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Debra R. Green, MPA, CPMSM, CPCS Director, Medical Staff Services and General Pediatric Residency Program Stanford University Medical Center Stanford Hospital & Clinics Lucile Packard Children’s Hospital

2 Background Director of Medical Staff Services and Pediatric Residency Program for Stanford University Medical Center which includes Stanford Hospital and Clinics and Lucile Packard Children’s hospital in Palo Alto, CA. Oversight of a combined medical staff of approximately physicians, 300+ Advanced Practice Professionals and 78 General Pediatric Residents. CPMSM and CPCS in addition to a Masters of Public Administration(MPA) degree with a concentration in Health Care Management and Policy 20+ years of healthcare administrative experience; primarily academic. Held previous leadership positions in New Jersey and Michigan. Served as an Expert Witness in negligent credentialing and privileging legal cases NAMSS Director at Large on the NAMSS Board for 5 consecutive years.

3 Objectives Overview of the main regulatory bodies
Who they are? What they do? Why they exist? Overview of Credentialing/Privileging Standards Requirements Compliance

4 Center for Medicare/Medicaid (CMS)
Who are they? Government Organization Surveyors are typically State DOH employees Gives deeming authority to TJC, HFAP and DNV What do they do? Validate TJC Can Survey For Cause Why do they exist? To ensure patient care and quality

5 The Joint Commission (TJC)
Who are they? Private Organization What do they do? - Unannounced Surveys - Tracer Methodology - Can Survey “For Cause” Why do they exist? To ensure patient care and quality

6 Other Authorities Deemed by CMS
Healthcare Facilities Accreditation Program (HFAP) Deemed Authority since 1965 Surveyors are experienced healthcare professionals Recognized by Fed Gov, State DOH, Ins Carriers and Managed Care Organizations (MCO) Surveys are unannounced Det Norske Veritas Healthcare, Inc (DNV) Deemed status since 9/08 Certifies other companies in additional to healthcare Existed since (began in Norway) in US since 1898 World wide reputation for quality and integrity

7 National Committee for Quality Assurance (NCQA)
Who are they? Private Organization What do they do? Accredits: MCO’s, MBHO’s, PPO’s, NHP’s etc. Certifies: CVO’s Delegated Credentialing Agreements Hospital does the work for MCO or Health Plan

8 The Accreditation Association for Ambulatory Health (AAAHC)
Who are they? Private Organization, non-profit What do they do? - Accredit Ambulatory Healthcare Organizations, Surgery Centers, Community Health Centers and Medical/Dental Group Practices - US Air Force and Coast Guard Why do they exist? To promote patient safety, quality and value for Ambulatory health care

9 URAC Who are they? What do they do?
Private Organization, non-profit What do they do? - Accredit Health Plans and Preferred Provider Organizations (PPO) Why do they exist? To promote healthcare quality through accreditation education and measurement programs

10 Verification of Medical Education
TJC NCQA HFAP URAC/AAAHC DNV/CMS (I) Primary Source verification from Medical School Alternate sources: AMA, AOA, ECFMG AAPA for PA’s (I) Primary source verification of (Highest Level of Credentials) Alternate sources: AMA, AOA, ECFMG (for foreign grads after 1986), state licensing agency (if the state performs PSV) FCVS for closed residency programs (I) Primary Source Verification of Medical Education Must be significant to support request for privileges Alternate sources: AMA, AOA, ECFMG (after 1986), state licensing agency URAC – (I) PSV required History of education and training included on app Can use the state lic Board as a PSV AAAHC – (I) PSV required No alternative sources noted. DNV (I) Primary Source Verification of Medical Education Requirements must be outlined in Bylaws CMS – Not specially addressed in standards (doesn’t mean its not required)

