mississippi association medical staff services · in addition to oversight of all consulting...

Mississippi Association Medical

Staff Services

Presented by

Vicki L. Searcy, CPMSM Vice President, Consulting Services

Morrisey Associates Inc. (312) 784-5579

[email protected]

mailto:[email protected]

Vicki L. Searcy

Vicki L. Searcy, CPMSM, is the Vice President, Consulting Services at Morrisey Associates, a Chicago-based company. In addition to oversight of all consulting services, she provides healthcare consulting services specializing in practitioner competency management, including credentialing, privileging, privileging of advanced practice professionals, quality and peer review as well as management issues related to medical staff organizations. Prior to joining Morrisey Associates, Inc., she served as the Practice Director, Credentialing & Privileging for The Greeley Company and as President of Searcy Resource Group, LLC. Ms. Searcy’s career also includes being a partner with BDO Seidman, LLP, one of the nation’s leading accounting, tax, and consulting firms, heading up their national healthcare accreditation and compliance consulting practice. For over ten years, Ms. Searcy was a surveyor for the National Committee on Quality Assurance for their CVO certification program. She is certified by the National Association Medical Staff Services as a CPMSM. She is a past-President of the National Association Medical Staff Services (NAMSS). Ms. Searcy provides consulting services to a variety of healthcare organizations, including hospitals, healthcare systems, health plans, medical groups and credentials verification organizations. Ms. Searcy is often involved in projects where changes in operations are necessary in order to meet accreditation/licensing standards as well as to improve productivity and operational efficiency. She has been instrumental in working with organizations achieve paperless/electronic credentialing. She also provides retreats and other education programs for physician leaders and governing body members. During her work in hospitals and health systems, Ms. Searcy had responsibility for program design and implementation in the following areas: Utilization/Case Management, Medical Records, Medical Staff Services, Quality Management, Risk Management, and Outpatient Services. Ms. Searcy has served as seminar faculty for several national educational providers and professional organizations, including the national seminars of The Greeley Company (Advanced Credentialing & Privileging Retreat, Credentialing Resource Center Symposium, Core Privileges Essentials), the American Society for Healthcare Risk Management, National Association Medical Staff Services, National Association for Healthcare Quality, the American

1

Medical Group Association, American Health Information Management Association and the American Hospital Association. Ms. Searcy was the founding editor for Health Care Competency & Credentialing Report. She has written numerous articles related to issues in medical staff organization management which have been published in a variety of newsletters and magazines. Books include:

Core Privileges for AHPs: A Practical Approach to Developing and Implementing Criteria-Based Privileges (to be published in 2008 by HCPro, Inc.) Co-authors: Carol Cairns and Sally Pelletier

Core Privileges for Physicians: A Practical Approach to Developing and Implementing Criteria-Based Privileges (published in 2007 by HcPro, Inc.) Co-authors: Wendy R. Crimp, Sally Pelletier and Mark A. Smith, M.D.

Measuring Physician Competency: How to Collect, Assess and Provide Performance Data (published by HCPro, Inc. 2007) Co-authors: Robert Marder, M.D. and Mark A. Smith, M.D.

Credentialing Audits: Tools for Compliance and Reduced Liability (published in 2006 by HCPro, Inc)

The Medical Staff Services Handbook: Fundamentals and Beyond (published by Jones and Bartlett in 2010). Co-authors are Cindy Gassiot and Christine Giles. See website: http://www.pohly.com/books/medicalstaffservices.html

Professional Excellence = Professional Advancement – 101 Smart Things Every Medical Staff Services Professional Should Do (published in 2005 by Searcy Resource Group, LLC and distributed by NAMSS). Co-author is Peggy A. Greeley.

Ms. Searcy is a recipient of the Woman of Achievement Award in Healthcare from the City of Los Angeles.

2

http://www.pohly.com/books/medicalstaffservices.html

Background Checks Conducting background checks at the time of initial appointment is a best practice to incorporate into the credentialing and privileging process. Obtaining information via a background check often reveals information that would not have been obtained by other means. A comprehensive, well-thought-out policy on background checks will provide the organization and medical staff with an important method to manage potentially troublesome situations. If your organization currently obtains background checks on new applicants, your policy should define how information will be handled. The medical staff and administration’s decisions during the development of the policy should focus on how an offense could impact patient care, patient safety, and staff safety. Additionally, if you are going to conduct background checks, it is a good practice to do an extensive search to pick up all the information. At a minimum, the following should be considered:

Will your organization define a zero tolerance policy within your bylaws that clearly states that if an applicant has a felony conviction, he or she is not eligible for appointment or privileges and your organization will not process his or her application?

Have you defined whether or not there are certain crimes that your organization will not tolerate, such as crimes against children or crimes of a sexual nature?

How will you handle practitioners who do not disclose information or respond in a conflicting manner to a routine question on the application? Do you have a clause in your bylaws or on your release form that says that any misstatement or misrepresentation will be cause for your organization to cease processing the application? If you have that particular clause, what is the culture of your medical staff leadership to adhere to that policy? Will leadership “allow” the practitioner a one time “grace” to correct what must have been an oversight on their part? (But you might ask yourself, “How many people forget that they had a felony conviction?”)

How comprehensive will the search be? What timeframes will you include in the background check (e.g., since the completion of training, lifetime, or just since adulthood)?

What venues and/or locations will you require in your background checks? For example, if a general surgeon from Florida applies to a healthcare organization in Michigan, does it make sense to query Michigan, the state that the physician is moving to, as opposed to Florida, where he or she could have had issues?

At what times will you require a background check (e.g., initial appointment, reappointment, upon return from a leave of absence)? Note — the vast majority of healthcare organizations that obtain background checks do so only at the time of initial appointment.

How will you ensure that the individual’s privacy is not violated during the background check?

Who will receive the information your organization collects during a background check, and under what circumstances? Will it be the entire credentials committee or a subgroup?

Will the physician well-being committee need to get involved, e.g. if the background check uncovers a drug-related offense?

Thorough background checks can be costly, so it is important that healthcare organizations determine in advance how they will deal with the information. During my career, I’ve seen many hospitals obtain background checks and simply file reports in credentials files with little or no analysis of the information. If a background check identifies problematic information, your organization should clearly document how the information factored into the credentialing and privileging decision that was made. That’s it for this issue. Thanks for reading! To sign up to receive the Searcy Exchange, visit http://www.morriseyonline.com/signup.

Vicki L. Searcy, CPMSM Vice President Morrisey Consulting Services

3

vsearcy

Highlight

vsearcy

Highlight

Credentialing and Privileging Quiz

# QUESTION YOUR ANSWER/COMMENTS

1. Who makes the decision to appoint a practitioner to the staff?

2. What is the recommended composition of the Credentials Committee?

3. Are criminal background checks required for new applicants?

4. Are medical staffs required to accept applications by all interested physicians?

5. Who requires that all existing staff members be offered an opportunity to reapply?

6. Must the Credentials Committee consider requests for privileges to “treat complex medical conditions” from any physician requesting them?

