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Credentials File Audits: Tools and Techniques

for Credentialing Compliance

Session Code: TU06

Date: Tuesday, October 24

Time: 9:30 a.m. - 11:00 a.m.

Total CE Credits: 1.5

Presenter(s): Kathleen Matzka, CPMSM, CPCS

Credentials File Audits:Tools and Techniques for Compliance

Kathy Matzka, CPMSM, CPCS www.kathymatzka.com 1

Performing Credentials File Audits:

Tips and Techniques for Credentialing Compliance

Kathy Matzka, CPMSM, CPCS, FMSP

What We Will Cover…

Reasons for Audits

How Audits are Performed

Creating Audit Tools

Reporting/Follow-up

3



Reasons for Audits

Comply with Requirements

Negligent Credentialing Issues

Tool for Performance Evaluation

Everyone Makes Mistakes!

4

Medicare CoP Privileging Criteria

Character

5

Criteria

CMS Survey Procedures

Review credential files to determine if the facility complies with CMS requirements and State law, as well as, follows its own written policies for medical staff privileges and credentialing

Review the hospital’s method for reviewing the surgical privileges of practitioners. This method should require a written assessment of the practitioner’s training, experience, health status, and performance

6



How Audits are Performed

7

Determine process to be auditedStep 1

Select filesStep 2

Review file, logging resultsStep 3

Compile summary reportStep 4

Share resultsStep 5

7

Determine Process to be Audited

New Applicant

Reapplicant Expirable

8

Identify Elements to be Included

Accreditation Standards

State Regulations

Bylaws/P&P

9

Include timeframes



Record Selection Options

Random sampling

Systematic sampling

(“Nth selection”)

Stratified sampling

10

Creating the Audit Tool – New Ap

11

New Application Summary Report

12



Creating the Audit Tool - Reap

13

Reapplication Summary Report

14

Creating the Audit Tool

15



Sharing Results

16

Follow-up

Discuss Results with Staff

• One-on-one

• Departmental meeting

Determine Cause of Deficiencies

• Lack of knowledge

• Performance deficiency

Develop Action Plan

• Retraining

• Staffing

• New P&P

17

Tracking Audited Files

• Keep record of all audits

• Try to audit all files over a period of time

• Continuous monitoring

18



Most Common Deficiencies

Inappropriate peer references

NPDB over 2 years at recredentialing

Privilege forms not completed correctly

Not all facility verifications returned prior to approval

Inconsistent dating

Approval signatures missing or out of sequence

19

Exercise: How Much Time to Audit YOUR Files

Step 1: Multiply number of credentials files X 20 minutes

_100__X 20 minutes = __2000___ minutes

# files

Step 2: Divide number of minutes by 60 minutes (number of minutes in an hour)

_ 2000 _minutes / 60 = _33.33_ hours required for audits

Step 3: Divide number of hours required by the number of work weeks in a year (i.e. deduct number of vacation weeks) to determine how much time you will have to spend each week to audit all files in a year.

_33.3__hours required for audits / _50__ weeks worked in a year = _.67__ hours

20

Record Retention

Policy for Access, Retention, and Content

Policy for Practitioners no Longer on Staff

21

Do I REALLY need to keep

this?

Who can see this file?

How long do I need to keep

this?



Questions

22

Credentials File Audits:

Tools and Techniques for Credentialing Compliance

Kathy Matzka, CPMSM, CPCS, FMSP Consultant/Speaker

1304 Scott Troy Road Lebanon, IL 62254

[email protected] website: www.kathymatzka.com

Phone (618) 624-8124

BIOGRAPHICAL SKETCH, KATHY MATZKA, CPMSM, CPCS, FMSP Kathy Matzka, CPMSM, CPCS, FMSS, is a speaker, consultant, and writer with 30 years of experience in credentialing, privileging, and medical staff services. Ms. Matzka worked for 13 years as a hospital medical staff coordinator before venturing out on her own as a consultant, writer, and speaker. She holds certification by the National Association Medical Staff Services (NAMSS) in both Medical Staff Management and Provider Credentialing. She is one of the first recipients of the NAMSS Fellow Designation. The Fellow Designation is the pinnacle of achievement and acknowledgment for the Medical Services Professional (MSP), recognizing a career MSP who has made outstanding contributions to the profession through service as a leader, mentor, and educator. Ms. Matzka has authored a number of books related to medical staff services including Medical Staff Standards Crosswalk: A Quick Reference Guide to The Joint Commission, CMS, HFAP, and DVN Standards, Chapter Leader’s Guide to Medical Staff: Practical Insight on Joint Commission Standards, Compliance Guide to Joint Commission Medical Staff Standards, and The Medical Staff Meeting Companion Tools and Techniques for Effective Presentations. For eight years, she was the contributing editor for The Credentials Verification Desk Reference and its companion website The Credentialing and Privileging Desktop Reference. She is co-author of the HcPro’s publication Verify and Comply: Credentialing and Medical Staff Standards Crosswalk, Sixth Edition. Her latest book is The Clinician’s Quick Guide to Credentialing and Privileging which is a resource for physicians and other practitioners. She has performed extensive work with NAMSS’ Education Committee developing and editing educational materials related to the field including CPCS and CPMSM Certification Exam Preparatory Courses and Study Guides, CPMSM and CPCS Professional Development Workshops, Standards Comparison Grid, and NAMSS Core Curriculum. These programs are essential educational tools for both new and seasoned medical services professionals. She also serves as instructor for NAMSS.

Ms. Matzka shares her expertise by serving on the editorial advisory boards for two publications – Credentialing Resource Center Journal, and Credentialing & Peer Review Legal Insider.

Ms. Matzka is a highly-regarded industry speaker, and in this role has developed and presented numerous programs for professional associations, hospitals, and hospital associations on a wide range of topics including provider credentialing and privileging, medical staff meeting management, peer review, negligent credentialing, provider competency, and accreditation standards. In her spare time, Ms. Matzka takes pleasure in spending time with her family, listening to music, traveling, hiking, fishing, and other outdoor activities.

Table of Contents Table of Contents ............................................................................................................ 1 Introduction ..................................................................................................................... 1 How Audits are Performed .............................................................................................. 1

File Selection ............................................................................................................... 1

Audits for New Applicants ............................................................................................ 2 Figure 1 - Audit Tool for New Applicants .................................................................. 3 Figure 2 - Summary Tool New Applicant Audits ....................................................... 4

Audits for Reapplicants ................................................................................................ 6 Figure 3- Audit Tool for Re-Applicants ..................................................................... 7

Figure 4- Summary Tool Re-Applicant Audits .......................................................... 8

Expirables Audits ......................................................................................................... 9 Figure 5- Audit Tool for Expirables ........................................................................... 9 Figure 6 - Summary of Expirables Audit ................................................................. 10

Keeping Track of Files that have been Audited ............................................................. 11 Figure 7- Tracking Tool for File Audits ....................................................................... 11

Reporting Results .......................................................................................................... 11 Follow up Deficiencies ................................................................................................... 12 Policy on Confidentiality, Access To, Retention, And Content of Credentials Files and Records of Medical Staff Committees and Departments ............................................... 13 Policy for Retention of Credentials File Documents for Practitioners No Longer on Staff ...................................................................................................................................... 19

Exercise: How Much Time to Audit YOUR Files ............................................................ 22

Kathy Matzka, CPMSM, CPCS, LLC Credentials File Audits 1

Introduction Although time consuming, credentialing audits are a good idea. Even the most experienced professionals make mistakes and overlook things – it’s part of human nature. In some cases, an element, such as primary source verification of licensure, is completed but the documentation does not get placed in the credentials file. Or perhaps an issue requiring follow-up is identified, but is forgotten when a more urgent issue presents itself. Audits are also helpful in monitoring the work of a new employee. Today’s healthcare market in which over 30 states have recognized the tort of negligent credentialing or have applied broad common law principles of negligence to credentialing issues, is another reason to perform credentials chart audits.

