated qualifications, verifications received, and established criteria Evaluate evidence of clinical outcomes Session 2: Gather & Verify Information Responsible Party: Credentialing professional Medical staff leaders Privileging Process Documented, objective, evidence based Consistently applied Approval process usually mirrors application approval process Continually monitored (FPPE/OPPE) Session 3: Assess and Recommend Action At the end of this session, participants will be able to: Describe the medical staff s leadership role in the privileging process Distinguish between the medical staff s role and the board s role in the privileging process

32 Session 3: Assess and Recommend Action What would be considered a Phase 3 activity for privileging? Session 3: Assess and Recommend Action Responsible Party: Medical staff leaders Process: Compare information provided by the applicant against data gathered and identify inconsistencies Assess applicant s qualifications against predetermined criteria Interview applicant (optional) Determine follow up required to resolve inconsistencies Recommend action Activity #10 Case Studies #11 # Session 4: Phase 4: Act Upon Medical Staff Recommendation At the end of this session, participants will be able to: Describe the board s leadership role in the privileging process Distinguish between the board s role and the medical staff s role in the privileging process 191 Session 4: Phase 4: Act Upon Medical Staff Recommendation What would be considered a Phase 4 activity for an initial appointment? Process: Approve Grant Reapplication Modify Privileges Requested Deny Responsible Party: Governing body Credentials Committee of the Board

33 Session 5: Other Issues At the end of this session, participants will be able to: Evaluate current medical staff policies regarding emergency and temporary privileges to determine whether they are in compliance with The Joint Commission standards Session 5: Other Issues Emergency privileges Temporary privileges Defined in: Bylaws DOP forms Emergency Privileges Temporary Privileges The Joint Commission Who Can Grant? CEO upon recommendation of the medical staff president/designee Temporary Privileges The Joint Commission Under What Circumstances Can TP Be Granted? Patient care need Pendency of an application

34 Temporary Privileges The Joint Commission What Verification Is Necessary? Patient care need Current licensure and current competence Pendency of applicationcompleted, verified application awaiting review and approval by the organized medical staff Temporary Privileges The Joint Commission For How Long Can Temporary Privileges Be Granted? Patient care need medical staff bylaws define time period Pendency of application no more than 120 days Activity #11: Temporary Privileges St. Mary s CEO enters the MSSD on the Friday afternoon before the July 4 holiday and says, We need this anesthesiologist credentialed by tomorrow. What does the MSP do? What policies and procedures should be in place to assist the MSP? Activity #11: Temporary Privileges Review sample bylaws and scenarios Discuss whether or not it is appropriate to grant temporary privileges Discuss what information needs to be verified to meet TJC standards and bylaws Module 6: Performance Monitoring/ OPPE/FPPE

35 Performance Monitoring/OPPE/FPPE At the end of this module, participants will be able to: Identify the CMS or TJC performance monitoring requirements applicable to their facilities Determine their organization s compliance with applicable OPPE and FPPE requirements Performance Monitoring/OPPE/FPPE CMS performance monitoring requirements TJC performance monitoring requirements Ongoing Professional Practice Evaluation (OPPE) Focused Professional Practice Evaluation (FPPE) CMS Performance Monitoring Requirements Medical staff must periodically conduct appraisals of its members Timeframe at least every 24 months Purpose Membership Privileges CMS Performance Monitoring Requirements Medical staff must periodically conduct appraisals of its members. Scope: Assessment of practitioner s qualifications and demonstrated competencies: Licensure Current work practice Special education/training Quality of specific work Patient outcomes NPDB Adherence to medical CME staff bylaws, rules, policies TJC Performance Monitoring Requirements OPPE identifies professional practice trends that impact quality and patient safety. Clearly defined process Data collected determined by individual departments Review of operative or other clinical procedures and outcomes Pattern of blood and pharmaceutical usage Requests for tests and procedures Length of stay patterns Morbidity and mortality data Use of consultants 209 TJC Performance Monitoring Requirements OPPE processes include: Periodic chart review Direct observation Monitoring of diagnostic and treatment techniques Discussion with others involved in the patient s care

