1. COMPARATIVE DIFFERENCES: TJC, CMS & NCQA MEDICAL STAFF and CREDENTIALING STANDARDS
Debra R. Green, MPA, CPMSM, CPCS
Director, Medical Staff Services and Pediatric Residency Program
Stanford University Medical Center
Stanford Hospital & Clinics
Lucile Packard Children’s Hospital

2. Objectives Overview of the 3 main regulatory bodies
Who they are?
What they do?
Why they exist?
Overview of Credentialing Standards
Requirements
Compliance
Survey Process

3. The Joint Commission (TJC)
Who are they?
Private Organization
What do they do?
- Unannounced Surveys
Can Survey “For Cause”
Why do they exist?
To ensure patient care and quality
Who are they?
Private Organization – established in early 50’s. It was written into the Medicare legislation in the 60’s, the law required that any hospitals participating under Medicare had to meet a certain level of quality of patient care as measured against a recognized norm.
Hospitals were given an option to be surveyed under the Joint Commission or Medicare
The cost to participate is substantial
Surveyors are Consultants hired by TJC – most are retired physicians
What they do?
Survey organizations and provides an “accreditation” to those who meet the standards they have set
Survey is done primarily through document review and interviews with leaders and staff
All surveys are unannounced
“Tracer” methodology
Can Survey “for cause” based on a patient complaint
Why do they exists?
To ensure that organizational provider a certain level of patient care and quality.

4. Center for Medicare/Medicaid (CMS)
Who are they?
Government Organization
Surveyors are typically State DOH employees
Gives deeming authority to TJC, HFAP and DNV
What do they do?
Validate TJC
Can Survey For Cause
Why do they exist?
To ensure patient care and quality
Who are they?
Government Organization
Typically employees of your State Department of Health
Give deeming authority to TJC “ Healthcare Facilities Accreditation Program (HFAP) and Det Norske Veritas Healthcare Inc. (DNV)
What do they do?
Survey organizations and provides an “accreditation” to those who meet the standards they have set
They typically perform a “validation” survey within 60 days of a JC visit
Survey is done primarily through document review and interviews with leaders and staff
“Can Survey “for cause” based on a patient complaint
Can randomly select organizations for unannounced surveys.
Why do they exist?
To ensure that organizational provider a certain level of patient care and quality.

5. Authorities Deemed by CMS
Healthcare Facilities Accreditation Program (HFAP)
Over 200 hospital and 200 other HC facilities and labs
Existed for 60 yrs
Det Norske Veritas Healthcare, Inc (DNV)
Certifies other companies in additional to healthcare
Existed since 1884 (began in Norway)
World wide reputation for quality and integrity

6. National Committee for Quality Assurance (NCQA)
Who are they?
Private Organization
What do they do?
Accredits: MCO’s, MBHO’s, PPO’s, NHP’s etc.
Certifies: CVO’s
Delegated Credentialing Agreements
Hospital does the work for MCO
Who are they?
Newest of the 3 –created in the late 70’s
Unlike TJC and CMS – they accredites Private Organization
What do they do?
Unlike TJC and CMS who accredits hospitals, NCQA accredits;
Managed Care organizations (MCO)
Managed Behavioral Healthcare organizations (MBHO’s)
New Health Plans (NHPs)
Preferred Provider Organizations (PPOs)
Disease Management
VA Human Research Protection Programs
NCQA certifies:
Credentials Verification Organizations (CVOs)
Delegated Credentialing Agreements
Hospital does the work for MCO
This is the area that applies to how I am involved with NCQA
Delegated Credentialing Agreements with 16 Managed Care Plans
We do the credentialing for them, they come in and audit us.
Audit Fairs – twice a year – March and October

7. Overview of Standards Joint Commission
13 total MS Standards
Several Elements of Performance (EP’s)
Several changes to MS Standard – 2007, eff 1/2008
CMS Conditions of Participation (CoP’s)
5 MS Standards
Evidence of Compliance
NCQA
12 Standards (Credentialing)
Elements of Performance for each Standard
Move right into comparing the differences.