How Audits are Performed While credentials file audits are typically performed by the department manager or person responsible for oversight of the MSP responsible for credentialing, some medical staff managers like to get everyone in the department involved in an audit committee. Here is a basic outline of how credentials file audits are performed:

1. A set number of files are identified for review. 2. The auditor reviews each file and completes a checklist 3. The results of the audits are then compiled into a master report.

Results of the audit can be used internally in the medical staff office, shared with hospital administration, and/or reported at the hospital performance improvement committee. There are different types of audits with individual focuses.

File Selection

In random sampling, each file has an equal and known chance of being selected. When there is a large medical staffs, it is often difficult to audit every file, so a random sample is selected. Systematic sampling, also known as “Nth selection” is often used instead of random sampling. After calculating the required sample size, every Nth record is selected. Systematic sampling is frequently used to select a specified number of records from a computer file.


Stratified sampling occurs when you choose a stratum, or a subset, of records that share at least one common characteristic. Examples of stratums might be members of a certain specialty or those who were appointed within a certain timeframe.

Audits for New Applicants

The audit tool in Figure 1 - Audit Tool for New Applicants is specifically constructed to focus on initial applicants to the medical staff. It includes an audit of all the information required for initial appointment. This audit form can be used for screening all initial appointments to the medical staff to assure that nothing is being missed. Final results can be tallied on the tool in Figure 2 - Summary Tool New Applicant Audits. Notice in the completed example, there are some problems with documentation in the credentials files of two applicants, both of whom are physician assistants. By highlighting the areas of non-compliance, you can easily see where improvement is needed. Figure 2 can also be printed and used in place of Figure 1 if reviews are being conducted by only one person instead of by a committee or group of people.


Figure 1 - Audit Tool for New Applicants

Scoring: 1 = Element is present and in compliance, 0 = Element is not present or is not in compliance, N/A = not applicable

Element of Review Score

Comments

Practitioner Name Justin Smothers, MD

Application present, complete, signed 1

Peer References Received and appropriate 0 One peer reference was from someone who had not worked

with him for 15 years.

All Hospitals/Clinics Verifications received 1

NPDB Query 1

OIG Exclusion Query 1

Medicare Attestation Signature Page 1

PSV Medical School 1 AMA profile

Medical School diploma present 1

ECFMG verification (if applicable) N/A

ECFMG certificate present N/A

Fellowship Verification(s) N/A

Fellowship certificate(s) present N/A

PSV of Residency present 1 AMA profile

Residency certificate(s) present 1

PSV of [your] state license 1

Copy of [your] state license present 1

PSV of other state License(s) N/A

PSV of state controlled substance license 1

Health Assessment/immunization record present 1

PSV Board Certification 1

Current professional liability Insurance face sheet present with acceptable limits/tail/nose 1

PSV of professional liability Insurance face sheet present with acceptable limits/tail/nose 1

Current DEA Certificate present 1

AMA Profile Present 1

FSMB Query Present 1

Privilege Form

Privilege form present and appropriate to specialty

1

Form signed by applicant 1

Form completed correctly 1

Form signed by department chair and completed appropriately

1

Date of Audit: _________5/6/2017 Audit Performed by: ______Kathy

Matzka__________________


Figure 2 - Summary Tool New Applicant Audits


Element of Review File 1 File 2 File 3 File 4 File 5 File 6 File 7 File 8 File 9 File 10

Rati

o

(#/#

)