36 TJC Performance Monitoring Requirements OPPE information is factored into decisions re: Maintain existing privilege(s) Revise existing privilege(s) Revoke an existing privilege prior to or at the time of renewal TJC Performance Monitoring Requirements Focused Professional Practice Evaluation (FPPE) Focus on practitioner for cause New applicant to confirm competence See Appendix H TJC Performance Monitoring Requirements FPPE New Privileges Clearly defined policy Requires practitioner to utilize the hospital Concurrent and/or retrospective review Time limited Should utilize OPPE measurements Activity #12: Performance Monitoring What would an FPPE plan look like for a: Emergency medicine physician? General surgeon? Family practitioner? OB GYN Joining a busy practice? Opening an office independently? Module 7: Reappointment, Reappraisal, and/or Renewal of Privileges Session 1: Phase 1 Develop Structure Session 2: Phase 2 Gather & Verify Information Session 3: Phase 3 Assess and Recommend Session 4: Phase 4 Act Upon Recommendation Session 5: Challenges to Reappointment/ Reappraisal/Renewal of Privileges

37 Session 1: Phase 1: Develop Structure At the end of this session, you will be able to: Structure the reappointment, reappraisal, and/or renewal of privileges process in accordance with medical staff documents Evaluate the current medical staff reapplication for compliance with CMS and TJC standards 217 Session 1: Phase 1: Develop Structure What would be considered a Phase 1 activity for reappointment, reappraisal, and/or renewal of privileges? Process: Bylaws, Rules & Regulations, Policies Documents Reapplication Delineation of privileges (DOP) Clinical profiles Professional reference questionnaire 218 Session 1: Phase 1: Develop Structure Responsible Party: Medical staff leaders Governing body Session 2: Phase 2: Gather & Verify Information At the end of this session, you will be able to: List the CMS and TJC requirements for credentials verification for the reapplicant Distinguish between required verification elements and industry best practices 221 Session 2: Phase 2: Gather & Verify Information What would be considered a Phase 2 activity for reappointment, reappraisal, and/or renewal of privileges? Process: Reapplications sent and returned on time Completed within 2 years Verify pertinent education, training, experience, current clinical activity, competence, etc. Identify discrepancies between information provided and data gathered Compare reapplicant s qualifications with applicable established criteria Follow up red flags

38 Session 2: Phase 2: Gather & Verify Information Responsible Party: Credentialing professional Medical staff leaders Supporting Documentation Copy of license only if required DEA/CDS Professional liability insurance face sheet Clinical privileges request CME Peer recommendations only if needed Clinical profile Statement attesting to applicant s ability to perform privileges requested Activity #13: Verification Red Flags Licensure Peer references DEA Registration/Controlled Ability to perform privileges requested Substance Professional liability Specialty Board coverage Certification Malpractice history Federal and State (last 2 years) Sanctions Criminal background NPDB/HIPDB check (as applicable) Current Competency Other Discrepancies between information on reapplication and response from written/oral verifications Suspended, revoked, reduced: Hospital privileges License DEA Red Flags Insurance cancelled/excessive claims, trends of complaints Insufficient performance monitoring/oppe data Low/no volume practitioner

39 Session 3: Phase 3: Assess and Recommend Action At the end of this session, participants will be able to: Describe the medical staff s leadership role in the reappointment, reappraisal, and/or renewal of privileges process Distinguish between the medical staff s role and the board s role in the reappointment, reappraisal and/or renewal of privileges process 229 Session 3: Phase 3: Assess and Recommend Action What would be considered a Phase 3 activity for reappointment, reappraisal and/or renewal of privileges? Process: Compare information provided by the reapplicant against data gathered and identify inconsistencies Assess reapplicant s qualifications against predetermined criteria Interview reapplicant as needed Determine follow up required to resolve inconsistencies Recommend action 230 Session 3: Phase 3: Assess and Recommend Action Responsible Party: Medical staff leaders Activity #14: Reappointment and/or Renewal of Privileges Dilemmas Case Studies #16 # Session 4: Phase 4: Act Upon Medical Staff Recommendation At the end of this session, participants will be able to: Describe the board s role in the reappointment, reappraisal and/or renewal of privileges process Distinguish between the board s role and the medical staff s role in the reappointment, reappraisal and/or renewal of privileges process

40 Session 4: Phase 4: Act Upon Medical Staff Recommendation What would be considered a Phase 4 activity for reappointment, reappraisal, and/or renewal of privileges? Process: Approve Grant Reapplication Modify Privileges Requested Deny Responsible Party: Governing body Credentials Committee of the Board Session 5: Reappointment/Renewal of Privileges Challenges At the end of this session, you will be able to: Evaluate current reappointment/renewal of privileges methodologies to ensure the process is completed on time Identify low/no volume practitioners in your facilities Identify appropriate membership and/or privileging strategies and criteria to apply to low/no volume practitioners Challenges to Reappointment, Reappraisal, and/or Renewal of Privileges Challenges Completing the process prior to expiration of the current appointment Low/no volume practitioners Timely Reappointment, Reappraisal, &/or Renewal of Privileges Start early Stagger reappointment/reappraisal/renewal Establish deadlines then enforce them! Consider rewards and penalties for late applications Reappoint based upon calendar dates not on board approval dates Activity #15: Case Study Case Study #23: Low/no Volume Practitioners

41 Low/No Volume Practitioners Determine if the practitioner has sufficient volume elsewhere Obtain information on reapplication regarding practice elsewhere Contact other institutions for competence information as available Low/No Volume Practitioners Determine if the practitioner is in a low/no volume specialty (dermatology, allergy) Secure professional references as appropriate Low/No Volume Practitioners Develop a strategic approach Membership Privileges Low/No Volume Practitioners Utilize FPPE to confirm competence Module 8 Credentialing Challenges Session 1: Disaster Privileges Session 2: Telemedicine Privileges Session 3: Responding to Reference Requests From Other Hospitals Session 4: Allied Health Practitioners (AHPs) Session 5: Document Retention and Confidentiality

42 Session 1: Disaster Privileges At the end of this session, you will be able to: Describe TJC requirements pertaining to granting disaster privileges Session 1: Disaster Privileges Included in Emergency Operations Plan Defined in medical staff governance documents Define requirements for credentialing Includes mechanism for oversight of volunteers Volunteers should only function within the scope of their license/certification Session 2: Telemedicine At the end of this session, you will be able to: Describe the recent changes in privileging requirements for telemedicine practitioners from CMS and TJC Session 2: Telemedicine What Is Telemedicine? Telemedicine is the use of medical information exchanged from one site to another via electronic communications Is Telemedicine a Separate Specialty? It is not a separate medical specialty just another way of providing services What Are Common Examples of Telemedicine Services? Session 2: Telemedicine What Is the Originating Site? The originating site is the site where the patient is located at the time the service is provided. What Is the Distant Site? The distant site is the site where the practitioner providing the professional service is located

43 Why Use Telemedicine? Access to Providers Provide healthcare and services that would not be available otherwise Specialty care consultations for isolated specialists, practitioners Eliminate Expensive Travel Reduce Need to Move Patient Provide CME for Isolated Healthcare Providers Telemedicine Requirements Telemedicine Standards Are Very Complex Read carefully the standards that apply to your organization. Apply your organization s specific circumstances to the applicable (CMS or TJC) standards Telemedicine Requirements CMS Overview New Requirements Announced 5/5/11 Effective 7/5/11 Telemedicine Requirements CMS Overview Requires written agreement with: Distant site hospital that participates in Medicare OR Distant site telemedicine entity Provides services that allow the hospital to meet all applicable CoPs related to credentialing and privileging telemedicine practitioners Telemedicine Requirements CMS Overview Examples of telemedicine services provided Simultaneous: Clinical services provided in real time similar to onsite practitioner Assessment of patient, including plan of treatment and medical orders (Example: telelcu services) Telemedicine Requirements CMS Overview Examples of telemedicine services provided Non simultaneous: Clinical services provided upon request of a physician but involves after the fact delivery of services similar to an on site radiologist Interpretation of diagnostic tests to provide assessment of patient s condition (Example: teleradiology services)

