1. FTCA Marti Wolf, RN, MPH Clinical Programs Director
North Carolina Community Health Center Association

2. When submitting FTCA application, it should include all providers, including new hires who are not yet working at the health center.
Minutes of meetings are adequate for documenting Board approval.
We are Joint Commission Accredited. Therefore our Credentialing/Privileging meets or exceeds HRSA standards.
QI/QA and Risk Management Plans should be approved every 3 years.
For Peer Review, NPs and PAs can review MDs.
Assessment

3. FTCA Remember you are working a year in advance Annual Re-deeming
2014 FTCA applications went in March 2013
Annual Re-deeming
New deeming can be done any time during the year
FTCA

4. Elements of FTCA Credentialing and Privileging Quality Improvement
Risk Management
Peer Review
FTCA “Bibles”
PIN
PIN
Annual PIN
Elements of FTCA

5. RISK MANAGEMENT

6. FTCA- Risk Management Assess, identify, analyze
Control/avoid/minimize/eliminate events
Cause a loss to the organization
Adverse outcomes
Harm
Proactive instead of Reactive
FTCA- Risk Management

7. Risk Management is comprehensive of the entire organization.
Risk Management is Board driven and Board overseen.
Risk Management and/or QI programs audit Cred/Priv processes to ensure compliance.
Risk Management PLAN
FTCA- Risk Management

8. FTCA-Risk Management Governance Administrative Business/Finance
Environment
Human Resources IT
Clinical
FTCA-Risk Management

9. FTCA- Risk Management Clinical risk management includes:
Annual risk assessment
Clinical protocols
Peer reviews
Supervision of health center staff: clinical and nonclinical
Medical records policies
Triage policies (walk-in and phone)
No show appointment policies
Tracking policies: referrals, hospitalizations and diagnostic testing
FTCA- Risk Management

10. NonClinical Building and Grounds- Safety and Security- Equipment management-Board Responsibilities- Contracts and Procurement- Record Retention- Corp/Regulatory/Grant Compliance-Disaster Prep- Incident Report management- Finance/billing- Human Resources compliance (FMLA, at will employment)- Staff Training- Credentialing-IT (backup, security levels)- Patient satisfaction- Disaster Response- HIPAA
FTCA-Risk Management

11. FTCA- Risk Management Staff training in Risk Management
Description of available opportunities
Process to ensure staff receive RM training
FTCA- Risk Management

12. FTCA- Risk Management Training Topics- depending on your Scope
Patient safety
Infection control/hand hygiene
Teamwork and communication
Medication safety
Fall prevention
Fire safety
Documentation
Disaster planning
Obstetrics safety
OSHA
Bloodborne Pathogen
Hazard Communication/ Disclosure
Hand Hygiene
Sharps Injury Prevention
PPE
MSDS
FTCA- Risk Management

13. FTCA-Risk Management Prevention of Medical Malpractice
Scope of grant and privileging
Clinical outcomes measurement
Event/incident monitoring
Supervisory agreements
NPDB
Claims reviews
FTCA-Risk Management

14. FTCA- Risk Management Implementation is documented by P/P
Training- right up to BOD
Data on RM activities
Minutes showing data being reviewed
Solutions to identified problems are implemented
On-going monitoring and risk assessment
Board reports
FTCA- Risk Management

15. FTCA-Risk Management P/P Triage No shows Supervision of staff
Referrals/Hospitalization/Diagnostics
FTCA-Risk Management

16. QUALITY IMPROVEMENT

17. FTCA- Quality Improvement
Plan should include:
Statement of purpose
Scope of plan
Administrative responsibility
Risk management systems
Committee membership
Committee accountability
Activities; tracking
Approval; review
FTCA- Quality Improvement

18. FTCA- Quality Improvement
QI and Board meeting minutes should:
Include specific data about ongoing QI projects
Report performance on selected measures from QI plan
Progress on goals for QI program
MINUTES FROM ANY 6 MEETINGS*
FTCA- Quality Improvement

19. FTCA- Quality Improvement
Clinical Protocols
Frequent conditions
Standards of Care
Updated
Provider/clinical staff training
Peer review based on Clinical Protocols
QI metrics
FTCA- Quality Improvement