Practitioner Name

Justin Smothers,

MD

Tim Jones,

MD

Leah Ahmed,

MD

Franklin Thomas,

MD

Wesley Cook,

PA

Peter Collins,

MD

Jennifer Cook, MD

A. Kumar,

MD

Joseph McGee,

MD

Linda Chappel,

PA

Application present, complete, signed 1 1 1 1 1 1 1 1 1 1 10/10

Peer References Received and appropriate 0 1 1 1 1 1 1 1 1 1 9/10

All Hospitals/Clinics Verifications received 1 1 1 1 1 1 1 1 1 1 10/10

NPDB Query 1 1 1 1 0 1 1 1 1 0 8/10

OIG Exclusion Query 1 1 1 1 0 1 1 1 1 0 8/10

Medicare Attestation Signature Page 1 1 1 1 N/A 1 1 1 1 N/A 10/10

PSV Medical School 1 1 1 1 1 1 1 1 1 1 10/10

Medical School diploma present 1 1 1 1 1 1 1 1 1 1 10/10

ECFMG verification (if applicable) N/A N/A 1 N/A N/A N/A N/A 1 N/A N/A 10/10

ECFMG certificate present N/A N/A 1 N/A N/A N/A N/A 1 N/A N/A 10/10

Fellowship Verification(s) N/A N/A 1 N/A N/A N/A N/A N/A N/A N/A 10/10

Fellowship certificate(s) present N/A N/A 1 N/A N/A N/A N/A N/A N/A N/A 10/10

PSV of Residency present 1 1 1 1 N/A 1 1 1 1 N/A 10/10

Residency certificate(s) present 1 1 1 1 N/A 1 1 1 1 N/A 10/10

PSV of state license 1 1 1 1 1 1 1 1 1 1 10/10

Copy of state license present 1 1 1 1 1 1 1 1 1 0 9/10

PSV of other state License(s) N/A 1 N/A N/A 0 N/A 1 N/A 1 0 8/10

PSV of state controlled substance license 1 1 1 1 N/A 1 1 N/A 1 N/A 10/10

Health Assessment/immunization record present 1 1 1 1 1 1 1 1 1 1 10/10

PSV Board Certification N/A 1 1 1 1 N/A 1 1 1 1 10/10

Current DEA Certificate present 1 1 1 1 N/A 1 1 1 1 N/A 10/10



Rati

o

(#/#

)

AMA Profile Present 1 1 1 1 1 1 1 1 1 1 10/10

FSMB Query Present 1 1 1 1 N/A 1 1 1 1 N/A 10/10

Current professional liability Insurance face sheet with acceptable limits/tail/nose 1 1 1 1 1 1 1 1 1 1 10/10

Privilege Form


1 1 1 1 1 1 1 1 1 1 10/10

Form signed by applicant 1 1 1 1 1 1 1 1 1 1 10/10

Form completed correctly 1 1 1 1 1 1 1 1 1 0 9/10


1 1 1 1 1 1 1 1 1 1 10/10

Date of Audit: _________5/6/2017 Audit Performed by: Kathy Matzka_____________________


Audits for Reapplicants

The audit tool in Figure 3- Audit Tool for Re-Applicants is specifically constructed to focus on reapplicants to the medical staff. It includes and audit of all the information required for reappointment. It does not include an audit of those areas that would have already been audited on initial appointment. Final results can be tallied on the tool in Figure 4- Summary Tool Re-Applicant Audits. These tools are completed the same as those for initial applicants. Highlight those areas that show potential problems.


Figure 3- Audit Tool for Re-Applicants


Element of Review Score COMMENTS

Practitioner Name Jesse Wagner, PA

Reapplication present, complete, signed 1

Peer References Received and appropriate 0

One peer recommendation is not in same discipline

All Hospitals/Clinics Verifications received 1

NPDB Query 1

PSV of [your] state license 1

Copy of [your] state license present 1

PSV of other state License(s) N/A

PSV of state controlled substance license 1


PSV Board Certification 1

Current professional liability insurance face sheet with acceptable limits/tail/nose 1

PSV of professional liability insurance face sheet with acceptable limits/tail/nose 1

Current DEA Certificate present N/A

FSMB Query Present N/A

Privilege Form


1

Form signed by applicant 1

Form completed correctly 1


1

OPPE/PI Profile

PI Profile Present 1

Profile Reviewed by Dept Chair 1

Department chair recommendation present 1

Date of initial appointment or reappointment <= 2 years from date of

reappointment 1

Date of Audit: _______5/6/2017 Audit Performed by: _____Kathy

Matzka______


Figure 4- Summary Tool Re-Applicant Audits Scoring: 1 = Element is present and in compliance, 0 = Element is not present or is not in compliance, N/A = not applicable


Rati

o

(#/#

)

Practitioner Name

Reapplication present, complete, signed

Peer References Received and appropriate

All Hospitals/Clinics Verifications received

NPDB Query

PSV of [your] state license

Copy of [your] state license present

PSV of other state License(s)