11 Post Graduate Training
TJC NCQA HFAP URAC/AAAHC DNV (I) PSV required from primary source or equivalent source Alternate sources: AMA, AOA (I) PSV Highest level of credentials (i.e. board certification) AMA, AOA, state licensing agency, transcripts (sealed), FCVS for closed programs (I) PSV of Training required Documentation must support requested Privileges Alternate Sources: AMA, AOA, URAC – (I) PSV required only if not board certified History of Education Required on app Can use the state lic board as a PSV AAAHC – (I) PSV required No alternative sources noted. DNV - Bylaws include criteria for determining privileges including, specific training requirements CMS – Not specifically addressed in standards (doesn’t mean its not required)

(R) Required if there is insufficient practitioner-specific data available Peer with knowledge of applicant Recommendations should address clinical competence and ability to perform privileges 6 General Competencies (I&R) Peer Review through Credentials Committee with representation from similar types and degrees of expertise (I) Obtain at least 1 peer with the same professional Credential Assessment of physical and mental health in relation to privileges requested. (R) Individual letters not required, can be obtained through PR, Cred Com, Dept Chair or MEC URAC – No specific requirement AAAHC – (I &R) Peer recommendation required DNV- 2 Peer recommendations at (I). Nothing in the standards assess Peer References at (R) CMS – Not specially addressed

13 Work/Affiliation History Verifications
How many organizations perform Work/Affiliation History Verifications?

14 Work/Affiliation History
TJC NCQA HFAP URAC/AAAHC DNV/CMS There is no specific requirement for verification of work history. The standards require, at the time of appointment to membership and initial granting of privileges, verification of relevant training or experience must be obtained from the primary source (s) whenever feasible. PSV not required. A minimum of five years of relevant work history must be obtained through the practitioner’s application or curriculum vitae. Gaps exceeding six months must be reviewed and clarified either verbally or in writing. (I) PSV Required Verification of where the applicant previously had privileges with confirmation of the applicant’s appointment and privilege history, and any pending investigations of disciplinary actions, voluntary resignations, or relinquishments of membership/clinical privileges URAC – Not addressed in standards AAAHC – (I) Reviewed for continuity and relevance. Document interruptions in practice DNV – Not addressed in standards. CMS – Not addressed in standards

Clearly documented process for granting Evidence of Physical Ability to perform requested privileges Grant or Deny must be objective and evidence based Must be criteria based No requirement for privileges Must be consistent with demonstrated competency Criteria based Surgical privileges must be delineated based on individual competency URAC – Privileges must be included in the application AAAHC – Reviewed and approved by the governing body DNV Criteria Based Practice within scope CMS All patients must be under the care of a practitioner with privileges Privileges can only be granted by the hospitals governing body Assess ability to perform

16 Temporary Privileges TJC NCQA HFAP DNV/CMS URAC/AAAHC
Can be granted under 2 conditions: 1. Urgent patient care need for limited time (PSV current license, NPDB and competency evaluation req) 2. New apps waiting for MS review and after a complete application and All verifications are complete Note: No challenges to license, membership or privileges Process for “provisional credentialing” for first time providers PVS of license, NPDB, completed application with signed attestation File must be valid and verified and approved by Medical Director or qualified physician Must not exceed 60 days Bylaws provide for the granting of temporary privileges: 1. During review and consideration of application. 2. For care of specific patient 3. For locum tenens. 4. For times of emergency or disaster. PSV of Lic, DEA, Insurance and 1 Ref from previous facility req URAC – Organization can grant “Provisional” Participation status for a limited time when justified by continuity or quality of care issues on approval of senior clinical staff person. AAAHC – Not specifically addressed. DNV Urgent Pt Care Complete app w/o negative or adverse info Not to exceed 30 days Verification of Lic, competence, Ref and AMA (education), NPDB and OIG CMS Not addressed

17 Ongoing Performance Monitoring
TJC NCQA HFAP URAC/AAAHC DNV/CMS FPPE – Focused evaluation (i.e. Proctoring) (R) OPPE – Ongoing Evaluation (i.e. data assessment for everyone) Added in MS Chapter in 2008 Not addressed URAC AAAHC DNV CMS Not Addressed

(I & R) Doctor must provide information regarding previously successful or currently pending challenges or relinquishment of registrations (I & R) Verify through copy of certificates, NTIS, AMA State CDS certificates must be verified, where applicable (I&R) Application includes actions against DEA/CDS URAC – (I&R)Evidence of current DEA/CDS May collect a copy of certificate or certificate # Must be verified within 6 months of review and approval AAAHC – (I) evaluated at initial appmt and monitored continually DNV (I &R) Provider must provide current DEA # CMS Not Addressed

TJC NCQA HFAP URAC/AAAHC DNV/CMS (I & R) LIPS must participate in Continuing Education Documented Considered in Privilege process Should be relevant to clinical privileges requested Not Addressed May request evidence of CME every 2 years URAC AAAHC Not Addressed for Medical Staff Members DNV Should participate in CME related to privileges CME should be considered at reappointment CMS Not addressed

TJC NCQA HFAP URAC/AAAHC DNV/CMS Not required unless outlined in bylaws Most hospitals require it Primary source verification not required (I & R) Attestation by doctor or copy of policy showing dates and amount of coverage or Face Sheet from the carrier Federal Tort letter or attestation from practitioner of Fed Tort is ok Must have evidence of PLI coverage Must have current certificates showing amount (s) of coverage URAC – Proof of PLI included on application A cover sheet or attestation from ins company is sufficient to prove coverage AAAHC – Req only if organization requires it Review information related to refused or cancelled coverage at (I&R) DNV Not addressed CMS

(I & R) evaluate evidence of “unusual pattern” or “excessive” number of actions resulting in a final judgment. (I & R) Attestation by doctor or copy of policy showing dates and amount of coverage or Face Sheet Verify history of claims that result in a settlement paid by or on behalf of the practitioner Confirm via NPDB or carrier last 5 years of settlements (I&R) Doctor must provide malpractice history for past five years. Organization verify history that resulted in settlements or judgments paid for practitioner. Verified through carrier or NPDB URAC – provider must include claims history on app AAAHC - provider must include claims history on app and evaluated DNV (I&R) organization must review involvement in any action CMS Not addressed

TJC NCQA HFAP URAC/AAAHC DNV/CMS Must query at granting of initial, renewal and when a new privilege is requested. Query if you can’t obtained last 5 years of claims from Insurance carriers. Use as alternate source for sanctions or limitations on licensure Must query at granting of initial and renewal URAC - Not required, but can be used to verify license and Medicare and Medicaid sanctions AAAHC - required at (I & R). PDS is acceptable. DNV (I) required only if Temporary Privileges are requested CMS Not addressed

Terminology is not used in Medical Staff Standards Required under HR Hospital Standards Not specially addressed Application must attest to his/her history of loss of license and felony conviction and lack of illegal drug use. *Attestation Statement Application must request information regarding any criminal history. Investigation must be conducted based on information provided on the application. URAC –Not specially addressed AAAHC - Not specially addressed DNV Required only if State requires it CMS

Verification not required unless bylaws /policy require board certification Organization Specific Verify through ABMS, AMA, AOA or specialty board Not required, but if practitioner says they are Board Certified, it must be verified (R) Required to determine if still current Verify Through ABMS, AMA, AOA, state licensing agency if confirmed by licensing board (I) Not required, but if practitioner says they are Board Certified, it must be verified URAC - Not required but verify if practitioner states they are board certified AAAHC – Verify on initial application and ongoing basis DNV Not addressed CMS

TJC NCQA HFAP URAC/AAAHC DNV/CMS May not exceed 2 years At least every 36 months Counts the 36 month cycle to the month, not to the day. (i.e Jan 5, 2007 to Jan 29, 2010 is ok) URAC - At least every 36 months Counts the 36 month cycle to Month AND day. (i.e Jan 5, 2007 to Jan 28, 2010 is NOT ok) it must be Jan 5 to Jan 5 every 3 yrs AAAHC – as defined by state law, not to exceed 3 years DNV May not exceed 3 years (defined by state law) CMS Recommends every 24 months