7. May hospitals require that all physician applicants be Board Certified or Board Admissible?

8. Is it required that all current/previous licenses to practice be verified at the time of initial appointment and reappointment?

9. What is the definition of a peer? Is it different for allied health professionals?

10. If a staff physician has provided no clinical service at all in the hospital over the past two years what is the recommended course of action relative to the reappointment process?

11. If a practitioner is making application for membership only (no clinical privileges) how would the credentialing and verification process be different?

12. What accreditation body requires that previous hospital affiliations be verified?

4


13. If your application asked the following question: “Do you currently have, or have you had, a problem associated with the use or misuse of drugs or controlled substances of any kind (whether obtained by prescription or otherwise), or alcohol? If your answer is yes, please provide a full explanation on a separate sheet, including, without limitation, frequency and amount of use, the time period in which you engaged in such use, and the date last used.” And an applicant indicated “NO” on her application and you subsequently determined that she had been reprimanded while in residency for self prescribing Temazepam, what action would you recommend? (Please note she also switched residencies shortly after the event.)

14. If you received an application from a physician and it failed to disclose five malpractice suits that had been filed against him over the past five years and that he had brought a single case against his former hospital, what course of action would you recommend? Assume that the application asked the following question: “Please complete this form for pending or settled professional liability action(s) filed and served, or any payment made on your behalf. All questions must be answered completely. *If you have additional pending or settled professional liability action, please submit additional pages with answers to the following questions.”

15. A physician on your staff has just been involved in a fair hearing at the other hospital in town. He does not do much work at yours; he has not informed you of any recommended or taken corrective action at the other hospital. Assume that your bylaws require that physician notify your facility if such action is taken or a fair hearing occurs. What action would you

5


recommend?

16. An applicant discloses that he is involved in litigation against his prior hospital as a result of a disciplinary action that was recommended by the MEC but not taken by the Board after a formal appeal. The other hospital will not discuss “pending litigation” with you. Assume that the physician has been recruited to fill a critical vacancy in neurosurgery at your facility and has excellent clinical recommendations. What action would you recommend?

17. You receive an application for reappointment from a physician who has recently taken a full time position as the director of surgery at the competing hospital across town. He is known to be an excellent physician and has often performed surgery in your OR suites. How should your organization proceed?

18. Your largest cardiology group has recently hired four Advanced Practice Registered Nurses and two RNs. They would like the APRNs to be permitted to attend their patients and round in their absence. They would also like to be able to use the two RNs as support staff when they perform caths and other peripheral vascular procedures. The only other cardiology group is in opposition to this arrangement and will not support it. You are the Chief of Medicine responsible for cardiology. What is your course of action?

19. An invasive cardiologist on your staff recently hired a Physician Assistant. The PA worked for the previous five years in a mental health clinic. Before that, he was in training. The cardiologist wants to use the PA in the cath lab, etc. and his position is that a PA can do anything that he agrees to supervise him to do. The PA is asking for the following type of privileges:

Supervise and interpret cardiac stress tests (pharmacological and

non-pharmacological)

Interrogation and programming pacemakers and ICD

Removal of pacing wire

Remove pulmonary artery catheter

Remove chest tubes

6


Elective cardioversion

Act as surgical/procedural assistant for supervising physician What is your course of action?

20. Your hospital recently appointed a new cardiac surgeon to the staff and granted her cardiac and thoracic privileges. During the first 12 months she performed many cardiac procedures but very few thoracic ones. Her work has been excellent and she is earning great respect among the primary care physicians on staff. You are accredited by The Joint Commission. What are the implications of this situation?

21. A large orthopedic group in town has just been successful in recruiting a very experienced, highly reputable, shoulder surgeon to augment their rapidly expanding practice. The group believes this is a great triumph and that he will be a tremendous asset to the community, the practice and the bottom line. Their group maintains a great relationship with the hospital and works diligently to grow the business through outreach, research and marketing. The orthopedic surgeon has a “domestic partner” who is a residency trained internist who has not practiced in years but wants appointment to the staff and clinical privileges “just in case.” Privately the orthopedic surgeon says that his partner will not practice but insists that he be accommodated if he is to begin to do surgery at the hospital. What would you recommend under these circumstances?

22. You have just received an application from a physician who is well trained, a clinical professor, out of residency for 15 years, joining a large group in town, has excellent references and seems like a terrific physician, He is personable and very competent. He completes the section of your application (below) by writing: “Plenty, been teaching in the IM program at the University past five years.” COMPLETE THIS FORM OR PROVIDE DOCUMENTATION OF YOUR CME ACTIVITY FOR THE PAST 2 YEARS. Minimum Requirements:

7


Physicians - 50 hours Category I in past TWO years Dentists - 50 hrs/25 of which must be Category I in past 2 yrs Clin. Psychologists - 36 hrs in past 2 yrs. List Activities sponsored by an accredited provider (formal courses, seminars etc. attended) ( The form continues with lines for each CME event attended) You politely asked him to complete the form or submit the AMA Physician’s recognition form and he has very politely responded by saying, “I am very sorry but that is just busy work. I won’t play those games any longer.” What would your course of action be? (He has lightheartedly provided you with a peer reviewed article suggesting that non-targeted CME does not improve performance based upon a randomized trial among experienced physicians.)

23. Two physicians on your staff are in practice together. One is a general surgeon and the other is an internist with an outpatient practice. For many months there have been rumors among the nurses and some physicians that the surgeon does nearly all his cases upon recommendation and referral from the internist (or from the ED). You know that they do not share the same office in the MOB near the hospital. Your surgical department’s quality review program has not identified any significant problems but you know that it rarely ever does. Rumors persist especially among the surgeons. Both physicians are up for reappointment. What is your course of action?

24. Your department of internal medicine has an unengaged Department Chair. The privilege delineation system is a very long list of diagnoses and procedures. Your hospital recently settled a corporate negligence suit alleging that an internist was allowed to treat a patient without any evaluation of his specific competence. The patient’s specific diagnosis “Porphyria” was

8


not included on the privileging form. When the Department Chair was deposed he was not able to explain the omission and admitted that he did not spend much time reviewing the physician request for privileges. The exchange went something like this: Plaintiff attorney: “Dr. Azumitry, you are the chief of internal medicine at Memorial is that correct?” Response: “Yes, I guess.” Question: “How did you obtain that position?” Response: “I think it was my turn.” …….. (Downhill from there)….. Question: “Dr. I note your privileging form asks that you signify your agreement with each requested privilege by checking the box next to the request, is that correct?” Answer: “Yeah, that’s what is on the form.” Question: “Could you point out the section of this form that indicates that you granted privileges to Dr. Smith?” Answer: “Well it really doesn’t work like that; we can’t put everything on the list.” Question: “Dr. - Could you point out any instance in which you reviewed any specific request of this physician?” Answer: “Well, I scanned the form and it seemed in order for a physician of Dr. Smith’s qualifications.” (etc. etc. etc.) Note: Needless to say there is no evidence that any of the forms used in medicine have been completed as designed and a quick review discloses items on the list that are no longer relevant to internists. Outline your proposed action plan, if any.