PSV of state controlled substance license

Health Assessment/immunization record present

PSV Board Certification

Current DEA Certificate present

FSMB Query Present

Current professional liability Insurance face sheet with acceptable limits/tail/nose

Privilege Form


Form signed by applicant

Form completed correctly


OPPE/PI Profile

PI Profile Present

Profile Reviewed by Dept Chair

Department chair recommendation present Date of initial appointment or

reappointment <= 2 years from date of reappointment

Date of Audit: _________________ Audit Performed by: __________________________________________


Expirables Audits

Expirable audits focus on documentation that is subject to expiration, such as current professional liability coverage face sheet, current licensure, current OIG Exclusion Query, current DEA, current privilege form, compliance with inservice educational requirements, immunizations, etc., such as the one in Figure 5- Audit Tool for Expirables. Final results can be tallied on the tool in Figure 6 - Summary of Expirables Audit.

Figure 5- Audit Tool for Expirables


Element of Review Score

Comments

Practitioner Name Timothy Reeves, MD

NPDB Query within 2 years 1

PSV of current [your] state license 1

Copy of current [your] state license present 1

PSV of current state controlled substance license 1

Copy of current state controlled substance license 1


PSV current Board Certification 1

Current professional liability Insurance face sheet present with acceptable limits/tail/nose 1

PSV of professional liability Insurance 1

Current DEA Certificate present 1

Date of Audit: ___5/4/2017_____________ Audit Performed by: ___Kathy Matzka_______


Figure 6 - Summary of Expirables Audit


File 1

File 2

File 3

File 4

File 5

File 6

File 7

File 8

File 9

File 1

0

Rati

o (

#/#

)

Practitioner Name

NPDB Query within two years

PSV of [your] current state license

Copy of [your] state license present

Copy of current state controlled substance license

PSV of current state controlled substance license

Health Assessment/immunization record present

PSV current Board Certification

Current professional liability Insurance face sheet with acceptable limits/tail/nose

PSV professional liability coverage

Current DEA Certificate present

Date of Audit: ______________ Audit Performed by: ______________________________________


Keeping Track of Files that have been Audited After you have done all the hard work of auditing these files, it is a good idea to keep track of your work. If you have your providers in a database, add fields for each type of audit and the date of the audit. If you are manually tracking your providers, the simple tool shown in Figure 7- Tracking Tool for File Audits can be used to keep track of files that have been audited.

Figure 7- Tracking Tool for File Audits

Name Audit Type Audit Date Next Audit Due

Comments

New

Re-A

p

Expire

Reporting Results Consider appropriate mechanisms for reporting results: Department Meetings – Report at staff department meetings as part of performance improvement process Support Periodic Performance Review – Include results as part of periodic performance evaluations. Medical Staff Meetings – Report to Credentials Committee or Medical Executive Committee


Follow up Deficiencies Be sure to develop a follow-up plan to address any insufficiencies found during audit. Discuss the results with staff. Evaluate and identify potential causes of deficiencies and develop plan for addressing these issues.


Policy on Confidentiality, Access To, Retention, And Content of Credentials Files and Records of Medical

Staff Committees and Departments I. POLICY STATEMENT

It shall be the policy of ______________ Hospital ("Hospital") to maintain, to the fullest extent possible permitted by law, the confidentiality of all credentials files and all discussions and/or deliberations related to credentialing, quality assessment, and peer review activities. Disclosure of any such records, information, and/or communications shall be permitted only as described in this policy.

II. PURPOSE OF POLICY

It is the express purpose of this policy to enhance the quality of patient care in the Hospital by encouraging good faith credentialing, quality assessment, and peer review activities among the members of the Medical Staff and appropriate personnel of the Medical Director's Office.

III. APPLICATION

This policy shall apply to all credentialing files and records maintained by the Hospital on behalf of its Medical Staff, including, but not limited to, the credentials files of individual practitioners, the records and minutes of all Medical Staff Committees and Departments, and the records of all Medical Staff credentialing, quality assessment, and peer review activities conducted under the authority of the Medical Staff and/or Hospital Board of Directors.

