Presentation on theme: "COMPARATIVE DIFFERENCES OF MEDICAL STAFF and CREDENTIALING STANDARDS"— Presentation transcript:
1 COMPARATIVE DIFFERENCES OF MEDICAL STAFF and CREDENTIALING STANDARDS Debra R. Green, MPA, CPMSM, CPCSDirector, Medical Staff Services and General Pediatric Residency ProgramStanford University Medical CenterStanford Hospital & ClinicsLucile Packard Children’s Hospital
2 BackgroundDirector 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 Policy20+ 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 casesNAMSS 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 StandardsRequirementsCompliance
4 Center for Medicare/Medicaid (CMS) Who are they?Government OrganizationSurveyors are typically State DOH employeesGives deeming authority to TJC, HFAP and DNVWhat do they do?Validate TJCCan Survey For CauseWhy do they exist?To ensure patient care and quality
5 The Joint Commission (TJC) Who are they?Private OrganizationWhat 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 1965Surveyors are experienced healthcare professionalsRecognized by Fed Gov, State DOH, Ins Carriers and Managed Care Organizations (MCO)Surveys are unannouncedDet Norske Veritas Healthcare, Inc (DNV)Deemed status since 9/08Certifies other companies in additional to healthcareExisted since (began in Norway) in US since 1898World wide reputation for quality and integrity
7 National Committee for Quality Assurance (NCQA) Who are they?Private OrganizationWhat do they do?Accredits: MCO’s, MBHO’s, PPO’s, NHP’s etc.Certifies: CVO’sDelegated Credentialing AgreementsHospital does the work for MCO or Health Plan
8 The Accreditation Association for Ambulatory Health (AAAHC) Who are they?Private Organization, non-profitWhat do they do?- Accredit Ambulatory Healthcare Organizations, Surgery Centers, Community Health Centers and Medical/Dental Group Practices- US Air Force and Coast GuardWhy 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-profitWhat 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 TJCNCQAHFAPURAC/AAAHCDNV/CMS(I) Primary Source verification from Medical SchoolAlternate sources:AMA, AOA, ECFMGAAPA 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 EducationMust be significant to support request for privilegesAlternate sources: AMA, AOA, ECFMG (after 1986), state licensing agencyURAC – (I) PSV requiredHistory of education and training included on appCan use the state lic Board as a PSVAAAHC – (I) PSV requiredNo alternative sources noted.DNV (I) Primary Source Verification of Medical EducationRequirements must be outlined in BylawsCMS – Not specially addressed in standards (doesn’t mean its not required)
11 Post Graduate Training TJCNCQAHFAPURAC/AAAHCDNV(I) PSV required from primary source or equivalent sourceAlternate 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 requiredDocumentation must support requested PrivilegesAlternate Sources:AMA, AOA,URAC – (I) PSV required only if not board certifiedHistory of Education Required on appCan use the state lic board as a PSVAAAHC – (I) PSV requiredNo alternative sources noted.DNV - Bylaws include criteria for determining privileges including, specific training requirementsCMS – Not specifically addressed in standards (doesn’t mean its not required)
12 PEER RECOMENDATIONS NCQA HFAP DNV and CMS URAC/AAAHC TJC Required (R) Required if there is insufficient practitioner-specific data availablePeer with knowledge of applicantRecommendations should address clinical competence and ability to perform privileges6 General Competencies(I&R) Peer Review through Credentials Committee with representation from similar types and degrees of expertise(I) Obtain at least1 peer with thesame professionalCredentialAssessment ofphysical and mentalhealth in relation toprivileges requested.(R) Individual lettersnot required, can beobtained throughPR, Cred Com,Dept Chair or MECURAC – No specific requirementAAAHC – (I &R)Peer recommendationrequiredDNV- 2 Peerrecommendations at(I). Nothing in thestandards assess PeerReferences at (R)CMS – Not speciallyaddressed