25. Your Medical Executive Committee is composed of physicians who have little experience with the credentialing process and they are constantly questioning why the process must take so

9


long, especially with their new partners. They have overturned the recommendation of the Credentials Committee and are generally not supportive of the privileging process. There is discussion of changing the composition of the Credentials Committee or abolishing it completely. One new physician has called the Joint Commission and has determined that a Credentials Committee is not required. What is your game plan?

10

Paperless Credentialing and PrivilegingHow to Prepare Your Department and Medical Staff for

Electronic Credentialing

Mississippi Association Medical Staff ServicesSeptember 28, 2012

Vicki L. Searcy, CPMSMVice President, Consulting Services

Morrisey Associates

[email protected]

(312) 784-5579

Know Thyself!

• Why do you want to do it?–Save paper

• Go green and save a tree!

11

Know Thyself!

–Tired of filing• Very hard on fingernails!

–Budget cuts

–Save time and streamline

–Physician complaints

Know Thyself!

• Who wants to do it?– You

– Your staff

– Management

– Your Medical Staff

– You have no idea, but everyone seems to be doing it, so why not?

Know Thyself (and Thy Office)!

• How “electronic” is your office?– Well, we have computers!

• How well do you and your staff adapt to change?Resist Change ------------------------Embrace Change

12

Know Thyself (and Thy Office)!

• Will your staff willingly adapt or will you have those who will actively be obstructive?– What is your plan to handle this?

– Will any of your staff act negatively to physicians about the change from paper to paperless?

Know Thyself!

• What do you want to be paperless?– Initial application

– Privileges

– Reappointment application

– Verifications

– Evaluation process (Department Chair, Credentials Committee, MEC, Governing Board

– And, everything in between

Things You Should Know

Not everything translates directly from paper to paperless! For example:

– Initialing each page of application

– Supervising physicians signing AHP privilege forms

– “Write In” privileges

– “Writing in” the # of procedures performed

Electronic Signatures– Minimize the number of signatures necessary

13

Planning Your New Reality

• What will happen to currently archivedfiles?• Cost/Labor vs Space Considerations

• How will you handle the paper in currently active files?• Cost/Labor vs Space Considerations


• What will be scanned on new applicants?– What are you currently collecting?

• Certificates (diplomas, training, board certification, etc.)

• Newspaper articles

vs

– What really needs to be in the file/scanned for review and decision making?

• Verifications (licensure, education, training, etc.)

• Peer evaluations

• Privilege documentation


Paperless vs Paper Lite?– Confidential and highly sensitive documents such as

quality information/profiles

May depend on what type of office you’re in

– Medical Staff Office – Hospital

– Managed Care Office

– Credentials Verification Organization

14


• What Processes can be Paperless?– Initial Applications

• Online Applications• Verifications

• Peer Evaluations

• Champus Form

– Privileges• Online Privileges

• Requests

• Grants

• Staff Access to View Privileges

Your

• imagination

• budget and

• software

are the primary limitations



• Obtaining resources

“You have to spend money in order to make

money”

15


Prepare a Cost/Benefit Analysis


• Medical Staff: Friends or Foes?


• Reappointment– Online Reappointment Application

– Verifications

• Other Processes– Locum Tenens/One Case Privileges

– Leave of Absence

– Privilege Requests Between Reappointment

16


• Evaluation and Decision-Making Process– For All of the Items Listed Previously

• Initial application

• Reappointment

• Privileges

• Temporary Privileges

• Etc.


• Paperless Team– Members

• MSO, IS, Physician, Office Manager, etc.

• What Will You Go Paperless with First?– Documents or an Entire Process

• What will be scanned?– Images – Documents and Responses

– Naming Conventions

CVO SCANNED DOCUMENTS AND RESPONSES Comment

DOCUMENT NAME DOCUMENT RESPONSE

1 AMA PROFILE X

2 AUDIT REPORT-INITIAL X

3 AUDIT REPORT-REAPPOINTMENT X

4 BOARD CERTIFICATION X

5 COLLABORATIVE AGREEMENT X

6 CONSENT AND RELEASE X

7 CONTROLLED SUBSTANCE X X

8 CRIMINAL BACKGROUND X

9 CURRENT MALPRACTICE INSURANCE X X

10 DEA NUMBER X X

11 ECFMG NUMBER X

12 IDHS-FOIA X

13 IDPA X

14 NON CLINICAL WORK HX X

15 NPDB CQ X

17


• Prepare a Work-Plan/ Roadmap/ Timeline

• Initial, Privileges Or Reappointment– Considerations: Volume, Complexity

• Additional Equipment– Desktop Scanners

Celebrate!

• Presentation– Trees saved

– Processing Time Saved

– Staff Hours Saved

– Staff Satisfaction

– Physician Satisfaction

• Thank Everyone!

Q&A

18

Regulatory AgenciesHow to Achieve a Continuous State of Readiness


We Will Discuss…

Our discussion today includes:

• Why do we care about CMS Medicare Conditions of Participation?

• The “other” accreditation organizations – DNV and HFAP

• Survey “hot” issues

• Defensive “positioning”

• Strategies for continuous compliance

• Pre-survey activities

• During a survey

Continuous State of Readiness

• Sources of Information—Joint Commission

2012 Comprehensive Accreditation Manual for Hospitals: The Official Handbook

2012 Accreditation Process Guide for Hospitals

Joint Commission website (for FAQs and additional information)

—CMS (Centers for Medicare and Medicaid Services) CMS website (to access Medicare

Conditions of Participation –Interpretative Guidelines)

19

Continuous State of Readiness

• Joint Commission Definitions and Acronyms – APR = Accreditation Participation Requirements

– EP = Elements of Performance

– MOS = Measures of Success

– PPR = Periodic Performance Review

– = Documentation Icon (in standards, indicates when written documentation is required)

– = Patient Care Impact (Situational)

– = Patient Care Impact (Immediate Threat)

D

2

3

State of Readiness Strategies

• Be aware of changes to the CMS Conditions of Participation– Interpretative Guidelines

• Why?– May indicate area(s) that will be emphasized by TJC,

DNV and HFAP

• Current Medical Staff-Related Issues (Interpretive Guidelines Changed 10/18/08)– Written criteria for privileges

– Granting of privileges based on meeting criteria

– Privilege-specific competence

– FPPE and OPPE (for TJC-accredited hospitals)