(I & R) Primary source verification required at initial appointment, reappointment, revision of privileges and at time of expiration Current and Valid Verify through state licensing board (I & R) Primary source verification Must be current and valid In effect at time of credentialing decision Verify through state license board (I & R) Primary source verification required URAC – (I&R) PSV required Current and valid AAAHC – (I&R) PSV required DNV CMS Not specifically addressed in standards

(I & R) The doctor must provide information regarding challenges or relinquishment of license *Attestation question State Licensing Board FSMB can used as PSV (I & R) Primary source verification required Verify through state licensing board NPDB/PDS and FSMB can be used as PSV Application must include current or pending challenges (I & R) Must be reviewed for each applicant FSMB and FACIS can be used at PSV URAC – History of sanctions should include at least a 5 yr history NBDB can be used AAAHC – review of sanctions required at (I&R) DNV Addressed for TP only CMS Not specifically addressed

TJC NCQA HFAP URAC/AAAHC DNV/CMS Not addressed (I&R) Current or previous sanctions must be verified Ongoing Monitoring required between re-credentialing cycles Verify through AMA, NPDB, OIG, FSMB, FEHB, State Medicaid Agency Application must request information regarding Medicare Medicaid Sanctions URAC Must be reported on application Can use NPDB as PSV AAAHC Must be disclosed and reported on application as well as evaluated at (I&R) DNV (I) Must be reviewed before Temporary Privileges are granted. CMS Not Specifically addressed

Disaster privileges may be granted to volunteer LIPs when the Emergency Operations Plan has been activated *removed from the MS Chapter, it now resides in EM Not specifically addressed. The hospital has a plan for dealing with clinical volunteers during emergency /disaster. This plan should provide for primary source ID from the volunteer’s hospital (A documented phone call is acceptable). The hospital should use volunteers as appropriate within the scope of their license/certification. URAC Not specifically addressed. AAAHC When hospitalization is needed due to emergencies, the organization may have a policy for credentialing and privileging physicians and dentists who have admitting privileges at a nearby hospital. DNV Identification, availability and notification of personnel that are needed to implement and carry out the hospital’s emergency plans should be considered when developing the Comprehensive emergency plans. CMS

30 Compliance Tips and Tools #1
Be prepared to implement disaster privileges in the event of an Emergency ……develop a process, not just a policy Tool # 2 – Disaster Credentialing Tool Kit

31 Disaster Credentialing Tool Kit
Includes: Disaster Credentialing Policy Employee Roster with Phone #s Disaster Privileging Tracking Logs (multiple copies) Disaster Privilege Forms (multiple copies) Excerpt from Bylaws regarding Disaster Privileges List of Links for licensure verification Written process for staff to follow Name Badges Markers Ink Pens

To be completed by Medical staff services  L Name F Name MD, DO, NP, PA, DDS, DPM, PHD Specialty Lic # Type ID Provided (See Key – A required) Lic Verified (Date) Verified In 72 hrs Y/N MS Member PRIV FORM COMP SAMPLE DOCTOR MD MED 123456 A, B 1/1/09 Y N ID Type Key A – Govt issued ID – REQUIRED B – ID from another HC Org C – License to practice D – ID from DMAT/MRC/ESARVHP E – ID from Govt entity granting authority to provide care F – Confirmation from another Medical Staff Member


34 Health Status Assessment
TJC NCQA HFAP URAC/AAAHC DNV/CMS Applicant must submit a statement that no health problems exist that could affect clinical privileges Confirmed by PD, Chief of Service or COS or at another hospital at (I) appmt or a Peer already on staff. Medical staff must evaluate prior to recommending privileges. Current signed attestation from the applicant attesting there are no health issues. Documentation of Health Status included in Professional references Can be a statement regarding the applicants physical or mental health status related to privileges requested. URAC Application must include a question about physical mental or substance abuse problems AAAHC Organization requires and reviews issues regarding physical, mental and chemical dependency DNV Not specifically addressed CMS