This policy shall also apply to any and all discussions and/or deliberations regarding credentialing, quality assessment, and peer review matters that take place in the course of the Medical Staff Department and Committee meetings or peer review activities.

IV. LOCATION AND SECURITY

All credentials files shall be maintained in locked files in the Medical Director's Office. After office hours, the Medical Director's Office shall be kept locked and is accessible only to the Medical Director's Office Staff, the Hospital President, Hospital Vice-Presidents, Safety and Security Officers, and Housekeeping.

V. CONTENTS OF CREDENTIALS FILES: A. Credentials Files of Individual Practitioners

The credentials files of each Medical Staff and Allied Health Professional appointee shall include, but not be limited to, the following:

1. Application for appointment and clinical privileges with all attachments


2. Application for reappointment and requested changes in staff status or clinical privileges, if any, with all attachments

3. All information gathered in the course of verifying, evaluating, and otherwise investigating applications for appointments, reappointment, and changes in staff status or clinical privileges

4. Reports of queries to and responses from the National Practitioner Data Bank

5. Department Chairmen's and proctor’s recommendations for approval of privileges and cessation of proctorship

6. Correspondence between the Hospital and practitioner concerning his/her practice in the Hospital and/or Medical Staff appointment

7. Correspondence from third parties, including, but not limited to, requests for and answers to verification of privileges and staff appointment, and letters of reference. Answers to verification of privileges and staff appointment provided to third parties shall be kept only if adverse information is provided.

Copies of fax cover sheets, routine notifications and duplicate copies of documents

will not be routinely kept in the credentials file. B. RECORDS OF MEDICAL STAFF COMMITTEES AND DEPARTMENTS

1. Minutes and related documents and reports of Medical Staff Committees and Departments shall be maintained in an orderly and accessible fashion in the Medical Director's Office, under the custody of the Medical Director.

2. Information contained in the minutes shall include the name of the body that is meeting, date of meeting, type of meeting (special or regular), notation as to approval and/or correction of minutes of previous meeting, recommendations made and action taken. Committee minutes will contain the names of members present. Medical staff policies, procedures, and forms presented for approval will be maintained as an attachment to the minutes. Policies, procedures, forms, etc. which are hospital documents presented for approval of the medical staff will not be attached to the minutes, but will be maintained in the responsible hospital department.

3. Meetings shall not be electronically recorded (or otherwise mechanically or electronically preserved) unless specifically authorized by ___________. Recordings and or notes taken shall be destroyed immediately after the official minutes are prepared.

4. Minutes and reports of committees or departments shall be maintained in a confidential manner when they pertain to credentialing, quality assessment, focused and ongoing professional practice review, and/or peer review matters.


VI. ACCESS A. REQUESTS FOR ACCESS

1. All requests for access to credentials files and records of Medical Staff Committees and Departments shall be presented to the ___________.

2. Unless otherwise stated, an individual permitted access under Section VI shall be afforded a reasonable opportunity to inspect the records requested, and to make notes regarding them, in the presence of _______________. In no case shall an individual remove the records (or any portion thereof), or make copies of them, without the express permission of _____________________.

B. ACCESS BY INDIVIDUALS PERFORMING OFFICIAL HOSPITAL OR

MEDICAL STAFF FUNCTIONS

1. The following individuals shall be permitted access to credentials and peer review files to the extent described:

(a) The Medical Staff Office staff, the Hospital's President, the

Hospital’s Board of Directors and the Hospital's legal counsel shall have access to credentials and peer review files as needed to fulfill their respective responsibilities.

(b) Medical Staff Officers shall have access to credentials and peer review files as needed to fulfill their respective responsibilities.

(c) Members of the Medical Staff's Credentials Committee, Executive Committee, and Departmental Officers shall have access to the respective credentials and peer review files of individual practitioners whose qualifications or performance are being reviewed.

(d) Attorneys and consultants engaged by the Medical Staff, Hospital, and/or Board of Directors to assist a Medical Staff Committee or Department shall have access to the credentials and peer review files of the practitioner being reviewed, and to any other relevant Medical Staff records which are necessary to enable such consultants to perform their function.