• Be part of (or lead) your organization’s accreditation task force/preparation activities– Will help you keep current on standards and

plugged in to organization strategies and decisions related to ongoing preparation

• Be knowledgeable about the standards that apply to the work that you do– Will include more than what is in the Medical Staff

Chapter of the CAMH• Leadership

• Performance Improvement

• Human Resources

20


• Be clear (and obtain clarification if necessary) on the scope of the work for which your department is responsible– Credentialing/privileging

• What healthcare professionals must be credentialed and/or privileged

• Where services are provided (i.e., those areas that are part of the survey process – this can be a key issue)

• Responsibility for production of performance profiles (OPPE reports)

– What meetings are “medical staff” and must therefore have a reporting relationship to the MEC

Don’t Make Yourself a Target


• Know the areas of the most risk– HR.01.02.05, EP 7

• Before providing care, treatment, and services, does the hospital confirm that nonemployees who are brought into the hospital by a licensed independent practitioner to provide care, treatment, or services have the same qualifications and competencies required of employed individuals performing the same or similar services at the hospital? (Direct Impact EP)

– HR.01.02.05, EP 8• Are physician assistants and advanced practice

registered nurses who practice within the hospital credentialed, privileged, and reprivileged through the medical staff process or an equivalent process? (Direct Impact EP)

21


• Risk areas, cont.– LD.03.01.01, EP 5

• Do leaders create and implement a process for managing disruptive and inappropriate behaviors? (Direct Impact EP)

– LD.03.03.01, EP 4• Do leaders provide the resources needed to support the

safety and quality of care, treatment and services? (Direct Impact EP)

– MS.03.01.01, EP 2• Do practitioners practice only within the scope of their

privileges as determined through mechanisms defined by the organized medical staff? (Situational Decision Rules EP)


• Risk areas, cont.– MS.06.01.05, EP 1

• Do all licensed independent practitioners that provide care possess a current license, certification, or registration, as required by law and regulation? (Situational Decision Rules EP)

Before a Survey…

• Keep your critical documents as up-to-date as possible– Bylaws– Rules and Regulations (if you have them)– Policies and Procedures

• Develop new “critical documents” as needed– FPPE and OPPE policies and procedures– Code of Conduct

• Assure that critical documents are appropriately approved

• Keep documentation of meetings current

22

Before a Survey…

• Know how you meet relevant standards• Put in place a medical staff leadership

program to keep leaders knowledgeable about key standards and the method chosen by the organization to meet those standards – Make sure that you (and medical staff leaders)

can articulate the selected privileging approach, how it meets standards and can demonstrate that it is effective in assuring competency

• Same for FPPE• Same for OPPE

Before a Survey…

• Keep credentialing performed on time– No one should go past 24 months– Follow your own requirements related to timeframes for

“credentialing milestones” such as FPPE evaluation, OPPE reviews, etc.

• Don’t be messy about approval dates in credentialing - inconsistencies will compromise the credibility of the work of your department

Before a Survey…

• Keep filing current (whether electronic or paper)

• Make sure that information about privileges has been disseminated

• Keep your credentials files organized (whether they are maintained in paper or electronically)

• When something important isn’t being done as it should – make it known (in writing) to individuals/groups who can do something about it

23

Before a Survey…

• Make sure that reports to the governing body are comprehensive and clear - and also make sure that you obtain notification of what was/was not approved by the governing body

• Tighten up documentation related to why you did/did not report to the NPDB – this is an issue currently under scrutiny

Before a Survey…

• Don’t avoid dealing with problems -inevitably the file requested during a tracer will be the file of a practitioner who is one of your organization’s biggest problems.

Before a Survey…

• Maintain evidence of orientation for all healthcare professionals that are credentialed and/or privileged

• Have a plan for reacting to new standards - use project work plans to show progress towards meeting new standards or making improvements in compliance with existing standards– Use transition documents when applicable

24

Before a Survey…

• Have a survey contingency plan for your department (remember that you may not be at your organization during a survey)

• Conduct and/or participate in “mock” surveys

• Be careful how temporary privileges are granted - and communicated

Before a Survey…

• Make sure that there is a process to assure that when supervision is required (for example, supervision of a physician assistant in the ER or residents) that the supervision is understood and evident (another good area for investigation during a mock survey)

• Constantly improve the data that is used to evaluate practitioner performance

Before a Survey…

• If any credentialing is delegated – or if you use a CVO - make sure that what has been delegated is well-defined and that there is appropriate oversight

• Make sure that patient care staff have been educated related to the method for checking granted privileges

• Hold a practice “Medical Staff Credentialing and Privileging Session”– Details of content, etc. provided in TJC’s 2012

Process Guide for Hospitals– Include Department Chairs, MEC members and

Credentials Committee members

25

Before a Survey…

– Prepare summaries/flow charts of how key credentialing and privileging functions are performed on card stock so that they can posted in the room where the credentials session will be held

Before a Survey…

– Remember that this is the medical staff’s credentialing and privileging process and your role is to help showcase it

– Be prepared with a few examples of how “out of the norm” situations were handled

• A physician who didn’t get appointed

• Privileges requested which were not granted

• A physician who became subject to FPPE because of OPPE findings

During a Survey…

• Attend “Daily Briefings” at the beginning of each survey day (except for the day 1)

• Accompany the physician surveyor if you can

26

During the Survey…

• Be part of organization communication mechanisms– Find out what occurred during tracers (may give

you an indication of what credentials files will be requested)

Specific Credentialing Issues…

• Be prepared to address the following questions related to FPPE that may be asked by a surveyor– Describe your FPPE process

– Who does it apply to?

– How long has it been in place?

– Let me see a file for a practitioner that was newly appointed in ___ of this year

– Let me see his/her FPPE plan

– How do you handle FPPE for existing practitioners who request new privileges?

– Does FPPE apply to PAs and APRNs?


• FPPE Questions, cont.– I saw that you recently began robotic surgery - Let

me see a file of a physician privileged to perform robotic surgery (and the FPPE plan and monitoring process)

– What are your trigger criteria for FPPE? May I see a file of someone who was put into FPPE for a trigger concern?

27


• OPPE Surveyor Questions– How often is OPPE data reviewed?

– Describe the process

– Who reviews the data?

– How is data used to continue, limit or revoke privileges?

– Show me a file of a practitioner where there was a concern raised as a result of evaluation of OPPE data

– How was it determined what OPPE data would be collected?

– How is data incorporated into credentials files?

28

1

Best Practices in CredentialingHow to Speed Up the Initial Appointment Process

Without Taking Risky Shortcuts


Today’s Topic

How organizations can legitimately –and safely – speed up the initial appointment process without putting patients –and the healthcare organization at risk

• Pre-application process

• Application process– Documents that applicants

are required to submit

– How to obtain a complete application

• Verifications– What to verify and

verification methods

• Accelerating the evaluation and decision-making process – Elimination of “idle time”

Pre-Application Process

• Historic purpose– Prior to implementation of National Practitioner Data

Bank• Process only applicants with real interest in organization

to avoid wasting time and money

• Eliminate processing of applications that do not meet organization requirements in order to avoid denials

• Current purpose?– Pre-application vs. intended practice plan

29

2

Application Process

• Ask only for information that is necessary/required and will be used– Copies of documents? Purpose?