13 Work/Affiliation History Verifications How many organizations perform Work/Affiliation History Verifications?
14 Work/Affiliation History TJCNCQAHFAPURAC/AAAHCDNV/CMSThere 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 RequiredVerification 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 privilegesURAC – Not addressed in standardsAAAHC – (I)Reviewed for continuity and relevance.Document interruptions in practiceDNV – Not addressed in standards.CMS – Not addressed in standards
15 Privileges TJC NCQA HFAP DNV/CMS URAC/AAAHC Clearly documented process for grantingEvidence of Physical Ability to perform requested privilegesGrant or Deny must be objective and evidence basedMust be criteria basedNo requirement for privilegesMust be consistent with demonstrated competencyCriteria basedSurgical privileges must be delineated based on individual competencyURAC – Privileges must be included in the applicationAAAHC –Reviewed and approved by the governing bodyDNVCriteria BasedPractice within scopeCMSAll patients must be under the care of a practitioner with privilegesPrivileges can only be granted by the hospitals governing bodyAssess 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 completeNote: No challenges to license, membership or privilegesProcess for “provisional credentialing” for first time providersPVS of license, NPDB, completed application with signed attestationFile must be valid and verified and approved by Medical Director or qualified physicianMust not exceed 60 daysBylaws provide for the granting of temporary privileges:1. During review and consideration of application.2. For care of specific patient3. For locum tenens.4. For times of emergency or disaster.PSV of Lic, DEA, Insurance and 1 Ref from previous facility reqURAC – 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.DNVUrgent Pt CareComplete app w/o negative or adverse infoNot to exceed 30 daysVerification of Lic, competence, Ref and AMA (education), NPDB and OIGCMSNot addressed
17 Ongoing Performance Monitoring TJCNCQAHFAPURAC/AAAHCDNV/CMSFPPE – Focused evaluation (i.e. Proctoring)(R) OPPE – Ongoing Evaluation (i.e. data assessment for everyone)Added in MS Chapter in 2008Not addressedURACAAAHCDNVCMSNot Addressed
18 DEA/CDS TJC NCQA HFAP DNV/CMS URAC/AAAHC (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, AMAState CDS certificates must be verified, where applicable(I&R) Application includes actions against DEA/CDSURAC – (I&R)Evidence of current DEA/CDSMay collect a copy of certificate or certificate #Must be verified within 6 months of review and approvalAAAHC – (I) evaluated at initial appmt and monitored continuallyDNV(I &R) Provider must provide current DEA #CMSNot Addressed
19 CONTINUING MEDICAL EDUCATION(CME) TJCNCQAHFAPURAC/AAAHCDNV/CMS(I & R) LIPS must participate in Continuing EducationDocumentedConsidered in Privilege processShould be relevant to clinical privileges requestedNot AddressedMay request evidence of CME every 2 yearsURACAAAHCNot Addressed for Medical Staff MembersDNVShould participate in CME related to privilegesCME should be considered at reappointmentCMSNot addressed
20 MALPRACTICE INSURANCE TJCNCQAHFAPURAC/AAAHCDNV/CMSNot required unless outlined in bylawsMost hospitals require itPrimary source verification not required(I & R) Attestation by doctor or copy of policy showing dates and amount of coverage or Face Sheet from the carrierFederal Tort letter or attestation from practitioner of Fed Tort is okMust have evidence of PLI coverageMust have current certificates showing amount (s) of coverageURAC – Proof of PLI included on applicationA cover sheet or attestation from ins company is sufficient to prove coverageAAAHC – Req only if organization requires itReview information related to refused or cancelled coverage at (I&R)DNVNot addressedCMS
21 MALPRACTICE HISTORY TJC NCQA HFAP DNV/CMS URAC/AAAHC (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 SheetVerify history of claims that result in a settlement paid by or on behalf of the practitionerConfirm 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 NPDBURAC – provider must include claims history on appAAAHC - provider must include claims history on app and evaluatedDNV(I&R) organization must review involvement in any actionCMSNot addressed
22 NATIONAL PRACTITIONER DATA BANK(NPDB) TJCNCQAHFAPURAC/AAAHCDNV/CMSMust 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 licensureMust query at granting of initial and renewalURAC - Not required, but can be used to verify license and Medicare and Medicaid sanctionsAAAHC - required at (I & R). PDS is acceptable.DNV(I) required only if Temporary Privileges are requestedCMSNot addressed