8. MEDICAL EDUCATION TJC Requirement
(I) Primary Source verification from Medical School
Alternate sources:
AMA, AOA, ECFMG
NCQA Requirement
(I) Primary source verification from Medical School
Not required if board certified or if residency has been verified
Alternate sources: AMA, AOA, ECFMG (after 1986), state licensing agency

9. POST GRADUATE TRAINING
TJC Requirement
(I) Primary source verification from training program
Alternate sources:
AMA, AOA
NCQA Requirement
(I) Primary source verification from training program
Alternate sources:
AMA, AOA, state licensing agency
Not required if board certified (n/a for dentists)
Because medical specialty boards verify education and training, verification of board certification fully meets the requirement for verification of education and training, unless otherwise stated below. Expired board certification may not be used to verify education or training.
Printout from state licensing agency's Web site: The organization may use a dated printout of the licensing agency's Web site in lieu of a letter or other written notice as long as the site states that the agency verifies education and training with primary sources and indicates that this information is current.
NCQA also accepts “sealed” transcripts as a primary source

10. PEER REFERENCES NCQA Requirements
(I&R) Peer Review through Credentials Committee with representation from similar types and degrees of expertise
TJC Requirements
(I&R) Required
Peer must be within same professional discipline (advisable to utilize peer in same specialty)
Recommendations should address training or experience, clinical competence and ability to perform privileges
6 General Competencies
Now we’ve discovered that a Surgeon could evaluate and Anesthesiologist and vice versa. Physicians who use other specialties as consultants or work closely together.
6 General Competencies:
Medical/Clinical Knowledge
Technical and Clinical Skills
Clinical Judgement
Interpersonal Skills
Communication Skills
Professionalism

11. WORK HISTORY TJC Requirement
(I) Doctor must provide chronological history of his education, training and experience
Determination of “significant” clinical performance
NCQA Requirement
(I) Doctor must provide five year work history on application or CV
No verification required but must explain gaps of 6 months or more
Determination of Significant clinical performance
Example: Physician who transitioned away from providing care to do research for example for 5 years. The physician has not had any clinical performance in 5 years……so you have to collect the work history to determine what he/she has recently done.

12. HOSPITAL PRIVILEGES TJC Requirement “Ability to perform”
Significant clinical performance
Practice within scope
Grant or Deny must be objective and evidence based
NCQA Requirement
Application must include attestation statement from applicant regarding history of limitation or loss of clinical privileges or other disciplinary action
NOTE: NCQA does not require doctors to have clinical privileges at an acute care facility
There are several references to “privileges” in the new standards – couldn’t capture them all on 1 slide MS
Collect information regarding the “ability to perform”
Medical Staff Must evaluate the practitioners “ability to perform”. Usually done through Peer Evaluation or Chief/Chair Evaluation
Significant clinical performance – we have volume criteria associated with our Medical Staff categories
Practice within scope – example of OB/GYN and Tummy tucks – “abdominoplasty”
Grant or Deny – must be evidenced based – cant not grant privileges just because you don’t like physician or the physician is a competitor.

13. Performance Monitoring
Required only by TJC
Focused Professional Practice Evaluation (FPPE)
Proctoring – Chart Review or Observations
Ongoing Professional Practice Evaluation (OPPE)
Ongoing data assessment for ALL MS
FPPE
USE A SAMPLE PRIVILEGE FORM FOR SHC UROLOGY
Proctoring Guidelines built right into the privileging forms
OPPE:
PPEC by clinical service that reports directly to the Care Improvement Committee (CIC)
Quality Managers assigned to each clinical service – some meet monthly, some meet quarterly.

14. MEDICARE/MEDICAID SANCTIONS
TJC Requirements
Not addressed in standards
NCQA Requirement
(I & R) Current or previous sanctions must be verified
Verify through NPDB, OIG, CMS, FSMB, state Medicaid agency

15. ONGOING MONITORING OF SANCTIONS
TJC Requirements
Not addressed in standards
NCQA Requirement
P&P’s for the ongoing monitoring of sanctions
1) Medicare/Medicaid
2) License
3) Complaints
Documentation is regularly obtained and reviewed
Monitoring Adverse Events

16. DEA/CDS TJC Requirement
(I & R) Doctor must provide information regarding previously successful or currently pending challenges or relinquishment of registrations
NCQA Requirement
(I & R) Verify through copy of certificates, NTIS, AMA
The National Technical Information Service serves as the largest central resource for government-funded scientific, technical, engineering, and business related information available today
MS EP 9
NCQA CR 7