20. Credentialing and Privileging

21. FTCA-Credentialing and Privileging
Credentialing: The process of assessing and confirming the qualifications of a licensed or certified healthcare practitioner to render specific health care service(s). Privileging: The process of granting the qualified health care provider (Licensed independent practitioners ) the permissions to render specific health care services and perform specific health care procedures for a limited time (2 years).
FTCA-Credentialing and Privileging

22. AND is the operative phrase
Credentialing IS NOT THE SAME as Privileging
FTCA-Credentialing and Privileging

23. FTCA-Credentialing and Privileging
Ensures all health care providers (LIP’s) and clinical staff (licensed and certified) are qualified to render the type of care for which they are employed.
Involves evaluating a practitioner’s eligibility to provide clinical services at the health center and evaluating the provider’s competency for specific clinical privileges.
Failure to fully credential may result in liability if a patient is harmed.
FTCA-Credentialing and Privileging

24. FTCA-Credentialing and Privileging
Policy Information Notice (PIN) , Credentialing and Privileging of Health Center Practitioners requires that "all Health Centers assess the credentials of each licensed or certified health care practitioner to determine if they meet Health Center standards." This policy applies to all health center practitioners, employed or contracted, volunteers and locum tenens, at all health center sites.
FTCA-Credentialing and Privileging

25. FTCA-Credentialing and Privileging
You must comply with HRSA policies
Joint Commission or other accreditation/recognition bodies do not supersede HRSA requirements
Must comply with any state regs
Cross check with your Scope to ensure they match your privileging/services provided
FTCA-Credentialing and Privileging

26. FTCA-Credentialing and Privileging
DOCUMENTATION: Attachment E: upload the credentialing list (excel spread sheet).
FTCA-Credentialing and Privileging

27. FTCA-Credentialing and Privileging
On your credentialing list
All practitioners, employed or contracted, volunteer and locum tenens
From all of your sites
ONLY THOSE CURRENTLY WORKING AT TIME OF THE SUBMISSION
FTCA-Credentialing and Privileging

28. FTCA-Credentialing and Privileging
DOCUMENTATION: ATTACHMENTS F1 AND F2
Approval of the Cred/Priv Policy
F1- your credentialing and privileging POLICY
Board approved- date and signature of board chair
F2- board minutes as proof of board approval
Signed and dated and clearly indicate board approval of the Policy
FTCA-Credentialing and Privileging

29. FTCA-Credentialing and Privileging
Credentialing Procedure (plan)
Addresses your duty to care for patients and prevent harm
STEP by STEP PROCESS
Provides for on-going education, training and licensure/certification
“Provides a clear pathway… to hire and/or dismiss clinical staff”
All LIPs, and other licensed/certified practitioners
FTCA-Credentialing and Privileging

30. FTCA-Credentialing and Privileging
TIPS For a HAPPY Credentialing Plan
HRSA likes to see the PINS referenced in the Policy and Procedure
Specifically indicates when primary and 2ndary sources are used (… see PINs )
Specifies re-credentialing every 2 years
Includes Board approval or specifies how Board approval of Policy and Credentialing are delegated
Policy and Plan should be approved and re- signed every 3 years
FTCA-Credentialing and Privileging

31. Common Confusion FTCA-Credentialing and Privileging
PRIMARY SOURCE VERIFICATION
Direct written correspondence
telephone
Internet
CVO report (cred verification org)
AMA Master File, other medical boards
SECONDARY SOURCE VERIFICATION
Original credential
Notarized copies
Copy of credential – must be made by approved health center staff member
FTCA-Credentialing and Privileging

32. FTCA-Credentialing and Privileging
Primary source verification for LIPs is obtained for the following:
Applicant’s license
Applicant’s education, training, experience
Applicant’s registration
Application’s certifications
Applicant’s current competence
Applicant’s ability to perform services for which privileges are requested
Secondary source verification for LIPs is obtained for the following:
Government-issued photo ID
DEA registration (if applicable)
Hospital admitting privileges (if applicable)
Immunization and PPD status
FTCA-Credentialing and Privileging