23 BACKGROUND CHECKS TJC NCQA HFAP DNV/CMS URAC/AAAHC Terminology is not used in Medical Staff StandardsRequired under HR Hospital StandardsNot specially addressedApplication must attest to his/her history of loss of license and felony conviction and lack of illegal drug use.*Attestation StatementApplication must request information regarding any criminal history.Investigation must be conducted based on information provided on the application.URAC –Not specially addressedAAAHC - Not specially addressedDNVRequired only if State requires itCMS
24 BOARD CERTIFICATION TJC NCQA HFAP DNV/CMS URAC/AAAHC Verification not required unless bylaws /policy require board certificationOrganization SpecificVerify through ABMS, AMA, AOA or specialty boardNot required, but if practitioner says they are Board Certified, it must be verified(R) Required to determine if still currentVerify 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 verifiedURAC - Not required but verify if practitioner states they are board certifiedAAAHC – Verify on initial application and ongoing basisDNVNot addressedCMS
25 LENGTH OF APPOINTMENT PERIOD TJCNCQAHFAPURAC/AAAHCDNV/CMSMay not exceed 2 yearsAt least every 36 monthsCounts 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 monthsCounts 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 yrsAAAHC – as defined by state law, not to exceed 3 yearsDNVMay not exceed 3 years (defined by state law)CMSRecommends every 24 months
26 LICENSURE TJC NCQA HFAP DNV/CMS URAC/AAAHC (I & R) Primary source verification required at initial appointment, reappointment, revision of privileges and at time of expirationCurrent and ValidVerify through state licensing board(I & R) Primary source verificationMust be current and validIn effect at time of credentialing decisionVerify through state license board(I & R) Primary source verification requiredURAC – (I&R) PSV requiredCurrent and validAAAHC – (I&R) PSV requiredDNVCMSNot specifically addressed in standards
27 LICENSURE SANCTIONS TJC NCQA HFAP DNV/CMS URAC/AAAHC (I & R) The doctor must provide information regarding challenges or relinquishment of license*Attestation questionState Licensing BoardFSMB can used as PSV(I & R) Primary source verification requiredVerify through state licensing boardNPDB/PDS and FSMB can be used as PSVApplication must include current or pending challenges(I & R) Must be reviewed for each applicantFSMB and FACIS can be used at PSVURAC –History of sanctions should include at least a 5 yr historyNBDB can be usedAAAHC – review of sanctions required at (I&R)DNVAddressed for TP onlyCMSNot specifically addressed
28 MEDICARE/MEDICAID SANCTIONS TJCNCQAHFAPURAC/AAAHCDNV/CMSNot addressed(I&R) Current or previous sanctions must be verifiedOngoing Monitoring required between re-credentialing cyclesVerify through AMA, NPDB, OIG, FSMB, FEHB, State Medicaid AgencyApplication must request information regarding Medicare Medicaid SanctionsURACMust be reported on applicationCan use NPDB as PSVAAAHCMust be disclosed and reported on application as well as evaluated at (I&R)DNV(I) Must be reviewed before Temporary Privileges are granted.CMSNot Specifically addressed
29 Disaster Privileging TJC NCQA HFAP DNV/CMS URAC/AAAHC URAC AAAHC DNV Disaster privileges may be granted to volunteer LIPs when theEmergency Operations Plan has been activated*removed from the MS Chapter, it now resides in EMNot specificallyaddressed.The hospital has a plan for dealing with clinical volunteers during emergency /disaster.This plan should provide for primary source ID from the volunteer’shospital (A documented phone call is acceptable).The hospital should use volunteers as appropriate within the scope of their license/certification.URACNot specifically addressed.AAAHCWhen hospitalization isneeded due toemergencies, theorganization may have apolicy for credentialingand privileging physicians and dentists who have admitting privileges at a nearby hospital.DNVIdentification,availability andnotification ofpersonnel that areneeded to implementand carry out thehospital’s emergencyplans should beconsidered whendeveloping theComprehensive 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 policyTool # 2 – Disaster Credentialing Tool Kit