35 Allied Health Professionals
TJC NCQA HFAP URAC/AAAHC DNV/CMS TJC does not use the term “allied health professionals.” It refers to LIPs and Non-LIPs. PAs and APRNs must be credentialed, privileged, and re-privileged through the medical staff process or an equivalent process that has been approved by the governing body. Equivalent Defined as: Evaluate credentials, Current competence, Peer recommendations and input from committees including MEC to make a decision about privileges. Non-physician practitioners who have an independent relationship with the organization and provide care under the organization’s medical benefits must be credentialed. All practitioners providing medical care or conducting surgical procedures either directly or under supervision, whether employed by the hospital, a physician, or a contracted provider must be credentialed. Annual competency/skill assessment required URAC All practitioners who are participating providers, provide covered health care services to consumers, and appear in the organization’s provider directory are AAAHC If allowed by the organization, the board must provide a process for the (I) appointment, (R) appointment, and assignment or curtailment of privileges and practice for AHPs (based on State law and evidence of education, training, experience and competence DNV NPs, PAs, DDS, PHD’s can be considered “medical staff in accordance with state law No mention of requirement for credentialing and privileging. CMS MS must be composed of MD and DO, but in accordance with state law, NP, PA CRNA, and CNM can be appointed to MS. Physicians and non-physicians can be granted privileges

36 Applicant Identity TJC NCQA HFAP DNV and CMS URAC/AAAHC
There must be a mechanism to determine the applicant is the individual identified in the credentialing documents by viewing either a current picture hospital ID card or a valid picture ID issued by a State or Federal agency, such as a driver’s license or passport. Not specifically addressed URAC AAAHC DNV CMS

37 Attestation Statement
TJC NCQA HFAP URAC/AAAHC DNV/CMS Not specifically addressed Statement from applicant required at (I) and (R) in order to inquire about: Illegal Drug Use Inability to perform Loss of Lic/privileges Disciplinary Actions Malpractice Coverage Felony Convictions Attest that the application is correct and complete Medicare deemed Organizations: Must be signed within 180 days of final approval 365 days for non-Medicare deemed Orgs Although not specifically addressed in the standards, the Scoring Procedure for the standard reflecting the responsibilities for all credentialed practitioners instructs surveyors to review a select sampling of files to verify practitioners attest to these responsibilities at appointment and reappointment. URAC The application includes a signed and dated statement attesting that the information submitted with the application is complete and accurate to the practitioner’s knowledge. Time limit is 180 days AAAHC The application includes a signed and dated statement attesting that the information submitted with the application is complete and correct. DNV CMS

There must be a process for evaluation of the credibility of a complaint, allegation, or concern against a privileged provider. A process to monitor and investigate member complaints related to the quality of all practitioner office sites is required Must conduct site visits for complaints related to physical accessibility, physical appearance and adequacy of waiting and examining-room space based on thresholds. Implements appropriate actions and evaluate the effectiveness of those actions at least every six months, until deficient offices meet the thresholds. QAPI functions include monitoring of complaints. URAC Policy must define parameters or triggers of potential quality of care issues that require further investigation. AAAHC Not addressed DNV The hospital must develop and implement a formal grievance procedure, which includes a referral process for quality of care issues to the Utilization Review, Quality Management or Peer Review functions, as appropriate. CMS establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.

A governance standard holds the hospital’s governing body responsible to comply with applicable law and regulation. Leaders are responsible to be aware of and comply with local, State, and Federal regulations related to credentialing and privileging of practitioners. The administrative policies and procedures indicate that organizations providing managed care services must comply with applicable Federal, State, and local laws and regulations, including requirements for licensure. Thus, the organization’s leaders are responsible for any regulations relating to credentialing. Standards require compliance with applicable law and regulations. URAC Standards require compliance with all applicable Federal, State and local laws. AAAHC Standards require compliance with all applicable Federal, State and local laws. DNV CMS The governing body must assure that the medical staff has bylaws and that those bylaws comply with State and Federal law and the requirements of CoPs.