• Licenses

• Diplomas

• Etc.

– CV

• Think about messages that are being sent to practitioners about the credentialing process– If applicants are asked to sign documents when they apply

that wouldn’t be necessary unless they were appointed, are we sending a message that the credentialing process is a mere formality?

Verifications

The Basics

• The Application – the data collection tool– Complete professional history

– Consent/Release/Attestation

• Request for clinical privileges

30

3

Requirements vs. Value

• WHAT GETS VERIFIED?

– Know what is required

– Value to the organization

– ROI – staff time, wait time, supplies, etc.

– We’ve Always Done It That Way

Verification Methods and Requirements

• Use this template to clearly document who must be credentialed, and what will be verified.

Requirement vs. Value vs. ROI

• Peer References (How Many)

• Gaps (How Long – How Far Back)

• Hospital Affiliations (Current – Previous -How Far Back)

• Claims History (How Far Back – Where do you get it)

• All Current and Previous Licenses

31

4

Summary

• Review current practices

• Know what is required and put procedures in place to meet all requirements

• When your organization decides to exceed requirements make sure that the additional information provides value

• Red Flags may precipitate verification of additional information

Accelerating the Evaluation Process

• Elimination of “idle time”

– How much time is spent waiting for Department Chairs to review a file, the Credentials Committee meeting, the MEC meeting, etc.?

– Is there a way to act more expeditiously on files that are determined to be “problem-free?”

– Does the Medical Executive Committee always need to meet in person to take action on “problem-free” credentialing decisions? Can they “meet” more often than once a month?

Accelerating the Evaluation Process

• Temporary Privileges Pending Appointment – Joint Commission sets the rules

• Accelerated Credentialing– Organization-specific rules

• Expedited Credentialing – Joint Commission allows the Board to

have an expedited decision-making process

32

Characteristics of High Functioning Medical Staff Offices


Generally…

• The department/office appears to be well-organized and efficient. There are no piles of paper/stacks of files everywhere. There are no bookcases full of minute books.

• There is a place for medical staff leaders to sit down and work and/or communicate with medical staff office staff.

• Phones calls are either personally answered or are responded to within a prescribed period of time.

• There are regular department meetings.

Meeting Management

• Meetings are held only when there is substantial business to conduct.

• Virtual and/or other types of electronic meetings are conducted when appropriate.

• Policies and procedures for meeting management are current and are used to train new staff. Policy/procedure specifies:– Process and timing for creating agendas

– Process and timing for distribution of agendas

– Process and timing for completion of minutes

– Documentation of case review

33

Meeting Management

• Meeting packets are electronic rather than paper and provided via secure web sites. LCDs are used to display information during meetings – or committee members are provided with computer access during meetings in order to view information.

• Consent agendas are used.

• During meetings, it is evident that the meeting coordinator and the chair are a team.

Meeting Management

• Minutes and follow-up items are completed within a week to ten days following a meeting.

• There is excellent collaboration between the meeting coordinator and the chair of the meeting.

Credentialing and Privileging

• Policies and procedures for credentialing and privileging are current and are used to train new staff (and are also used to train new medical staff leaders as well as board members).

• The department is either already paperless or in the planning phase to become paperless.

34


• When information about a practitioner is needed, the information is retrieved electronically.– Status of application

– Granted privileges

– Demographic information


• The department has implemented and adheres to operational standards related to credentialing (i.e., applications are processed within 24-48 hours of receipt; follow-up verification requests are made at 10-14 day intervals, etc.).

• Privilege delineations are criteria-based and current. There is a plan for regular updating of privilege delineations.

• Privileges are communicated electronically.


• A quality-control process is in place to assure that once a file is ready for review by a department chair, credentials committee, etc., that it is complete. Files rarely have to be sent back for further verification/information.

• The credentialing database is considered to be “the source” of information on practitioners – it is accurate and updated regularly.

35


• Reports on credentialing and privileging statistics are regularly provided to management (and the credentials committee and/or medical executive committee). These reports provide information about the length of time it takes to credential new applicants, process reappointment, etc. and dissect the statistics in such a way that it is evident where improvements can be made.

36

Onboarding PractitionersCoordinating Credentialing/Privileging

with Recruitment and Enrollment


Onboarding vs. CredentialingWhat’s the Difference?

Organizational Socialization

Credentialing

Recruitment ---------------------------------------- Retention

Onboarding vs. Credentialing

Credentialing and privileging is one of

many components of onboarding.

37

Onboarding vs. Credentialing

• Onboarding in an organization can include some (or all) of these processes:• Recruitment

• Contracting and/or hiring

• Making application for healthcare organization malpractice insurance

• Faculty appointment

• Credentialing and privileging (potentially at multiple facilities)

• Joining a PHO

• Enrollment with payers

• Marketing

• Practice management

Onboarding

• The Five A’s of Onboarding:

• Align• Prepare – Business Plan

Timeline

• Acquire• Recruit

Evaluate

Onboarding

• Accommodate• Head Start

Get Ready, Market

• Assimilate and Accelerate• Enable and Inspire

Orientation, Resources, Support, Working Relationships, Mentoring

38

What is Driving the Need for Accelerated Onboarding?

• Increasing numbers of employed physicians

• Physician shortage

The Physician Shortage

Nationwide physician shortages are expected to balloon to 62,900 doctors in five years and 91,500 by 2020, according to new Assn. of American Medical Colleges work force projections. That's up more than 50% from previous estimates. AAMC officials attribute the widening gap to increased demands from the aging baby boomer generation and expansion of coverage by 2019 to 32 million uninsured Americans under the health system reform law.

The Dept. of Health and Human Services estimates that the physician supply will increase by just 7% in the next decade and decrease in specialties such as urology and thoracic surgery. During the same period, one-third of practicing physicians are expected to retire and the number of Americans 65 and older is projected to grow 36%, according to figures released Sept. 30 by the AAMC Center for Workforce Studies.

Source: amednews.com Oct. 2010

39

We Need More Doctors, Stat!Why is it taking so long to address the physician

shortage?

From a Practitioner’s Point of View….A Case Study

40

Case Study

Onboarding process at a

healthcare system

Phase 1: Recruitment1. Contacted by physician recruiter

2. Physician submits an application and CV

3. Some references contacted in writing and/or by phone

4. Site visit and interviews with physicians/healthcare organization representatives

5. Background check obtained

Case Study, cont.

Phase 2:

Contract/Hiring Process1.Contract offered

2.Negotiation of terms of contract

3.Practitioner notified by contracting department to start application for license in the state

4.Contract signed

Case Study, cont.