31 Disaster Credentialing Tool Kit Includes:Disaster Credentialing PolicyEmployee Roster with Phone #sDisaster Privileging Tracking Logs (multiple copies)Disaster Privilege Forms (multiple copies)Excerpt from Bylaws regarding Disaster PrivilegesList of Links for licensure verificationWritten process for staff to followName BadgesMarkersInk Pens
32 DISASTER PRIVILEGES TRACKING LOG FOR VOLUNTEER LIP’S To be completed by Medical staff services L NameF NameMD, DO, NP, PA, DDS, DPM, PHDSpecialtyLic #Type IDProvided(See Key – A required)Lic Verified(Date)VerifiedIn 72 hrsY/NMS MemberPRIVFORM COMPSAMPLEDOCTORMDMED123456A, B1/1/09YNID Type KeyA – Govt issued ID – REQUIREDB – ID from another HC OrgC – License to practiceD – ID from DMAT/MRC/ESARVHPE – ID from Govt entity granting authority to provide careF – Confirmation from another Medical Staff Member
34 Health Status Assessment TJCNCQAHFAPURAC/AAAHCDNV/CMSApplicant must submit a statement that no health problems exist that could affect clinical privilegesConfirmed 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 referencesCan be a statement regarding the applicants physical or mental health status related to privileges requested.URACApplication must include a question about physical mental or substance abuse problemsAAAHCOrganization requires and reviews issues regarding physical, mental and chemical dependencyDNVNot specifically addressedCMS
35 Allied Health Professionals TJCNCQAHFAPURAC/AAAHCDNV/CMSTJC does not use the term “allied health professionals.” It refersto 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 approvedby 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-physicianpractitioners who havean independentrelationship with theorganization andprovide care under theorganization’s medicalbenefits must becredentialed.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 requiredURACAll practitioners who areparticipating providers,provide covered health care services to consumers, and appear in the organization’s provider directory areAAAHCIf allowed by theorganization, the boardmust provide a process for the (I) appointment,(R) appointment, andassignment or curtailmentof privileges and practicefor AHPs (based on Statelaw and evidence ofeducation, training, experience and competenceDNVNPs, PAs, DDS, PHD’s can be considered “medical staff in accordance with state lawNo mention of requirement for credentialing and privileging.CMSMS 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 theindividual identified in thecredentialing 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 addressedURACAAAHCDNVCMS
37 Attestation Statement TJCNCQAHFAPURAC/AAAHCDNV/CMSNot specifically addressedStatement from applicant required at (I) and (R) in order to inquire about:Illegal Drug UseInability to performLoss of Lic/privilegesDisciplinary ActionsMalpractice CoverageFelony ConvictionsAttest that the application is correct and completeMedicare deemed Organizations: Must be signed within 180 days of final approval365 days for non-Medicare deemed OrgsAlthough not specificallyaddressed in the standards, the Scoring Procedure for thestandard reflecting theresponsibilities for allcredentialed practitionersinstructs surveyors to review a select sampling of files to verify practitioners attest tothese responsibilities atappointment and reappointment.URACThe application includes a signed and dated statement attesting that the information submitted with the application is complete and accurate to the practitioner’sknowledge.Time limit is 180 daysAAAHCThe application includes a signed and dated statement attesting that the information submittedwith the application iscomplete and correct.DNVCMS
38 Complaints TJC NCQA HFAP DNV/CMS URAC/AAAHC 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 tothe quality of allpractitioner office sites is requiredMust conduct sitevisits for complaintsrelated to physicalaccessibility, physicalappearance andadequacy of waiting and examining-room space based on thresholds. Implements appropriate actions and evaluate the effectiveness of thoseactions at least everysix months, until deficient offices meet the thresholds.QAPI functions includemonitoring of complaints.URACPolicy must define parameters or triggersof potential quality of care issues that require further investigation.AAAHCNot addressedDNVThe hospital mustdevelop and implementa formal grievanceprocedure, whichincludes a referralprocess for quality ofcare issues to theUtilization Review,Quality Management orPeer Review functions,as appropriate.CMSestablish a process forprompt resolution ofpatient grievances andmust inform each patient whom to contact to file a grievance.