17. CONTINUING MEDICAL EDUCATION
TJC Requirement
(I & R) Participate in Continuing Education
Documented
Considered in Privilege process
Should be relevant to clinical privileges requested
NCQA Requirement
(I & R) Not Required MS

18. MALPRACTICE INSURANCE
TJC Requirements
Primary source verification not required unless required by bylaws.
(I & R) MS must evaluate professional liability actions
NCQA Requirement
Primary source verification not required
(I & R) Attestation by doctor or copy of policy showing dates and amount of coverage or Face Sheet
MS EP 9
NCQA CR 7 C

19. MALPRACTICE HISTORY TJC Requirement
(I & R) evaluate evidence of “unusual” or “excessive” number of actions resulting in a final judgment.
NCQA Requirement
(I&R) Doctor must provide malpractice history for past five years.
Verified through carrier or NPDB
MS EP 9
NCQA CR 7 B

20. NATIONAL PRACTITIONER DATA BANK
TJC Requirement
(I&R) Must query at granting of initial, renewal and when a new privilege is requested.
NCQA Requirement
(I&R) Query if you can’t obtained last 5 years of claims from Insurance carriers.
Use as alternate source for sanctions or limitations on licensure
MS EP 7

21. HISTORY OF FELONY CONVICTIONS/Drug Use
TJC Requirements
Terminology is not used in Medical Staff Standards
Required under HR Standards
NCQA Requirements
(I&R) Application must attest to his/her history of loss of license and felony conviction and lack of illegal drug use.
JC – if a physician is employed by the hospital, they will need a back ground check.
We use USA Fact to do complete back ground checks at initial and reappointment for all MS and APPs
NCQA CR 4 - A

22. BOARD CERTIFICATION NCQA Requirement TJC Requirement
(I) Verification not required unless bylaws require board certification
(R) Organization Specific
Verify through ABMS, AOA or specialty board
NCQA Requirement
(I) Not required, but verify through ABMS, AMA, AOA, state licensing agency if board certified
(R) Verify only if certification has expired (including lifetime)
Must document “lifetime” in lieu of expiration date
We currently to not have Board Certification as a Medical Staff Requirement because as an Academic Medical Center, we recruit physicians from other countries. They do not qualify to American Boards because they didn’t train in the U.S. However, all of the clinical departments have adopted a privileging criteria to include board certification of foreign equivalent.

23. LICENSE NCQA Requirement TJC Requirement
(I & R)Primary source verification required at initial appointment, reappointment, revision of privileges and at time of expiration
Current and Valid
Verify through state licensing board
NCQA Requirement
(I & R) Primary source verification required
Must be current and valid
In effect at time of credentialing decision
Verify through state licensing board MS
NCQA CR A

24. LICENSE SANCTIONS TJC Requirements
(I & R) The doctor must provide information regarding challenges or relinquishment of license (attestation question)
NCQA Requirements
(I & R) Primary source verification
Verify through state license board, NPDB, or FSMB
MS EP 9

25. ATTESTATION STATEMENT
TJC Requirements
Terminology Not Used
NCQA Requirements
Applicant must provide a current, signed attestation statement regarding the correctness and completeness of application
NCQA CR 4 - A

26. TIME FRAME FOR COMPLETION
TJC Requirement
Structured procedure must be defined in bylaws
Complete applications must be acted upon within reasonable time frame as specified in bylaws
NCQA Requirement
Credentials information must be no more than 180 days old at the time of credentialing committee’s decision
MS EP 11
NCQA - ALL

27. LENGTH OF APPOINTMENT PERIOD
TJC Requirement
May not exceed two years
NCQA Requirement
Effective 7/1/01 credentialing period may be for 36 months
MS EP 8
NCQA CR 8

28. NOW ABOUT CMS…..
Some of the standards and the interpretations for the standards are very vague and obscure. Like with other regulatory standards, they tell you what you have to do, but not how you have to do it.
5 Major Standards – some of the standards are broken down into several parts
Changes to H&P standard 2007

29. Medical Staff Organization
Regulation:
Organized medical staff ; operates under bylaws that are approved by governing body; responsible for quality of care.
Compliance:
Bylaws, R&R’s, Cred files, Quality Reports, Meeting minutes

30. MS Composition (a) Regulation: Compliance:
MS composed of MD’s, DO’s according to state law; may also include others appointed by Governing Body.
Compliance:
MS Rosters, Cred Files, Minutes or approved Bylaws categories.