2. The following individuals shall be permitted access to Committee and

Department meeting minutes, reports, and quality assessment activities to the extent described:

(a) Department Chairmen shall have access to all Medical Staff

records relating to the activities of their respective Departments including meeting minutes, reports, and quality assessment activities of the Department as a whole and of individual practitioners whose qualifications or performance are being reviewed.


(b) Committee and Department members shall have access to the minutes, related documents and reports of meetings of Committees and/or Departments to which they are assigned.

(c) The Medical Staff Office staff, the Hospital's President, Board of Directors, the Quality Improvement Department's Staff and the Hospital's Legal Counsel shall have access to Department and Committee minutes, reports, and quality assessment activities as needed to fulfill their respective responsibilities.

C. ACCESS BY MEDICAL STAFF APPOINTEES:

1. Credentials Files

(a) A Medical Staff appointee shall have access to the credentials

files of another Medical Staff appointee only as described in Section VI.B. above.

(b) A physician shall be permitted access, upon request, to those items in his/her personal credentials file identified in Section V.A. above.

2. Access to Medical Staff Department and Committee Files By Those

Not On/In Committee/Department

1. A Medical Staff appointee shall have access to the files, minutes, and reports of Committee or Department meetings of which he/she is not a member upon request and approval of ___________(or designee). Access to files, minutes, and reports of Committee or Department meetings containing specific peer review information shall not be allowed.

D. ACCESS BY INDIVIDUALS OR ORGANIZATIONS OUTSIDE THE

HOSPITAL OR MEDICAL STAFF:

1. CREDENTIALING REQUESTS FROM HOSPITALS, CREDENTIALS VERIFICATION ORGANIZATIONS, MANAGED CARE ORGANIZATIONS, INSURANCE COMPANIES

Telephone Verifications The following information can be provided over the telephone without a signed consent form:

Staff Status and date on staff

Specialty

Statement that physician has “privileges in good standing” meaning “the practitioner’s hospital privileges and medical staff appointment are current with no disciplinary action”.

Written Verifications


The following information can provided without a signed consent form:

Staff Status and date on staff

Specialty

Statement that physician has “privileges in good standing” meaning “the practitioner’s hospital privileges and medical staff appointment are current with no disciplinary action”.

Whether or not the practitioner has admitting privileges. Upon receipt of a request accompanied by a specific, signed authorization and release, or copy thereof, additional information contained in that physician’s credentials file including past or current disciplinary actions can be released.

2. REQUESTS FROM HOSPITAL SURVEYORS

Requests for records covered by this Policy from hospital surveyors from organizations, such as, the Joint Commission, or the Department of Public Health, shall be referred to ___________________ for further disposition in accordance with the applicable state laws, regulations, and/or accreditation standards. Original or photocopied records may not be removed from the hospital premises, unless there is shown to be explicit statutory or regulatory authority to the contrary, which authority has first been reviewed by the Hospital Legal Counsel.

3. SUBPOENAS All subpoenas pertaining to Medical Staff records shall be referred

to the Hospital’s President who may first consult with the President of the Medical Staff, Medical Director, and Hospital Legal Counsel regarding the appropriate response.

4. OTHER REQUESTS All other requests for Medical Staff records (or portions thereof)

shall be reviewed by the Medical Director, the Hospital President, or their authorized designees. The release of any information may be conditioned upon approval of the Medical Staff Executive Committee or Board of Directors.

VII. SANCTIONS

All suspected violations of this Policy shall be reported to the Executive Committee of the Medical Staff. The Executive Committee, or an ad hoc committee thereof, shall conduct an investigation and determine if there has been a violation of any provision of this policy.


If it is determined that a Medical Staff appointee has violated this policy, the committee may, depending on the nature of the violation: (1) issue a written warning, or (2) recommend more severe disciplinary action in accordance with the Medical Staff Bylaws, Article __________, which may include a recommendation to revoke the Medical Staff appointment and clinical privileges of the individual found to have violated the policy. If a violation by a Hospital employee occurs, this will be handled in accordance with Hospital Policies and Procedures.


