2015 HFAP Standards CMS Final Rule – Burden Reduction II May 2014 Karen Beem, MS, RN HFAP Standards Interpretation 2015 National Credentialing Forum1

Governing Body Periodically Consults with Medical Staff (NEW) The governing body must consult directly with the individual assigned the responsibility for the organization and conduct of the hospital’s medical staff, or designee. 1.To discuss matters related to the quality of medical care provided to patients of the hospital 2.Twice per year with minutes to memorialize discussions 3.Face-to-face or via telecommunications 2015 National Credentialing Forum2

Governing Body Periodically Consults with the Medical Staff Does not preclude having a physician as member of the governing body However; physician membership on the governing body is not sufficient to satisfy the requirement for periodic consultation National Credentialing Forum3

Eligibility and Process for Appointment to Medical Staff 1.All practitioners w ho require privileges to furnish care to hospital patients must be evaluated under the hospital’s medical staff privileging system before the hospital’s governing body may grant them privileges. 2.All practitioners g ranted hospital privileges must function under the bylaws, regulations and rules of the hospital’s medical staff. 3.The privileges granted to an individual practitioner must be consistent with State scope-of-practice laws National Credentialing Forum4

Eligibility and Process for Appointment to the Medical Staff Non-physician Practitioners: Physician assistant Nurse practitioner Clinical nurse specialist Certified registered nurse anesthetist Certified nurse-midwife Clinical social worker Clinical psychologist Anesthesia Assistant Registered dietician or nutrition professional 2015 National Credentialing Forum5

Eligibility and Process for Appointment to the Medical Staff Other types of licensed healthcare professionals with a more limited scope of practice and USUALLY not eligible for privileges unless permitted by State Scope of Practice: Physical Therapist Occupational Therapist Speech Language Therapist Some States:  Licensed pharmacists are permitted to provide ordering medications and laboratory tests 2015 National Credentialing Forum6

Recommendation for Appointment to Governance Standard: Enforcement The medical staff must enforce its medical staff requirements and take appropriate actions when individual members or other practitioners with privileges do not adhere to the medical staff’s bylaws, regulations, or rules. Standard: Protection and Due Process Rights It must likewise afford all members/ practitioners who hold privileges the protections and due process rights provided for in the bylaws, rules and regulations National Credentialing Forum7

Multiple-Hospital Systems Multiple-Hospital Systems: Each hospital has a separate CMS Agreement and CCN Hospitals have the option of a unified integrated medical staff. The following apply to hospitals with a unified medical staff: Unified and Integrated Medical Staff Voting Requirements Bylaws of the Unified Medical Staff Unique Circumstances of the hospitals Policies of the Unified Medical Staff 2015 National Credentialing Forum8

Multiple-Hospital Systems: Unified and Integrated Medical Staff (NEW) When granting practitioners privileges the governing body must: 1.Specify the hospital(s) in the system where the privileges apply 2.Consider the services provided at each hospital when granting privileges. – Would be inappropriate to grant neurosurgical privileges if a hospital has no neurosurgical services 2015 National Credentialing Forum9

Multiple-Hospital Systems: Voting Requirements for Separately Certified Hospitals Standard: The medical staff members of each separately certified hospital in the system have voted by majority, in accordance with medical staff bylaws, either: a)To accept a unified and integrated medical staff structure, or a)To opt out of such a structure and to maintain a separate and distinct medical staff for their respective hospital; 2015 National Credentialing Forum10

Multiple-Hospital Systems: Voting Requirements for Separately Certified Hospitals If a unified medical staff, the Medical Staff Bylaws address: 1.Processes for voting to accept /opt out of a unified medical staff 2.Whether the decision for acceptance or to opt-out is determined by “majority” vs “supermajority” 3.How a vote can be requested 4.Whether all categories of members holding privileges to practice on-site at the hospital are afforded voting rights 2015 National Credentialing Forum11

Multiple-Hospital Systems: Voting Requirements for Separately Certified Hospitals The Bylaws address (continued): 5.Whether voting will be in writing and open or by secret ballot 6.Minimum interval between votes to accept or opt-out, e.g., once every two years 7.If a majority of a hospital’s medical staff voted to use a unified medical staff in the past, the members of the unified medical staff with voting rights and holding privileges to practice onsite at that hospital still retain the right to hold a vote to opt-out at a future date National Credentialing Forum12

