1. MANAGEMENT OF TEMPORARY PRIVILEGES – 2016 NCF KAREN BEEM & MAGGIE PALMER

2. HISTORICAL REVIEW For 30 + years, hospitals have adopted policies allowing the CEO (designee) and Chief of Staff to review and grant Temporary Privileges: 1.To fill an urgent patient care need, treatment, or service 2.While awaiting review and approval of privileges by the Governing Body 2

3. THE DILEMMA – SUMMER 2015 At two (2) public forums, a CMS representative cited, “Only the Governing Body can grant privileges.” 3

4. WHAT DOES CMS REQUIRE? CMS is silent on the topic of Temporary Privileges. 4

5. CALLS TO CMS REQUESTING CLARIFICATION 1.May the Governing Body delegate or designate its authority to others to sign off on Temporary Privileges? NO! 2.Would it be acceptable to identify an ad hoc group of 1 or 2 members of the Governing Body for this purpose? NO! This does not constitute a committee. The GB can in its Bylaws identify a committee structure to perform this function. 5

6. CALLS TO CMS REQUESTING CLARIFICATION 3.If the CEO is an ex-officio member of the Governing Body, is it acceptable for the CEO to grant temporary privileges? No! 4.Is it acceptable if a hospital’s Accreditation Organization (AO) allows the CEO to grant temporary privileges? No! The AO would be cited during validation survey. 6

7. REASONS FOR TEMPORARY PRIVILEGES 1.Infrequent Governing Body meetings 2.Canceled Governing Body meetings, e.g., due to bad weather 3.For a “Mission Critical” position 4.For weekend coverage in the ED, etc. 7

8. IS THIS CMS INTERPRETATION A “BAD” THING? Let’s consider: 1.How often is the Medical Staff Office notified on Thursday / Friday to expedite an application? 2.How often have the CEO and Chief of Staff inconvenienced for this urgent request? 3.Is the granting of Temporary Privileging placing your facility at RISK? 8

9. CAN THIS BE A “GOOD” THING? 1.Medical Staff Professionals (MSP) can say, “I cannot process Temporary Privileges” 2.Reduce risk of “Negligent Credentialing” 9

10. MANAGING TEMPORARY PRIVILEGES Best Practice: 1.Idea #1: 1.Idea #2: 2.Idea #3: 10

11. THANK YOU! Maggie Palmer, MSA, CPCS, CPMSM, FACHE National Director of Credentialing Tenet Healthcare 469-893-6230 Maggie.Palmer@tenethealth.com 11

12. THANK YOU! Karen Beem, MS, RN Standards Interpretation The Healthcare Facilities Accreditation Program (AOA/HFAP) 312-202-8069 Kbeem@hfap.org 12