1. JOINT COMMISSION PANEL
Panel discussion regarding recent joint commission surveys
MASSACHUSETTS ASSOCIATION OF MEDICAL STAFF SERVICES
May 11, 2017

2. PANEL MEMBERS
Kimberley M. Coon, BA, CPMSM, CPCS – Director of Medical Staff Services/Provider Enrollment, Southcoast Health System
Barbara E. Prats, CPMSM, CPCS – Manager Baystate Health, Central Verification Organization
Karen Roy, CPCS, Sr. Credentials Specialist, Emerson Hospital
Inna Voskresensky, MHA, CPCS, CPMSM – Spaulding Rehabilitation Network Credentialing Manager

3. PANEL MEMBERS
This interactive panel will share their experience with their most recent JC survey, the focus areas of the surveyors, survey findings, and the surveyor’s recommendations and suggestions for improving our practices.

4. Key Learning Objectives
How to prepare for a successful JC survey
Review of the recent JC surveys & lessons learned
Review of the best practices shared by the surveyors
The survey is over – now what?

5. Preparing for the JC survey
MOCK survey
The JC binder (include MS governing documents, credentialing policies and procedures, etc.)
Credentialing files audit
FPPE/OPPE audit
Policies revision
Evaluation of compliance with the JC MS standards
Follow up on findings/things that need to be fixed
Educational flyers

6. Preparing for the JC Survey (cont’d)
Notes for surveyor
Arrange scribing of the JC MS session
Review most recent JC surveys notes/findings from other institutions
Prepare your Credential Committee Chair and Medical Staff President
Once the JC arrives

7. Preparing for the JC Survey (cont’d)
Identify key staff and leaders to attend the session:
Credentials Office Staff
Credentials Committee Chair
Chief Medical Officer
Department of Medicine Chair
Department of Surgery Chair
FPPE/OPPE Coordinator
Professional Review Committee Chair

8. Preparing for the JC Survey (cont’d)
Send Bylaws and other policies to the team leader for the JC surveyors if you haven’t at this point
Wait to receive your list of files for the audit,
then review your files prior to the scheduled
session with the JC
Know your surveyor (google him/her) prior to meeting him/her

9. SURVEY “HOT TOPICS” Authentication of providers orders
FPPE/OPPE – Your own policy needs to be followed
Restraint documentation is properly completed and timeline is followed
Temporary Privileging process
Expedited Privileging process
Medical Executive Committee recommendation to Board of Trustees for all credentialing matters
Medical Executive Committee meeting minutes carefully reviewed

10. SURVEY “HOT TOPICS” (cont’d)
Credentialing telemedicine providers
Residents and fellows oversight (GMEC role and responsibilities)
Orientation/onboarding of new providers
Education of clinical staff on how to check who is credentialed and what privileges practitioner has
Practitioners with procedural privileges in regards to F/OPPE
FPPEs – when, how, who

11. SURVEY “HOT TOPICS” (cont’d)
OPPE for Advanced Practitioners
Services Contract – particularly the opt out clause if metrics and expectations weren’t met
Credentials Committee Chair’s knowledge of the FPPE and OPPE
Proof of valid ID for Providers
Transition from a paper file to an electronic credential file

12. Best Practice - Medical Staff Leadership Collaboration = Survey Success
Build a partnership with medical staff members and leaders
Provide education regarding standards
Collaborate to identify opportunities for process improvement
Accountability to the Medical Staff Office – for a win/win outcome
Reinforce the value of going the extra mile

13. BEST PRACTICES IDENTIFIED BY SURVEYOR
State license and NPDB report completed within 2 months from the Board approval date
Consistency in how you address outliers (OPPE)
Telemedicine providers OPPE completed by the distant site
The use of a Premier Benchmarking Report on our Physicians for OPPE
The review of electronic files

14. Best Practice Identified for OPPE
OPPE Preparation:
Create a dashboard “on paper” showing the metrics of interest for each group, listed by practitioner name
The dashboard was created using PowerPoint. It consisted of screen shots from a physician performance evaluation tool, excel pivot tables, and excel graphs.
Once the list of practitioners to be audited were identified; names were highlighted for easy identification.
Snap shots of “sign offs” were also prepared to validate timely approvals.

15. THE SURVEY IS OVER – WHAT’S NEXT?
Present the findings/recommendations/suggestions to the Credentialing Committee & Medical Staff Executive Committee
Develop a plan to improve current practices (include goals, timelines for implementation, responsible parties, etc.)
Monitor new practices
Measure success
Re-educate, re-evaluate

16. THE SURVEY IS OVER – WHAT’S NEXT?
If major findings, submit any improvement plan to the JC by the required time frame

17. Appreciation/M0tivation for Staff