44 Telemedicine Requirements CMS Overview Written agreement requires the hospital receiving the telemedicine services to Grant privileges appropriate to the capabilities of telecommunication systems Telemedicine Requirements CMS Overview The governing body of the hospital receiving the telemedicine services may opt to: 1) Credential and privilege telemedicine practitioners as any other privileged practitioner OR Telemedicine Requirements CMS Overview 2) Consider MS recommendations that rely on credentialing and privileging decisions of the distant site In this instance, the hospital may have a single file for all practitioners covered by each agreement that includes the telemedicine services privileges granted to each practitioner Telemedicine Requirements CMS Overview If the GB chooses to consider MS recommendations that rely on credentialing and privileging decisions of the distant site, a written agreement requires: 1. Distant site is a Medicare participating hospital OR a telemedicine entity compliant with the hospital CoPs related to credentialing and privileging 2. Distant site has privileged the practitioner and provides a current list of the practitioner s privileges Telemedicine Requirements CMS Overview 3. The practitioner has a license in the state where the hospital is located 4. The hospital has evidence of internal review of the practitioner s performance and sends the information to the distant site hospital for use in periodic appraisal of the practitioner At a minimum, adverse events resultant from the services provided All complaints regarding the practitioner Telemedicine Requirements The Joint Commission Overview New requirements effective 8/1/11 Pre publication version subject to CMS review and approval Final version anticipated in the fall Requirements stated Leadership (LD) chapter Medical Staff (MS) chapter

45 Telemedicine Requirements The Joint Commission Overview LD requirements Clinical leaders and MS provide advice re: sources of contracted clinical services Contract describes nature and scope of services Telemedicine Requirements The Joint Commission Overview LD requirements continued Services are monitored by establishing and evaluating performance expectations Originating site governing body grants privileges based on MS recommendations that rely on information from distant site Telemedicine Requirements The Joint Commission Overview Telemedicine Requirements The Joint Commission Overview MS requirements for originating site: All LIPs are credentialed and privileged by one of the following three routes: 1. Fully credentialing & privileging the practitioner in accordance with MS standards 2. Utilizing the credentialing information from a distant site of a TJC accredited organization 3. Utilizing the credentialing and privileging decision of the distant site if: a) Distant site is TJC accredited hospital or ambulatory care org (following TJC MS requirements) b) Distant site has privileged the practitioner for the requested services c) Distant site provides a current list of the LIP s privileges Telemedicine Requirements The Joint Commission Overview d) Originating site performs internal review of the practitioner s performance and provides distant site information useful to assess the individual s performance Information is used in privileging and performance improvement by distant site Must include all adverse outcomes (sentinel events) Complaints from patients, LIPs, or staff

46 Session 3: Responding to Reference Requests From Other Hospitals At the end of this session, participants will be able to: Complete a professional reference on each practitioner as they leave the organization Activity #16: Case Study Case Study #24 Departed Anesthesiologist Reference The Solution Setting a national best practice: Forevermore professional references Forevermore Reference Policy: Steps to Implementation Educate medical staff and senior management re: best practice Accurate and timely documentation of practitioner performance Effective and efficient use of MSL & MSP resources Secure champions Develop policy Forevermore Reference Policy Content When would the reference form be completed? What information is provided? What form is utilized? Who completes the professional reference? How should negative responses be managed? Where should the response be kept?