31. MS Composition (a)(1) Regulation: Compliance:
MS must conduct periodic appraisals
Compliance:
Cred Files, Profiles, Summary Reports of Credentialing activity, Board minutes documenting last 2 appraisals

32. MS Composition (a)(2) Regulation: Compliance:
MS must examine credentials of applicants for membership and make recommendation to Board.
Compliance:
Definition of Creds Review Process in the Bylaws; any MS or Dept minutes that document review and recommendations.
Notice:….it says nothing of privileges – but they definitely look a privileges and competency when they survey.
Compliance: Definition of Credentials Review process in Bylaws, R&Rs, Policies

33. MS Organization & Accountability
Regulation:
MS must be well organized and accountable to Governing Body for quality of Medical Care provided.
Compliance:
MS Org Chart, Bylaws Description, Board Minutes, definition of MS Composition in Bylaws, Bylaws approval by Board

34. Medical Staff Bylaws Requirement: Compliance: MS must adopt & enforce.
Must be approved by Board; include category descriptions, H&P requirement and criteria for privileges to be granted; describe MS Organization and applicant qualifications;
Compliance:
Bylaws, R&R, Minutes, Medical Records (H&Ps), Quality reports (H&P timelines data)

35. Autopsies Requirement: Compliance:
Secure in all cases of unusual deaths and for med/legal educational interests.
Compliance:
R&R, Autopsy Policy, QA or PI reports; Medical Record Review.

36. History & Physicals (H&P)
New Requirement as of 2007:
No more than 30 days before or 24 hrs after admission
Old Requirement:
No more than 7 days before and 48 hrs after
Clarification as of 2007

37. Success Tips for Compliance
Continuous Readiness
File Audits
Database Audits (Appendix A)
Increased Staff Knowledge (Appendix B)
Employee Motivators/Incentives
Continuous Readiness
Surveys are unannounced – we no longer have 6 to 12 months to prepare
File Audits
Monthly – we do as a group. All coordinators get together an audit each others files. Complete an audit sheet that goes to the manager. The audit sheets are anonymous so that the staff are unaware of who audited them. The credentials manager collects all audit sheets and they become part of the employees evaluation. For more serious issues, the employee is counseled immediately.
Database Audits
Increased Staff knowledge- sample
Fun Quizzes at staff meeting – offer grab bag
Employee Motivators/Incentives
“Comp” time – 2 hours for no errors in file audit
2 hours for no errors in database audit

38. Appendix A This is a aggregate of weekly audits
Report is complied every month

39. Appendix B Fun Quiz Educational and Motivational Tool
Temporary Privileges
(Answer Sheet)
1. Under certain circumstances, temporary clinical privileges may be granted for a limited period of time.
TRUE
2. When temporary privileges are granted to meet an important care need, the organized medical staff verifies only current licensure and current competence before the provider can begin seeing patients.
3. Temporary privileges for new applicants are granted for no more than 90 Bylaws/120 TJC days.
4. All temporary privileges are granted by the chief executive officer or authorized designee.
5, Under which circumstances does the Joint Commission allow temporary privileges to be granted?
a. To fulfill an important patient care, treatment, and service need.
b. When a new applicant with a complete application that raises no concerns is awaiting review and approval of the medical staff executive committee and the governing body.
Bonus Question:
Temporary privileges for new applicants may be granted while awaiting review and approval by the organized medical staff upon verification of……? List 5 items
- Current licensure.
- Relevant training or experience.
- Current competence.
- Ability to perform the privileges requested.
- Other criteria required by the organized medical staff bylaws.
- A query and evaluation of the National Practitioner Data Bank (NPDB) information.
- A complete application.
- No current or previously successful challenge to licensure or registration.
- No subjection to involuntary termination of medical staff membership at another organization.
- No subjection to involuntary limitation, reduction, denial, or loss of clinical privileges.
All answers can be found in the Joint Commission Medical Staff Standards under MS
Educational and Motivational Tool
Appendix B
Done at staff meeting
Blank exam given
Who ever gets all of the answers get a gift from a grab bag
Who ever gets the bonus gets a 2nd gift
The quizzes come back randomly until everyone gets all answers correct

40. Questions????
Contact information:
Phone: