Healthcare Facilities Accreditation Program (HFAP) 2007 Medical Staff Credentialing Standards George A. Reuther Director, HFAP 312-202-8060

The HFAP Accreditation History HFAP first began in 1945 Accrediting Hospitals and Other Health Care Facilities for over 60 years Accrediting Hospitals Under Medicare for Over 40 years Recognized by Managed Care Organizations and Insurance Companies

Current Areas of Accreditation Hospitals Clinical Laboratories Ambulatory Care / Surgical Facilities Mental Health & Substance Abuse Facilities Physical Rehabilitation Facilities Critical Access Hospitals

Government Recognition Deeming Authority from the Centers for Medicare and Medicaid Services (CMS): Medicare Conditions of Participation for Hospitals, CAHs, and ASCs. Clinical Laboratory Improvement Amendments (CLIA)

Accreditation Survey Related Activities Hospitals – Three (3) day survey Three (3) member Survey Team reviews hospital compliance with HFAP accreditation requirements Physician, RN, and Administrator

Patient Safety Initiatives National Quality Forum (NQF) 30 Safe Practices (2003) HFAP adopted 28 of the 30 Safe Practices

National Quality Forum 30 Safe Practices (2003) For example: #14 Operative Site Verification #18 Anti-Thrombotic Therapy #20 Prevent Central Venous Catheter Infections #21 Surgical Site Infections (SSI) #22 Contrast Media

“The Organized Medical Staff” The hospital must have an organized medical staff that operates under bylaws approved by the governing body and is responsible for the quality of medical care provided to patients by the hospital. 482.22

Credentialing and Privileging Process HFAP standards for credentialing and privileging provide for the periodic appraisals by the facility’s medical staff of its members. The appraisal is to determine the suitability of individual members and all other credentialed providers for membership/continued membership on the medical staff, or

Credentialing and Privileging Process (cont’d) credentialing / re-credentialing (for non-member credentialed providers), and to determine if an individual practitioner’s clinical privileges should be approved, continued, discontinued, revised or otherwise changed. (HFAP hospital 03.00.04)

Credentialing and Privileging Process (cont’d) The standards describe the responsibilities of credentialed professionals to the facility in which they work, to the patients which they treat, and to the Governing Body of the facility. (HFAP hospital 03.00.05, 03.00.06, and 03.00.07)

Medical Staff Membership The standards identify the selection criteria for membership on the medical staff. These criteria must include: licensure, training / education, current competence, health status, experience, character, and judgment. (HFAP hospital 03.01.13)

Required Application Information The standards identify the required application/reapplication information to be provided for review. This information includes: 1. licensure history, 2. medical education and post graduate training,

Required Application Information (cont’d) 3. malpractice insurance and history, 4. specialty board status, 5. sanctions or disciplinary actions, 6. criminal history, 7. healthcare employment history, 8. professional references, and 9. clinical activity.

Required Application Information (cont’d) 10. All information provided by the applicant/re-applicant is to be compared against verified information. (HFAP hospital 03.01.15)

Quality Assessment and Performance Improvement The facility’s quality assessment and performance improvement (QAPI) function involve: A. clinical assessments by Medical Staff and other providers for all service types of patients,

QAPI (cont’d) B. diagnostic procedures – including invasive and non-invasive procedures from clinical laboratory, imaging, cardiorespiratory, physical or behavioral medicine, etc., for patients of all service types; and

QAPI (cont’d) C. therapeutic interventions – including those processes and outcomes as appropriate to Medical Staff functions. (HFAP hospital 03.02.03)

QAPI Information Used in Review of Candidates Information derived from the facility’s QAPI functions is used in the review of candidates for appointment and privileging and addresses: 1. medication therapy, 2. infection control, 3. surgical / invasive and manipulative procedures,

QAPI Information Used in Review of Candidates (cont’d) 4. blood product usage, 5. data management (with emphasis on medical record pertinence and timeliness), 6. discharge planning, 7. utilization management,

QAPI Information Used in Review of Candidates (cont’d) 8. complaints from patients and families or from hospital staff, 9. restraint / seclusion usage, and 10. mortality review. (HFAP hospital 03.02.02)

Medical Staff Accountability The Medical Staff is accountable to the Governing Body for the quality of medical care provided to patients by all credentialed practitioners and for aggregating their QAPI finding from the departments, services, committees or other structural components to:

Medical Staff Accountability (cont’d) A. develop plans for continuing the education of its members and all credentialed staff; B. provide annual evaluations of improvements in the clinical care provided;

Medical Staff Accountability (cont’d) C. utilize as information in the process of evaluating Medical Staff for all membership categories including associate (provisional), active, consulting, and hospital-based membership categories;

Medical Staff Accountability (cont’d) D. utilize as information in the process of evaluating and acting upon reappointment and reprivileging requests from its members and all other credentialed staff; and

Medical Staff Accountability (cont’d) E. utilize as information in an ongoing process of evaluating the members of the medical staff. (HFAP hospital 03.02.04)

03.00.04 Demonstrated Competencies To include: Current work / practice Special training Quality of specific work Patient outcomes Education Maintenance of CME (continued)

03.00.04 Demonstrated Competencies (cont’d) Adherence to Medical Staff guidelines Certifications Appropriate licensure Currency of compliance with licensure requirements to perform each task, activity, privilege requested for the category of practitioner.