Policy for Retention of Credentials File Documents for Practitioners No Longer on Staff

POLICY STATEMENT

It shall be the policy of _______________ Hospital to retain the credentials files

of practitioners no longer on staff who were credentialed and/or privileged

through the medical staff process for a period of time following their departure in

paper or electronic form. A permanent electronic record of certain information

concerning all departed physicians shall be maintained by the Hospital after other

credentials file materials have been discarded.

PURPOSE OF POLICY

A. To retain for a reasonable period of time relevant information and

materials concerning any practitioner who has departed from medical or

allied health professional staff.

B. To reasonably manage the retention and discarding of materials in

departed practitioners' credentials files.

PROCEDURES

A. The medical staff office shall confirm the date upon which a medical staff

appointee or allied health professional (AHP) has ceased to be affiliated

with the hospital. The medical staff office shall briefly record the reason

for the practitioner's departure from the medical staff. For a period of ten

years following the physician's departure date, the following "essential"

documents will be maintained, in either paper or electronic form, as a part

of the practitioner's credentials file:

1. The physician's initial application and related documents,

responses to primary source verification conducted, and Board

appointment documentation;

2. The physician's last reapplication form and related documents,

responses to primary source verification conducted, and Board

appointment documentation;

3. Documented actions taken in connection with questions concerning

the physician's clinical competence, behavior, or other concerns;

(Only such actions that involved a letter of reprimand or more

severe actions are to be kept in accordance with this paragraph.


Actions taken that were less severe than a letter of reprimand, such

as a letter of warning, need not be kept for the full ten year period.

However, records of such lesser actions that are part of a larger

pattern of behavior that resulted in a more severe action being

taken shall be kept for the full ten-year period.);

4. The practitioner’s most recent FPPE/OPPE report and/or

reappointment profile;

5. Practitioner’s final assessment report (“evergreen” report);

6. Reports made to the National Practitioner Data Bank or state

licensure board; and

7. Information provided to third parties regarding documented actions

taken in connection with questions concerning the physician's

clinical competence, behavior, or other concerns.

B. All other "non-essential" documents in the physician's credentials file shall

be destroyed via a secure means that protects the confidentiality of the

documents.

C. Ten years after the date the physician leaves the medical staff, all

materials contained in the physician's credentials file can be destroyed.

However, a record of the following information concerning the physician

shall be permanently maintained by the Hospital in the electronic record:

1. Name;

2. Date of birth;

3. Social security number;

4. Degree;

5. Medical/Professional school attended;

6. Date of initial appointment and all reappointments;

7. Department of the medical staff in which clinical privileges were held;

8. Clinical privileges held by the physician;

9. Date appointment ended;


10. Actions taken in connection with questions concerning the physician's clinical competence, behavior, or other concerns and Information provided to third parties regarding the same.

11. Reports made to the National Practitioner Data Bank or state licensure board;

12. Reason for departure;

13. Last known address or forwarding address; and

14. Who took over practice (if applicable and if known).

D. If there is a question concerning whether a particular document in the

physician's credentials file should be retained or discarded, legal counsel

should be contacted for a determination as to whether the document

should be retained or discarded.

E. For those cases in which the practitioner is no longer affiliated with the

hospital and the hospital has been named in a lawsuit involving the

practitioner, the entire credentials file will be kept until the case is

concluded. On conclusion of the case, the procedure specified herein will

be followed.


Exercise: How Much Time to Audit YOUR Files Step 1: Multiply number of credentials files X 20 minutes ______X 20 minutes = _________ minutes # files Step 2: Divide number of minutes by 60 minutes (number of minutes in an hour) ________minutes / 60 = _________ hours required for audits Step 3: Divide number of hours by the number of work weeks in a year (i.e. deduct number of vacation weeks) ________hours required for audits / _________ weeks worked in a year = _________ hours Summary You will have to spend ________ hours a week doing file audits if you want to audit all files at least once a year.


Some information and forms contained in this resource are excerpted from the Medical Staff Meeting Companion: Tools and techniques for effective

presentations, by Kathy Matzka, CPMSM, CPCS; an HCPro publication. For more information, visit www.HCPro.com.