TJC NCQA HFAP URAC/AAAHC DNV/CMS Organizations that use information from a CVO should have confidence in the completeness, accuracy, and timeliness of that information. Evaluation of agency can include; processes utilized, limitations of information available, identification of primary source info versus secondary source information, quality control measure, data integrity, security and transmission. CVOs are allowed to be used and credentialing policies and procedures include the process used to delegate credentialing and re-credentialing, what can be delegated, how the decision to delegate is made. A mutually agreed upon document describing each organizations responsibilities is required HFAP refers to a Professional Credentialing Organization (PCO). PCO can be used to perform the PSV, but the process for credentialing by the organization must reflect the requirements as stated in the standards URAC The organization can delegate credentialing to a network, group or clinic organization with which they contract. Oversight is required The organization must retain the authority to make credentialing determinations and must conduct an on-site survey every three years. AAAHC CVO is allowed Assessment of CVO’s quality of work is required DNV Not specifically addressed. CMS

41 Use of Designated Equivalent Sources
TJC NCQA HFAP URAC/AAAHC DNV/CMS AMA – MD or PA Education ABMS – Board Certification ECFMG Foreign Medical Graduates AOA – DO Education and Board Certification FSMB – Licensure actions NCCPA certification NPDB – paid claims or privilege suspension/revocation NCQA does not use the language “designated equivalent sources.” The standards refer back to the specific credentialing event to determine an NCQA approved source. URAC AAAHC Refers to “secondary source” list of 20 DNV CMS Not specifically addressed

Not specifically addressed. The application must include a statement regarding felony convictions. The application requests information regarding any criminal history and a criminal background investigation is conducted based on information provided in the application or as required by Federal and State regulations. URAC Not specifically addressed. AAAHC The applicant must provide information regarding criminal convictions other than minor traffic violations. DNV Addressed CMS

43 Site Visits TJC NCQA HFAP DNV/CMS URAC/AAAHC Not required.
The organization implements appropriate interventions by conducting site visits of offices about which it has received member complaints and those for which established thresholds are exceeded. URAC AAAHC Not required DNV CMS Not Specifically addressed

44 Compliance Tips and Tools #2
Audit, Audit and More Audits!!! Tool # 3 – Credentialing Audit Forms I think that in order to sustain the culture of “Continuous readiness” we have to be prepared at all times. Back in the time before un announced surveys, we had time to review our credentials files to make sure everything was in order and correctly done before presenting them to the surveyor. We don’t have time to do that any longer. So it is important to ensure that Audits are done in order to proactively find errors and mistakes to correct them before a survey. We have multiple audits that occur: Data Audit, Self Audit and Peer Audits.

45 EMPLOYEE #123



48 Telemedicine Not addressed under: NCQA URAC AAAHC
Very detailed standards for: TJC HFAP CMS DNV

49 Telemedicine – TJC, HFAP, CMS
Prior to Last year, hospitals were required to credential and privilege all telemedicine providers at the “Distant location”. (Even Tele-radiologists in Australia). CMS changed the rule and revised the standard in Last year; published May 2011 New standard effective July 2011 Hospitals can now rely on the credentialing and privileging of “Distant Site” The Joint Commission and HFAP are derived from the CMS Distant Site: The site where the practitioner providing the telemedicine services is located. Originating Site: The location where the patient is being treated.

50 Telemedicine – TJC, HFAP, CMS
Here are the options that hospitals and CAHs have under the new rule: Option 1: Credentialing and Privileging Provided under Contract A distant-site telemedicine entity, acting as a contractor of services, furnishes its services in a manner that enables the originating-site hospital to comply with all applicable Medicare conditions of participation and standards (via contract) OR Option 2: Credentialing and Privileging Provided without a Contract The distant-site hospital providing the telemedicine services is another Medicare-participating hospital AND The individual distant-site physician or practitioner is privileged at the distant-site hospital providing telemedicine services, and that this distant-site hospital provides a current list of the physician’s or practitioner’s privileges AND The individual distant-site physician or practitioner holds a license issued or recognized by the State in which the hospital whose patients are receiving the telemedicine services is located AND The originating-site hospital has evidence of an internal review of the distant-site physician’s or practitioner’s performance under these telemedicine privileges and provides the distant-site hospital this information for use in its periodic appraisal of the individual distant site physician or practitioner. (Sounds like OPPE to me!!) OR Option 3: Originating Site Credentials and Privileges practitioners at the distant site Organizations can credential telemedicine practitioners the same way that they would credential and privilege any other practitioner who provides patient care services to patients at the organization Source: The Searcy Exchange June 2011