47 Session 4: Allied Health Practitioners At the end of this session, participants will be able to: Distinguish between the CMS and TJC requirements regarding credentialing allied health practitioners Privileged Non privileged 277 Session 4: Allied Health Practitioners CMS requirements: Governing body in accordance with state law may appoint and/or privilege non physician practitioners* upon recommendation of the medical staff Credentialing and privileging processes would be essentially the same as a physician applicant *NPs, CRNAs, CNMs, CNSs and PAs 278 Allied Health Practitioners CMS requirements: CMS requirements apply consistently to all privileged practitioners CMS specifically requires privileging for surgical procedures CMS Privileging Requirement (a)(4) Surgical privileges must be delineated for all practitioners performing surgery in accordance with the competencies of each practitioner. The surgical service must maintain a roster of practitioners specifying the surgical privileges of each practitioner CMS Privileging Requirement CMS relies upon the definition of surgery developed by the American College of Surgeons to determine whether or not a procedure constitutes surgery. CMS Privileging Requirement Thus, individuals performing these surgical functions need privileges through the medical staff process Examples: Nurse First Assistant at surgery (RNFAs) Surgical Assistants (SAs)

48 Allied Health Practitioners TJC requirements: All licensed independent practitioners (LIPs) must be privileged All APRNs and PAs, whether an LIP or not, must be privileged therefore all processes apply Advanced Practice Professionals Special Considerations Supervisory/collaborative agreements Clearly defining collaborative and supervisory responsibilities on privilege forms Non Privileged AHPs The Joint Commission Credentialing processes defined in Human Resources section of the Standards Privileging does not apply Requires a separate policy Credentials verification equivalent to HR policies Scope of responsibilities need to be specifically defined Periodic competence assessment performed consistent with hospital employees Activity #17: Privileged/Non Privileged Podiatrist Psychologist Osteopathic Physician Nurse Practitioner Nurse Anesthetist Nurse Midwife Dialysis Nurse RN First Assistant Occupational Therapist Physical Therapist Physician Assistant Social Worker Audiologist Dentist Office Nurse Optometrist Clinical Nurse Specialist Physicist Neurodiagnostic Technician Surgical Assistant Session 5: Document Retention and Confidentiality At the end of this session, participants will be able to: Identify the pertinent elements of a document retention and confidentiality policy and apply them to their own facility

49 Session 5: Document Retention and Confidentiality Factors influencing policy New technologies State statutes Document Retention Policy should address: Description of credentials file content Management of protected peer review documents Description of control and security mechanisms Retention timeframe and methodology Location of inactive files Purging of information Confidentiality Policy must address: Scope Responsible party Immunity and indemnification Signed confidentiality statement requirements Location and security precautions Identification system (passwords) Access control Document Confidentiality Policy Policy should address: What can be provided What type of consent is necessary Who has access to records Who is responsible for administering policy What information can be provided without a consent form What information may be copied, and under what circumstances Course Summary

50 How to Survive as a Medical Services Professional 295 What Attributes Do You Need to Survive as a Medical Services Professional? Communication skills Organizational skills Thirst for knowledge Flexibility Efficiency Trustworthiness Detail orientation Tenacity 296 What Do You Need to Do to Survive as a Medical Services Professional? Be a patient advocate Be a hospital advocate Be a physician advocate Develop good people skills Keep knowledge current Compliance Best practices 297 What Do You Need to Do to Survive as a Medical Services Professional? Be a resource to: Medical staff Senior management Organization departments Know the pertinent governance documents Bylaws Policies Rules and Regulations Be ethical Hold all matters confidential 298 What Do You Need to Do to Survive as a Medical Services Professional? Learn from every one and every circumstance Be as organized as possible Do not become an urgency addict Ask for help when needed Cultivate relationships Networking What Do You Need to Do to Survive as a Medical Services Professional? Become as efficient as possible Learn how to research Use the Internet Develop good data and professional resources Embrace technology Stay abreast of changes

51 What Do You Need to Do to Survive as a Medical Services Professional? Anticipate change Pick your battles Identify the hills you are willing to die on Learn to manage stress! Resources for Learning NAMSS State Association Local Chapter Regulatory & Accreditation Standards American College of Graduate Medical Education (ACGME) Accreditation Council for Continuing Medical Education (ACCME)