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CREDENTIALING & PRIVILEGING A Legal Primer Marcy Auclair BUMED Attorney Advisor for Health Care Law October 23, 2013 1.

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Presentation on theme: "CREDENTIALING & PRIVILEGING A Legal Primer Marcy Auclair BUMED Attorney Advisor for Health Care Law October 23, 2013 1."— Presentation transcript:

1 CREDENTIALING & PRIVILEGING A Legal Primer Marcy Auclair BUMED Attorney Advisor for Health Care Law October 23,

2 World-Class Care…Anytime, Anywhere Fundamental Principles Patient Safety Quality Assurance / Risk Management Compliance with requirements of The Joint Commission 2

3 World-Class Care…Anytime, Anywhere Implementing Regulations DoD Level: DOD Instruction (17 Feb 11) Medical Quality Assurance (MQA) in the Military Health System (MHS) DOD R – MHS CQA Program Regulation (being reissued as a Manual) 3

4 World-Class Care…Anytime, Anywhere Implementing Regulations Service Level: Navy BUMEDINST E, “Credentials Review and Privileging Program” BUMEDINST A, Ch1, “Adverse Privileging Actions, Peer Review Panel Procedures, and Health Care Provider Reporting” 4

5 World-Class Care…Anytime, Anywhere Implementing Regulations Air Force AFI , “Medical Quality Operations” Army AR 40-68, “Clinical Quality Management” 5

6 World-Class Care…Anytime, Anywhere Definitions Credentials: Documents that constitute evidence of appropriate education, licensure, experience, and expertise of health care providers/practitioners. Clinical Privileges: Permission to provide medical and other patient care services in the granting institution, within defined limits, based on an individual’s education, professional license, experience, competence, ability, health, and judgment. 6

7 World-Class Care…Anytime, Anywhere Definitions Adverse Privileging Action: Denying, suspending, restricting, reducing, or revocation of clinical privileges based upon misconduct, impairment, or lack of professional competence. Adverse Practice Action: Restricting, reducing, or revoking the clinical practice of a non- privileged healthcare provider based upon professional misconduct, impairment, or lack of professional competence. 7

8 World-Class Care…Anytime, Anywhere Disciplinary Actions Misconduct: Military: Violations of the Uniform Code of Military Justice (UCMJ); allegations handled through Non-Judicial Punishment, Courts-Martial, and/or Administrative Separation Boards Civilians: Allegations of lying, stealing, assault, etc. will be investigated and actions coordinated with HRO (i.e. suspensions, termination, etc.) Contractors: Similar to civilians; allegations need to be investigated and actions coordinated with contracting officer 8

9 World-Class Care…Anytime, Anywhere Disciplinary Actions If misconduct is not related to patient safety or the delivery of a health care item or service, no further professional action is required. If misconduct is related to patient safety or the delivery of a health care item or service then consideration must be given to initiating an adverse privileging action (if privileged provider),notifying the state licensing board (if not privileged provider), and reporting to the National Practitioner Data Bank. 9

10 World-Class Care…Anytime, Anywhere Disciplinary Actions DoD requires the Surgeons General to report UCMJ actions, adverse civilian personnel actions, and contract terminations for default of any healthcare provider, supplier or practitioner where the acts or omissions were related to the delivery of a healthcare item or service. Anyone involved in patient care can be reported to the NPDB; it is not limited to licensed healthcare practitioners (i.e. dental techs, corpsmen can be reported) 10

11 World-Class Care…Anytime, Anywhere Disciplinary Actions Misconduct reports were formally made to the Healthcare Integrity and Protection Data Bank (HIPDB); however, in May 2013, the HIPDB merged with the National Practitioner Data Bank (NPDB). The requirements to report provider misconduct remain in effect. 11

12 World-Class Care…Anytime, Anywhere Reporting Final actions resulting in the denial, suspension, restriction, reduction, or revocation of a provider’s clinical privileges are reported to the National Practitioner Data Bank, state(s) of licensure, Federation of State Medical Boards, professional organizations, and DoD Health Affairs. Final actions resulting in the restriction, reduction, or revocation of a non-privileged healthcare provider’s clinical practice, are reported to state(s) of licensure, professional organizations, and DoD Health Affairs. 12

13 World-Class Care…Anytime, Anywhere Reporting Reporting of adverse professional/clinical information to outside entities and licensing bodies is performed by the Surgeons General Headquarters staff; local reporting in not authorized. 13

14 World-Class Care…Anytime, Anywhere Questions ??? Contact Info: Marcy Auclair Phone: (703) DSN:


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