51 Telemedicine - DNV If the hospital contracts for telemedicine to be used including the radiology, the hospital verifies that the radiologist is licensed and/or meets the other applicable standards that are required by State or local laws in both the state where the practitioner is located and the state where the patient is located OR is subjected to the credentialing and privileging process through the medical staff to be approved for providing this service for the hospital. Criteria that includes aspects of individual character, competence, training, experience and judgment is established for the selection of individuals working for the organization, directly or under contract, and/or appointed through the formal medical staff appointment process; and, the personnel working in the organization are properly licensed or otherwise meet all applicable Federal, State and local laws. The governing body is responsible for services furnished in the hospital whether or not they are furnished under contract. The organization must evaluate and select contracted services (including all joint ventures or shared services) (and non-contracted services) entities/individuals based on their ability to supply products and/or services in accordance with the organization’s requirements. Criteria for selection, evaluation, and reevaluation shall be established. The criteria for selection will include the requirement that the contracted entity or individual to provide the products/services in a safe and effective manner and comply with all applicable NIAHO standards, and standards required for all contracted services.


53 Medical Staff Organization
Regulation: Organized medical staff ; operates under bylaws that are approved by governing body; responsible for quality of care. Compliance: Bylaws, R&R’s, Cred files, Quality Reports, Meeting minutes

54 MS Composition (a) Regulation: Compliance:
MS composed of MD’s, DO’s according to state law; may also include others appointed by Governing Body. Compliance: MS Rosters, Cred Files, Minutes or approved Bylaws categories.

55 MS Composition (a)(1) Regulation: Compliance:
MS must conduct periodic appraisals Compliance: Cred Files, Profiles, Summary Reports of Credentialing activity, Board minutes documenting last 2 appraisals

56 MS Composition (a)(2) Regulation: Compliance:
MS must examine credentials of applicants for membership and make recommendation to Board. Compliance: Definition of Creds Review Process in the Bylaws; MS minutes that document review and recommendations.

57 MS Organization & Accountability
Regulation: MS must be well organized and accountable to Governing Body for quality of Medical Care provided. Compliance: MS Org Chart, Bylaws Description, Board Minutes, definition of MS Composition in Bylaws, Bylaws approval by Board

58 Medical Staff Bylaws Requirement: Compliance: MS must adopt & enforce.
Must be approved by Board; include category descriptions, H&P requirement and criteria for privileges to be granted; describe MS Organization and applicant qualifications; Compliance: Bylaws, R&R, Minutes, Medical Records (H&Ps), Quality reports (H&P timelines data)

59 Autopsies Requirement: Compliance:
Secure in all cases of unusual deaths and for med/legal educational interests. Compliance: R&R, Autopsy Policy, QA or PI reports; Medical Record Review.

60 History & Physicals (H&P)
As of 2007: No more than 30 days before or 24 hrs after admission Old Requirement: No more than 7 days before and 48 hrs after

61 Compliance Tips and Tools #3
Continuous Readiness: Increase staff knowledge on policies, regulations, bylaws, rules and regulations, privileges Tool # 1 – Credential Jeopardy Game

62 Credentialing Potpourri
Jeopardy Acronyms Credentialing Potpourri The Joint Commission Privileges Policy & Privileges 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

63 Stanford Hospital:
Questions???? Contact information: Phone: Website(s) Stanford Hospital: Lucile Packard Children’s Hospital:;jsessionid=E579B5885A691DCEF80629F89C3D4E67.Int1


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