33. FTCA-Credentialing and Privileging
Primary source verification for other providers is obtained for the following:
Applicant’s license
Secondary source verification for other providers is obtained for the following:
Applicant’s education, training, experience
Applicant’s registration and certifications
Applicant’s current competence
Applicant’s ability to perform services for which privileges are requested
Government-issued photo ID
DEA registration (if applicable)
Hospital admitting privileges (if applicable)
Immunization and PPD status
FTCA-Credentialing and Privileging

34. FTCA-Credentialing and Privileging
CHECKLIST of required information
Curriculum vitae (CV)
Diplomas (e.g., undergraduate, post-graduate, medical school, residency, fellowship)
Statement confirming health fitness
Certificates (e.g., board certification, BLS, ACLS)
Medical licenses
Drug Enforcement Administration (DEA) registration (if applicable)
Controlled Dangerous Substances (CDS) registration (if applicable)
Peer references
FTCA-Credentialing and Privileging

35. FTCA-Credentialing and Privileging
But Wait! There’s MORE! CHECKLIST of required information
Proof of liability insurance
Summary of malpractice claims/adverse actions filed against the provider
National Practitioner Data Bank (NPBD) query q 2 yr
Delineation of privileges
Government-issued picture identification
Immunization and PPD status
Life support training (if applicable)
Fit for duty
Verification of hospital and/or facilities privileges
FTCA-Credentialing and Privileging

36. Your responsibilities
Maintain complete and organized required credentialing documentations and records.
Regularly identify expiring credentials before expiration
Review each file once per year to identify any missing items.
If you use a credentials verification organization (CVO):
Ensure the CVO understands FTCA requirements.
The contract with the CVO speaks to privacy, document owners, document retention.
Ensure your privacy release (signed by LIP) speaks to the use of a CVO by the organization.
Your responsibilities

37. Each practitioner should be privileged specific to the services prior to rendering services.
Privileging processes verifies clinical privileges and medical staff membership at local facilities (admitting privileges, etc)
Renewal or revisions of privileges for LIPs and other licensed or certified practitioners must occur at least every two years.
Full and temporary privileges need to be clearly defined (time limited with only specific reasons for temporary).- at least q 2 yrs
Providers must be privileged prior to rendering health care services.
Privileges

38. Approved applicants are notified in writing within a defined timeframe.
Approved applications and a copy of the approval letter are forwarded to appropriate internal personnel within a defined timeframe.
Applications whose requests are denied are notified within a defined timeframe.
The health center has a defined policy for making changes to final approved/denied applications.
Board must approve privileges or must formally delegate this activity to a committee
Board must document approval of privileges
Privileges

39. Peer Review Peer Review is a QI process Quality of care Patient safety
Learn from past performance, errors, near misses
Is integral to credentialing and privileging
Per FTCA, Midlevels can review MDs
Peer Review

40. Peer Review Who is in charge of Peer Review Process
Duties/Responsibilities of that person
Frequency of review
Number of charts reviewed per provider
How feedback is communicated and documented
Maintains pt confidentiality during the process
How peer review is communicated to BOD
Methodology for improvement strategies
Peer Review

41. ALIGNS WITH PCMH Referral/hospitalization/diagnostic tracking P/P
Quality Improvement Plan and Activities
ALIGNS WITH PCMH

42. When submitting FTCA application, it should include all providers, including new hires who are not yet working at the health center.
Minutes of meetings are adequate for documenting Board approval.
We are Joint Commission Accredited. Therefore our Credentialing/Privileging meets or exceeds HRSA standards.
QI/QA and Risk Management Plans should be approved every 3 years.
For Peer Review, NPs and PAs can review MDs.
Assessment

43. HRSA Resources FTCA/BPHC Help Line
Phone: BPHC ( )
9:00 AM to 5:30 PM (ET)
FTCA Website:
HRSA Quality Improvement Webinars:
HRSA Resources

44. ECRI Resources (paid for by HRSA)
Sample Risk Management Policy: Physician Office Practice
Patient Satisfaction Questionnaire
Anecdotal Note for Patient Concerns
Handling Patient Complaints
Safety Attitudes Questionnaire (Ambulatory Version)
Risk Management Plan:
Event Reporting Toolkit:
Webinars
Clinical Risk Management Basics Part I
Developing a Risk Management Plan
ECRI Resource Page: Quality Improvement:
ECRI Resources (paid for by HRSA)