Phase 3: Enrollment and Credentialing Process (two separate departments – simultaneous processes)1. Practitioner receives a pre-application from one of the

hospitals in the health system and a separate application for medical staff appointment and clinical privileges from another hospital within the health system (there are a total of five hospitals within the health system) – also required to submit multiple copies of documents (CV, diplomas, copies of licenses, etc.)

41

Case Study, cont.

– Once applications are received, each hospital proceeds to verify information received, including soliciting peer recommendations from individuals who provided references during recruitment phase

– One of the hospitals obtains a background check (separate from the one obtained during recruitment)

– One of the hospitals requires an interview with the department chair

• Practitioner receives packet (2+inches) of forms to complete for enrollment with payers as well as an application for the organization’s liability insurance carrier (duplicates information provided in application for medical staff appointment and clinical privileges). 50+ signatures required throughout documents.

Case Study, cont.

3. Practitioner completes and submits application forms.

4. Enrollment holds managed care application forms waiting for practitioner to complete credentialing process at one of the organizations (can’t submit enrollment applications until practitioner is credentialed). Enrollment submits application to organization malpractice carrier.

5. Board makes affirmative credentialing decision within 90 days after the practitioner submitted the application.

6. Enrollment submits applications to managed care organizations.

7. Managed care organizations now begin to credential the practitioner (which may take from 30-90 days, depending upon the efficiency of each organization).

Repeated Submission of Roughly the Same Data Elements to Different End Users

• Demographic Information

• Practice history

• Signed attestations

42

Why We Should More Effectively Manage Onboarding

The result of not integrating onboarding activities can include:

• Physician dissatisfaction due to the redundancy of completing multiple application forms, many of which ask essentially the same information. (This physician dissatisfaction can impact retention.)– “I’ve been asked for the same information at least five

times!!!”

Why We Should Do It

• Delays in revenue streams from third party payers because credentialing (as part of the hospital privileging process or the payer process) is not completed expeditiously.

• Massive duplication in effort in terms of staff and resources to gather and process information within each function (recruitment, credentialing, enrollment, etc.). This duplication adds time as well as cost to the process.

Barriers to Effective Onboarding

• Individuals in various departments don’t want to cooperate – like to work independently

• Control issues

• Lack of trust

• Concern that physician data and documents will become discoverable (must have organization policies on what can be shared and under what circumstances)

• No mechanism for sharing information

43

The Use of Business Process Redesign

BPR uses a “clean slate” perspective to enable the designers of business processes to disassociate themselves from today’s process and focus on a new process. The steps involved in BPR include:

• Identify the processes to be redesigned.

• Understand and measure the existing processes (provides a baseline for measuring the improvements made by the redesign).

• Identify how technology can and should influence process design.

• Design and build a prototype of the new process.

Typical Goals of Redesign of Onboarding Process

• Improve service experience for new recruits

• Eliminate duplicative activities

• Combine related activities

• Change the order of activities

• Minimize hand-offs and data exchanges

• Perform activities when it makes the most sense

• Minimize reconciliation

The Solution

44

Considerations

• Software

Recruitment

Credentialing

Enrollment

• Collaborate

Recruitment

HR

Risk Management, etc.

• Enter in Database

Fill out “The Super Application”

Use to Pre-Populate all Other Documents

Considerations, cont.

• Obtain the criminal background check early in the process (during recruitment)

• Process applications for all organizations simultaneously

TJC, NCQA, AAAHC, DNV

• Verifications

Do them once

Scan

Share


• Go Paperless

Everything electronic

Personal email addresses

• Eliminate Barriers

What items/documents are really necessary

Do the “right thing” at the “right time”- Credentialing

- TB testing

- Etc.

• Onboarding Liaison

45


• Track Process– Prospect

– Candidate

– Applicant

– Member (Privileges)

• Provide / Share Information– Marketing, Practice Management,

Risk Management, Enrollment, Contracting, etc.

What to do – Right Now!

• Approach:

Recruitment

Contracting

HR

IS

• Collaborate

• Be seen as part of the solution – not the “major” part of the problem!

Onboarding Checklists

• Employed - Non-Employed– HR Forms - payroll, benefits, travel, email, performance

expectations

– Marketing – business cards, website, introductions, mentoring, advertising

– Security – name badge, passwords

– Orientation – facility, units, rosters

– Other – TB testing, behavioral expectations, red rules, culture of safety

46

Onboarding Success

• How will your organization define success in onboarding practitioners? Elimination of duplication of activities/effort by multiple

departments and/or individuals

Practitioner is asked for information once and it is shared with those individuals/departments who need it

Elimination of as much “dead time” as possible (i.e., nothing is happening because the organization is waiting for a committee to meet, etc.)

Contracts/employment are not offered to practitioners who do not meet criteria to be credentialed/privileged

Activities related to onboarding are done concurrently whenever possible

The credentialing/privileging process is of high integrity

47

MSPs: What Does the Future Hold for Medical Staff and

Credentialing Professionals?


MSP’s Have Come a Long Way…

• The Medical Staff Services profession is less than 40 years old


• The National Association Medical Staff Services was established as a national organization in 1976.– Started in Southern California by

Charlotte Cochrane and Joan Covell Carpenter

48


• Skills and knowledge required for the “profession” in the early years included…

Secretarial and clerical “organization” skills


Typing (at least 60 wpm)


49

Shorthand was a plus for taking minutes



• “People” skills to work effectively with physicians

• Ability to self-manage workload

• Willingness to learn accreditation and licensing standards

Primary Scope of Services of Early Medical Staff Offices

Credentialing– Emphasis on

• credentialing rather than privileging

• reputation of applicants rather than clinical competency

• content of application

• verification procedures

– Early “profiles” for reappointment were almost always the responsibility of the Medical Staff Office and were focused on citizenship factors, volume of clinical activity, and other issues

50

Primary Scope of Services of Early Medical Staff Offices

Meeting coordination and minutes– Often included some involvement in peer review

activities in order to document results of case review and follow-up

– If the organization had an IRB, this committee was usually the responsibility of the Medical Staff Office

Primary Scope of Services of Early Medical Staff Offices, cont.

Maintain Governance Documents Medical Staff Bylaws

Rules and Regulations

Policies and Procedures

Discrete Additional Tasks– ER call lists

– Physician referral services

– Event planning• Doctor’s Day activities

• Parties involving the medical staff

• Other social events that involved the medical staff organization

Tools Available to Early Medical Staff Offices

Early Automation –The Basic Tool

51


Remember when a person answered the phone? No voice mail was available to early MSOs.


Early Automation –Copy machine was a big step up from a mimeograph or ditto machine


Vicki’s First Automation

(1983)

52


• Filing cabinets were an important component of our offices


Sticky notes hadn’t been invented yet!

