1. Standards Update June 2010 Presented by Lynn L. Buchanan, President Buchanan & Associates Consulting For Alaska Assn. Medical Staff Services 1www.Edge-U-Cate.com

2. The Joint Commission 2010 – New Scoring Methodology All EPs in Medical Staff Chapter are Category A requiring 100% compliance (except 4 which are category C scored on occurrences of non-compliance – 90% or ESC) www.Edge-U-Cate.com2

3. Medical Staff Standards POSSIBLE – Preliminary Denial of Accreditation MS.03.01.01 EP2: Practitioners practice only within the scope of their privileges as determined through mechanisms defined by the OMS (CONVERTED to Direct Impact as PDA) MS.06.01.05 EP1: Licensed independent practitioners possess a current license www.Edge-U-Cate.com3

4. TJC / CMS Several changes have been made in order to “sync” with CMS Conditions of Participation Separate Language for organizations that use TJC accreditation for deemed status – Bylaws (MS.01.01.01) – MEC (MS.02.01.01) – Oversight of Quality of Care (MS.03.01.01) – Autopsies (MS.05.01.01) – Radiology Service Supervision www.Edge-U-Cate.com4

5. MS.01.01.01 – MS Bylaws Task Force continues work to determine best approach to review standard Key Issues: – Relationship between OMS and MEC – What needs to appear in bylaws and how such decisions are made – How to manage conflict between OMS and GB / between OMS and MEC – regarding bylaws, R&R, policies Effective 3/31/2011 - 36 Elements of Perf. www.Edge-U-Cate.com5

6. MS.01.01.01 – MS Bylaws EP 3 – New – Associated details for EPs 12-36 may reside in bylaws, R&R or policies OMS adopts what constitutes associated details, where they reside and whether adoption can be delegated – If a process is required for EPs 12-36, bylaws must include the basic steps (as determined by the OMS and approved by GB) www.Edge-U-Cate.com6

7. MS.01.01.01 – MS Bylaws EP 8 – New – OMS has the ability to adopt MS bylaws, R&R, policies and amendments thereto, and to propose them directly to the GB EP 9 – New – If voting members of OMS propose to adopt R&R, policy or amendment, first communicate with MEC; If MEC proposes, must first communicate with MS (applies only if MEC has been delegated authority over R&R, policies by OMS & GB) www.Edge-U-Cate.com7

8. MS.01.01.01 – MS Bylaws EP 10 – New – OMS has process to manage conflict between MS and MEC on issues, including but not limited to proposals to adopt R&R, policy or amendment – Does not prohibit members of MS from communicating with GB. GB determines method of communication www.Edge-U-Cate.com8

9. MS.01.01.01 MS Bylaws EP 11 – New – When documented need for urgent amendment to R&R/Policy to comply with law or regulation, MEC (if so delegated) may provisionally adopt and GB provisionally approve without prior notification MS notified immediately Opportunity for retrospective review/comment If no conflict, amendment stands If conflict, conflict resolution (EP10) is implemented and any revision submitted to GB for action www.Edge-U-Cate.com9

10. MS.01.01.01 MS Bylaws EP 15 (2010) – A statement of the duties and privileges related to each category of the medical staff (ex: active, courtesy) – NOTE: Solely for purposes of this EP, TJC defines “privileges” as the duties and prerogatives of each category of MS membership, and the clinical privileges to provide patient care, services & treatment www.Edge-U-Cate.com10

11. MS.01.01.01 MS Bylaws EP 17 – New – Description of MS members eligible to vote EP 19 – New – List of all MS officer positions EP 24 & 25 – New – Process for adopting and amending MS bylaws, R&R, policies www.Edge-U-Cate.com11

12. MS.01.01.01 MS Bylaws Former EP 19 – related to medical staff governance documents that supplement the bylaws Implementation date still suspended pending work of the Medical Staff Bylaws Task Force – continues to not be in effect www.Edge-U-Cate.com12

13. MS.03.01.03 Pain Mgmt (New, not CMS) Hospital educates all LIPs on assessing and managing pain – Philosophy – conservative vs aggressive – Assessment/reassessment components and time frames – Pain Sclaes – Medication policies related to orders with multiple pain medication choices, dose and frequency ranges, parameters for administration www.Edge-U-Cate.com13

14. Telemedicine (7/15/10) LD.04.03.09(9), MS.13.01.01(1) For hospitals using TJC for deemed status – All LIPs who are responsible for the patient’s care, treatment and services via a telemedical link are credentialed and privileged to do so at the originating site – can use CVO if it meets TJC 10 guidelines – If distant site is Medicare-participating hospital, may use copy of distant site’s credentialing packet for privileging if packet includes list of all privileges granted, attestation that packet is complete, accurate and up to date www.Edge-U-Cate.com14

15. Telemedicine (7/15/10) LD.04.03.09(9), MS.13.01.01(1) For hospitals not using TJC for deemed status – Specify in the written agreement that the contracted organization will ensure that all contracted services provided by LIPs will be within scope of their priv. www.Edge-U-Cate.com15

16. Telemedicine – MORE NEWS! CMS Reconsidering CMS has delayed effective date of TJC’s revised standards until March 2011 www.Edge-U-Cate.com16

17. TJC Position - Core Privileges MS.06.01.07 Per John Herringer, 5/10 at FAMSS meeting: – Core Privileges – activities for which the majority of practitioners who meet the defined criteria should be able to perform – Core terminology must define the specific activities included and any limitations, e.g., those that are outside the core – Cannot assume applicant can perform all core activities www.Edge-U-Cate.com17

18. MS.08.01.01 FPPE Focused professional practice evaluation is done for all initial privileges – effective January 1, 2008 – Time of application – When additional privileges are requested – Predefined to ensure consistent implementation Criteria are developed for evaluating performance when issues affecting care are identified www.Edge-U-Cate.com18

19. MS.08.01.03 OPPE Ongoing continuous evaluation Identify performance problems early and resolve Results in evidence-based privileging at time of renewal Process includes evaluation of each practitioner’s professional practice Good and the negative (outlier) www.Edge-U-Cate.com19

20. HR.01.02.05 PAs & APRNs EPs 10-15 – Credentialed and privileged through MS process (or equivalent) Approved by governing body Evaluates applicant’s credentials Evaluates applicant’s competence Includes peer recommendations Input from individuals and committees incl. MEC No inherent right to a fair hearing CMS requires GB grant privileges www.Edge-U-Cate.com20

21. HR.01.02.05 – Other individuals brought in by an LIP EP 5 & 7 (Not applicable to PA/APRN) – Must be authorized prior to provision of care, treatment or service – Organization determines that the qualifications and competence are same required of like employees performing same or similar services – Organization reviews qualifications, performance and competence at same periodic time frame as like employees www.Edge-U-Cate.com21

22. Industry / Manufacturers / Vendors No current standards, but FAQ posted 4/10 offers consultative advice – EC.02.01.01 – Identify who is entering organization and what individuals are doing – RI.01.01.01 – ensure patient rights are respected – IC.02.01.02 – Infection control precautions and other organization-specific P&Ps are followed – LD.04.01.05 (EP 1&3) – leaders oversee operations, and administrative and clinical direction responsibilities are defined – LD.04.04.05 (EP 1,3,4) – the development and implementation of a patient safety program www.Edge-U-Cate.com22

23. OTHER REGS CMS Anesthesia Guidelines Revised ABMS Implements Continuous Reporting of MOC Pilot (ABP) Changes to Ambulatory Center Surveys www.Edge-U-Cate.com23

24. QUESTIONS www.Edge-U-Cate.com24