Multiple-Hospital Systems: Voting Requirements for Separately Certified Hospitals A hospital may NOT: 1.Set up bylaws that unduly restrict the rights of medical staff members when voting on the issue of accepting or opting out of a unified medical staff structure 2.Establish different criteria as to which categories of medical staff members have voting rights with respect to a vote to accept or opt out of a unified medical staff than are used for other amendments to the medical staff’s bylaws 2015 National Credentialing Forum13

Multiple-Hospital Systems: Bylaws of the Unified Medical Staff (NEW) Standard: If a unified medical staff, The unified and integrated medical staff has bylaws, rules, and requirements that describe its processes for: Self-governance Appointment Credentialing and privileging Oversight Peer review policies and due process rights guarantees, and include a process for the members of the medical staff of each separately certified hospital to be advised of their rights to opt out of the unified and integrated medical staff structure 2015 National Credentialing Forum14

Multiple-Hospital Systems: Unique Circumstances (NEW) Standard: If a unified medical staff, The unified and integrated medical staff is established in a manner that takes into account each member hospital’s unique circumstances and any significant differences in patient populations and service National Credentialing Forum15

Multiple-Hospital Systems: Unique Circumstances The separately certified hospitals belonging to a multi-hospital system and using a single unified medical staff may: 1.Be very different from each other, presenting different needs and challenges for the medical staff. 2.Consist of hospitals that differ in size or provide specialized services. 3.Such differences could have implications for various medical staff requirements, such as on-call requirements National Credentialing Forum16

Multiple-Hospital Systems: Unique Circumstances Example: A multi-hospital system may consist of a mixture of hospitals, such as: short-term acute care hospitals psychiatric hospitals rehabilitation hospitals children’s hospitals long-term care hospitals For this reason, the medical staff must assure that standard orders, policies, and procedures: 1)Address the unique hospital circumstances 2)Are approved by the nursing and pharmacy leadership at each separately certified hospital 2015 National Credentialing Forum17

Multiple-Hospital Systems: Policies of the Unified Medical Staff Standard: If a unified medical staff, The hospital’s unified medical staff must have written policies and procedures that address how it considers and addresses need s and concerns expressed by members who practice at the hospital. Example: Physicians practicing in a children’s hospital may have concerns about protocols for medication administration that reflect specific pediatric patient concerns National Credentialing Forum18

Orders for Outpatient Services Standard: Outpatient services must be ordered by a practitioner who: 1.Is responsible for the care of the patient. 2.Is licensed in the State where he/she provides care to the patient. 3.Is acting within his or her scope of practice under State law. 4.Is authorized in accordance with State law and policies adopted by the medical staff, and approved by the governing body, to order the applicable outpatient services. Benefit: Hospitals have the flexibility to determine whether or not they will allow a practitioner who is not a member of the medical staff to order outpatient services National Credentialing Forum19

Orders for Outpatient Services Through the Bylaws, the Medical Staff establishes w hether to allow a practitioner who is not a member of the medical staff to order outpatient services consistent with State law and regulations: 1.Non-physician practitioners, such as Physical Therapists, Occupational Therapists, Speech Language Pathologists, Qualified dietitians and qualified nutrition professionals 2.Practitioners with a professional license from another State 2015 National Credentialing Forum20

Medical Staff Approved Policies A.The procedure to implement when a patient presents with a referral or order for outpatient services B.Before start of test/procedure, verify the practitioner is: 1)Licensed in the State where he/she provides care to patient 2)Acting within scope of practice per State law 3)Authorized by the medical staff and governing body to order the applicable outpatient services. C.Documentation expectations 2015 National Credentialing Forum21

Diet Orders Standard: All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals. Includes: Orders for Therapeutic Diets 2015 National Credentialing Forum22

Diet Orders Hospitals have the flexibility to determine whether or not they: 1.Will allow a practitioner who is not a member of the medical staff to order outpatient services 2.The ability to establish through medical staff bylaws and hospital policy other parameters for who will and who will not be authorized to order outpatient services. In accordance with respective State laws, regulations, and other appropriate professional standards. This does not require the granting of privileges, but allows the flexibility to do so if they so choose National Credentialing Forum23

QUESTIONS? Please submit questions to: or 2015 National Credentialing Forum24