What About Credentialing Software?

• Early software devised to– Produce rosters and other lists

• Lists by specialty

• Lists of licenses and expiration dates

• Etc.

– “Automate” credentialing by merging information from database into letters and other documents (i.e., reappointment applications)

– Track attendance at meetings

53

Changes Occurring in Healthcare Organizations that Impact MSPs

• Healthcare systems – fewer “stand-alone” hospitals– Centralized credentialing within healthcare systems

– Difficult to pull off without standardization

• Increasing number of employed/contracted practitioners– More recruitment and need for integration with credentialing

– Enrollment with payers

• Physician shortages

• Changing status of the medical staff organization

• Busier physicians– More difficult to find volunteer medical staff leaders

Changes Occurring in Healthcare Organizations, cont.

• Increasing number of advanced practice AHPs with increasingly complex privileges– Advanced practice nurses (CRNAs, Nurse Midwives,

Clinical Nurse Specialists, Nurse Practitioners)

– Physician Assistants

– Others – Radiology Assistants, Anesthesiologist Assistants, Pharmacists that do Medication Management Therapy

The nurse practitioner population will nearly double by 2025, according to an analysis published in the July 2012 Medical Care, the official journal of the medical care section of the American Public Health Assn.

“Nurse practitioners really are becoming a growing presence, particularly in primary care,” said David I. Auerbach, PhD, the author and a health economist at RAND Corp.

Auerbach used modeling to project that the count of those trained as nurse practitioners would increase 94% from 128,000 in 2008 to 244,000 in 2025. The subgroup of those providing patient care as nurse practitioners, rather than filling administrative or other roles, will rise 130% from 86,000 in 2008 to 198,000 in 2025.

54

Other research has found significant growth in the number of nurse practitioners and other midlevel clinicians and indicated that more physicians are working with them. According to the annual census by the American Academy of Physician Assistants, 40,469 physician assistants were practicing in 2000, and that number went up 106% to 83,466 in 2010. A data brief released Aug. 17, 2011, by the Centers for Disease Control and Prevention’s National Center for Health Statistics found that 49% of office-based physicians worked with physician assistants, nurse practitioners and/or certified nurse midwives.

Experts who study health care work force issues believe that midlevel practitioners are becoming more common because the medical system is looking for more efficient ways to use physicians, who can be in short supply. There is also a need to meet the growing medical demands of an aging population. A December 2008 report on the physician work force by the Health Resources and Services Administration found that the U.S. would need 976,000 physicians by 2020, but only 926,600 would be available to provide care.


• Focus on current competency by accreditation and regulatory agencies

• Impact of technology on privileging

• Boundaries between some specialties blurring– Interventional cardiology and interventional

radiology


• Former “generalists” in urban areas more likely to specialize and not practice full scope of privileges– Family physicians

– General surgeons (except for surgicalists)

• More data available via the internet and used by consumers of healthcare

• Emphasis on patient satisfaction

• Reimbursement (to hospitals and physicians) based on quality

– No payment for errors

• Bundled payments

55


• Electronic patient records

• Increased expectations for use of technology throughout the organization

• Need to reduce FTEs– Largest portion of the budget

• Choices (and changes) in accreditation organizations– Can’t assume that all organizations are accredited by

The Joint Commission

Changes in Credentialing and Privileging

Past and Current Changes in Credentialing and Privileging

• Evolving (slowly) from being paper-based to electronic– Some organizations have no paper files. Most

organizations (particularly those who have large numbers of credentialed practitioners) are moving in the direction of becoming electronic.

• Movement to “super applications” from state or organization-based– In an effort to capture at one time all information

needed for credentialing, privileging and other activities

• “Get everything signed upfront” – May be changing because of unintended message sent

to practitioners being credentialed

56

Past and Current Changes in Credentialing and Privileging, cont.

• Becoming much more common to limit the number of documents that applicants must submit– For example, copies of certificates and other

information that will be verified from primary sources

• Scope of verifications is changing– Most organizations do not verify all current/past

hospital affiliations

– NPDB continuous queries

– Obtaining more information for privileging, such as clinical activity during training or at other healthcare organization affiliations

– Use of data repositories such as AMA/AOA profiles, ECFMG, etc. rather than seeking information from original source (i.e., writing directly to Medical School)


• Time for credentialing shortened• $90,000 per month in lost opportunity

• Focus on current competency and how to obtain that documentation

• FPPE and OPPE

• Use of background checks

• Evidence of immunizations and TB status

• Return of substantial orientation programs due to electronic patient records

• Aging physicians

• Physicians returning to the work force


• Focus on data management– More interface between credentialing database and

other business applications

– The “source of truth”

57

Emergence of Onboarding

Impact of Technology

58

Impact of Technology

• Paperless Credentialing

• Paperless Meetings– Some meetings may be virtual

• Work from Home – Primarily because of web-based software

• Off-Site Medical Staff Offices

Competencies Needed by Today’s MSPs

Today’s Needs and Themes

• Expert knowledge of regulatory and accreditation requirements

• Legal expertise– When to get attorneys involved

• Skill in facilitation of the medical staff organization

• Proficiency in application of technology to manage and disseminate data

• Capability of re-thinking processes and integrating with other departments and/or functions

• Leadership/management

59

Today’s Needs and Themes, cont.

• Expertise in credentialing – not only what/how to verify (i.e., building the file), but identification of red flags and facilitate the use of information to make excellent – and defensible – credentialing decisions

• Expertise in privileging and competency management– Expertise in design and implementation of

criteria-based privileges and other processes designed to provide information about competency (FPPE and OPPE)

The Time is NOW

With Change Comes Great Opportunity

What Do I See as the Future for MSPs?

• Management of Department– Management skills

– Leadership

– Expert in all aspects of medical staff organization

• Privileging/Competency– Expertise in designing privileging systems, including

data to support competency

– May require clinical background or education in clinical areas (anatomy and physiology, clinical nomenclature)

• Database Administrator and/or Application Specialist “Super User”– Use of technology to support all department functions

– Bridge between department and IT

60

What are you doing to prepare for your future?

Q&A

61

The MSP Guide to…

Preparing a Compelling Cost Benefit Analysis

By Hugh Greeley, Peggy A. Greeley, Michael Greeley

The Medical Staff Office (MSO) is often responsible for significant hospital fund expenditures. In the past, these costs were easily absorbed within the hospital’s overall budget. This is not the case today. In many states, over fifty percent of hospitals have no operating margin at all. In other words: no profit. Each expense is subject to a more rigorous analysis than in the past. And even with this thorough analysis, many worthwhile projects are not funded. Many projects previously funded without being subject to intense scrutiny are now being delayed or denied due to lack of available funds. These include medical staff bylaw projects, leadership retreats, leadership development programs, new technology, sophisticated software programs and even additional personnel. In the current environment of diminishing resources, most prudent CEOs will be more likely to seriously consider requests that can clearly and effectively show a positive return on investment (ROI) for the organization. As a result, as a requester of funds it is most effective to frame a request in these terms. Performing a cost-benefit analysis can aid an MSO in focusing and submitting a request for funds. A description of performing a cost benefit analysis follows, from definition, to applicability and the process, broken down into five points.