39 Compliance with Law TJC NCQA HFAP DNV/CMS URAC/AAAHC A governance standard holds the hospital’s governing bodyresponsible 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 privilegingof practitioners.The administrativepolicies and proceduresindicate thatorganizations providingmanaged care servicesmust comply withapplicable Federal,State, and local lawsand regulations,including requirementsfor licensure. Thus, theorganization’s leadersare responsible for anyregulations relating tocredentialing.Standards require compliance with applicable law andregulations.URACStandards require compliance with all applicable Federal,State and local laws.AAAHCStandards requirecompliance with allapplicable Federal, State and local laws.DNVCMSThe governing body must assure that the medical staff has bylaws and thatthose bylaws comply with State and Federal law and the requirements of CoPs.
40 Use of a CVO NCQA HFAP DNV/CMS URAC/AAAHC TJCNCQAHFAPURAC/AAAHCDNV/CMSOrganizations 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, limitationsof 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 requiredHFAP refers to a ProfessionalCredentialing Organization(PCO).PCO can be used to perform the PSV, but the process forcredentialing by the organization must reflect the requirements as stated in the standardsURACThe organization candelegate credentialing to a network, group or clinic organization with which they contract.Oversight is requiredThe organization must retain the authority to make credentialing determinations and must conduct an on-site survey every three years.AAAHCCVO is allowedAssessment of CVO’s quality of work is requiredDNVNot specificallyaddressed.CMS
41 Use of Designated Equivalent Sources TJCNCQAHFAPURAC/AAAHCDNV/CMSAMA – MD or PA EducationABMS – Board CertificationECFMG Foreign Medical GraduatesAOA – DO Education and Board CertificationFSMB – Licensure actionsNCCPA certificationNPDB – paid claims or privilege suspension/revocationNCQA does not use thelanguage “designatedequivalent sources.” The standards refer back to the specific credentialing event to determine an NCQA approved source.URACAAAHCRefers to “secondary source” list of 20DNVCMSNot specifically addressed
42 Felony Convictions TJC NCQA HFAP DNV/CMS URAC/AAAHC Not specifically addressed.The application mustinclude a statementregarding felonyconvictions.The application requestsinformation 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.URACNot specificallyaddressed.AAAHCThe applicant mustprovide informationregarding criminalconvictions other thanminor traffic violations.DNVAddressedCMS
43 Site Visits TJC NCQA HFAP DNV/CMS URAC/AAAHC Not required. The organizationimplements appropriateinterventions byconducting site visits of offices about which ithas received member complaints and those for which established thresholds areexceeded.URACAAAHCNot requiredDNVCMSNot Specifically addressed
44 Compliance Tips and Tools #2 Audit, Audit and More Audits!!!Tool # 3 – Credentialing Audit FormsI 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.
48 Telemedicine Not addressed under: NCQA URAC AAAHC Very detailed standards for:TJCHFAPCMSDNV
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 2011New standard effective July 2011Hospitals can now rely on the credentialing and privileging of “Distant Site”The Joint Commission and HFAP are derived from the CMSDistant 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 organizationSource: The Searcy Exchange June 2011
51 Telemedicine - DNVIf 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 appraisalsCompliance: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 admissionOld 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, privilegesTool # 1 – Credential Jeopardy Game