…the list of privileges is modified for that practitioner. 03.00.04 If the practitioner is not competent to perform one or more task/ activity/ privilege… …the list of privileges is modified for that practitioner.

03.01.04 Bylaws – Categories of Medical Staff Include a statement of the duties, responsibilities, and privileges for each category of medical staff. Categories must include all practitioners who provide a “medical-related” level of care, such as…

03.01.04 Bylaws – Categories of Medical Staff Physicians Dentists Allied Health Practitioners, e.g., RN First Assistants, Surgical Assistants, Anesthesia Assistants, CRNAs, Midwives

03.01.15 Re-application References – Re-applicants Must have Clinical Competence Review Must have peer review reports, e.g., Clinical peer review, Medical record review, Credentials Committee/Function , and / or Medical Executive Committee review

03.01.15 Re-application Clinical Activity – Application & Re-applications Must have QAPI clinical / objective data with signature of department chairperson # Cardiac Stents # Complications Must have recommendation from department in which privileges are sought Lack of Physician Participation: Citation would be against the Medical Staff / Department of Medicine (not the individual physician.)

03.01.15 Re-application Clinical Activity – Re-applicants Examples of QAPI clinical / objective data Timeliness of H&P Content of Discharge Summary # Patient Complaints # Surgical Complications # Re-intubations

Medical Staff Bylaws provide granting of emergency privileges. Within scope of license For life saving procedures During times that a staff member who is a credentialed practitioner with appropriate privileges is not available.

03.01.18 Temporary Privileges Bylaws provide for the granting of temporary privileges while a file is waiting to go to MEC and Board for final approval. Application must be complete. Credentialing Committee has reviewed file. Applicable for: For specific patients For locum tenens For times of emergency and / or disaster

Disaster – Clinical Volunteers: 03.01.18 Temporary Privileges Disaster – Clinical Volunteers: A plan is in place for clinical volunteers The plan provides for primary source identification from the volunteer’s hospital, e.g., a documented telephone call Volunteers function within their scope of license / certification

Chapter 2 – Allied Health Professionals 02.00.01 Allied Healthcare Practitioner (AHP) Categories The governing body with the medical staff will determine which allied health practitioner disciplines will function under each category.

Chapter 2 – Allied Health Professionals 02.00.02 Credentialing Procedures Appointed using privilege lists or a defined scope of practice. Privileges that require physician supervision are identified. Privileges that require direct or indirect supervision are identified.

Practitioners that provide a Medical – Related Level of Care… or Conduct Surgical Procedures: Must be individually credentialed based on their own individual qualifications. Regardless if care is provided directly or under supervision, Whether employed by the hospital, a physician or other entity, or a contracted provider

Chapter 2 – Allied Health Professionals 02.00.02 Credentialing Procedures The privileging process for AHP is the same process as used for the Medical Staff

Allied Health Professionals - Employed by Hospital 02.00.02 Credentialing Procedures If the AHP functions in an education or leadership role, This individual would not usually be privileged by the medical staff. Files would be maintained in the HR department or as defined by hospital.

Professional Credentialing Organizations (PCO) Definition: “An independent contractor who has no clinical or financial affiliation with the people on whom data is being collected. There can be no evidence of any relationship that could raise the question of a conflict of interest.” Facilities may use PCOs to assist in data collection for the credentialing and re-credentialing process, but the responsibility for granting privileges always remains with the facility.

Professional Credentialing Organizations (PCO) The PCO may perform: Personal reference checks Verification of privileges at all facilities where the candidate maintains privileges Verification of education and certification, etc.

Professional Credentialing Organizations (PCO) Minimally, the facility granting privileges MUST : Verify State licensure Query the National Practitioner Data Bank, and Perform verification immediately prior to appointment.

CMS Conditions of Participation Final Rules (2006) November 27, 2006: H & P within 30 days / 24 hours of admission (before surgery) Verbal Orders: Authenticate and time order within 48 hours Final Rule – December 8, 2006: Restraint or Seclusion

The Healthcare Facilities Accreditation Program (HFAP) George A. Reuther, Director 142 East Ontario Street Chicago, IL 60611-2864 312-202-8060 greuther@hfap.org