Definition

Cost benefit analysis, or CBA, can be defined as a systematic process for calculating and comparing benefits and costs of a project for two purposes:

a. to determine if a project or acquisition is a sound investment b. to see how one project or acquisition compares with alternative initiatives.

When contemplating multiple options, a cost benefit analysis is useful in identifying which project(s) are likely to benefit the organization more than others. For example, if the MSO is interested in purchasing a multifunctional photocopier there are multiple choices of products and vendors. Each vendor may vary in product availability, service, warranty, long term as well as initial cost. A CBA will clearly identify the most important factors in deciding which vendor to choose and compare those factors. A CEO might request a CBA in order to determine if the gains justify the cost for a variety of initiatives, including adding personnel, purchasing new technology, renovation of office space or implementation of a medical staff project.

62

The MSP Guide to…Preparing a Compelling Cost Benefit Analysis


Page 2

Applicability

When Cost Benefit isn’t Applicable

While considering all projects in the light of cost versus gain is advantageous, creating a cost benefit analysis is not essential or desirable to justify all MSO projects. The time necessary to conduct and document a CBA may not always be appropriate. If a project is required or the importance or priorities have already been established, it is not necessary to perform a CBA. This includes projects motivated solely by a need to meet legal or accreditation requirements. This includes new standards such as Joint Commission requirements for FPPE, revision of background checking, or health status confirmation. Also within this category fall changes in medical staff organization size, building of new facilities or the provision of new services that are a part of a broader hospital master plan. For another example, undertakings motivated by a need to address specifically identified deficiencies in personnel, technology, space or skill level of either MSO personnel or medical staff leaders would not be organized using an CBA. Also, projects that are merely maintenance in nature, such as an ongoing agreement for existing technology or equipment would not justify a CBA. It is important to remember that a CBA is a valuable tool that requires time and should be utilized in exploring and justifying new projects of whose details are not yet known.

Cost Benefit Appropriate

A cost benefit analysis is most applicable for evaluating proposed projects that meet the following criteria:

a. The potential expenditure is significant enough to justify spending resources on

forecasting, measuring and evaluating the expected benefits and impacts.

Example

Purchase of a standalone piece of equipment or training costing less than $1000 would not justify the time and resources necessary to perform a comprehensive cost benefit analysis. However, if the intended purchase is more than $1000, or if there will continuing costs incurred for maintenance, supplies, leasing, it may be a candidate for a CBA. Discussions with management will determine what should be the subject of a complete CBA. After these discussions the MSP can develop criteria to be used in the future to determine if such a study should be undertaken for any type of project.

63



Page 3

b. The purpose of the proposition is to improve the ability of the MSO to carry out

expected duties and functions such as credentialing, organizing and supporting committee meetings, filing, orientation, improving medical staff leadership skills or improving hospital/physician relations. (As opposed to meeting a legal requirement or social goal.)

c. The project is in regards to environmental, regulatory/accreditation or medical

staff issues that have articulated benefit(s) but have previously not been measurable or have had intangible benefit to the hospital.

Some different initiatives that warrant a cost benefit analysis: 1. Purchase and installation of software that has the intended benefit of improving the

speed and accuracy of the credentialing process. This may be a new acquisition or may entail switching from an existing software vendor to a new vendor.

2. Purchase of a teleconferencing capability with the aim of reducing the amount of

time physicians must spend in meetings, while increasing the amount of physician input into critical decisions.

3. Purchase of a combination high-speed scanner and digital storage unit, which will

eliminate or significantly reduce the need for filing cabinets, the space they occupy and attendant security concerns.

4. The employment of a dedicated staff person to conduct telephone reference checks

for all or designated applicants 5. Any situation in which your supervisor suggests that an expenditure is not “in the

budget” or not worth the time and financial resources projected in your request.

The Process

While invaluable when created with time and care, A CBA is not a simple statement on the part of a manager that a technology, human resource or project is necessary in order to have a “state of the art” MSO. It also does not assume that:

64



Page 4

the expected benefit will easily justify the initial cost;

the expenditure is required by the Joint Commission;

this is the latest thing and all MSOs either already have it or are in the process of getting it.

Consider the following actual request for a new high tech combination photocopier, digital scanner, fax and printer. This was provided as an explanatory note in conjunction with next year’s budget projection. “While it may seem expensive, item number 4 in my proposed budget is really necessary. We are

way behind the times in this area. It will allow us to clear our desks of printers, our stand alone

fax, and the office photocopier. It will also allow us to scan documents for digital faxing and

storage. I have seen a number of these in other MS offices and they really pay for themselves

quickly.”

Though clearly stated and justified logically based on the requester’s perception, this request does not carry much weight with someone looking for clear and supported justification of much needed resources in these times. A proper analysis requires consideration of a number of steps and will result in a far more documented, polished and persuasive case for any expenditure. The first step in conducting and documenting a valid and compelling CBA is to consider each of the following questions:

1. Purpose and Effort

What is the problem or goal that the project is intended to address? What are its intended benefits? Given the cost of the project, how much effort should be devoted to benefit-cost analysis and which aspects should receive the most attention?

2. Project Information

What will be done? Where? When? How? By whom? How will this change the status quo and to what degree? What alternative means may have the same result?

3. Know Your Audience

What is the constituency that will benefit from the project? For whom are benefits being sought? Who will incur the direct and indirect costs?

4. Project schedule

When will costs be incurred? When will benefits be realized?

65



Page 5

5. CBA Types and Templates

Should the project be evaluated on the basis of its benefit-cost ratio, net present value, internal rate of return or some combination of these?

Purpose and Effort

Before you begin, it is important to evaluate and document the aim of analyzing the project, its purpose, and the level of effort that should be used in creating a cost benefit analysis. For these and subsequent steps to creating a cost benefit analysis, please see examples following. Purpose of the Analysis How will the analysis be used?

to determine if the project should be undertaken to establish priorities for approved projects to determine how a project should be done

Example

Should the hospital have a Medical Staff (MS) lounge?

The base case would be that there is no MS lounge. The benefits and costs of the project should be determined and compared to the base case. Which aspect of the MS lounge project should be initiated this year?

The benefits and costs of each project component should be identified and compared. The project component with the most favorable cost-benefit measure (such as net-present value, cost-benefit ratio, or internal rate of return) would be selected and implemented first.

Defining the purpose will help determine what benefits and costs should be included, as well as other aspects of the analysis. Purpose of the Project What problem(s) does the project seek to solve or mitigate? What goal(s) does it address? What are the intended direct and indirect benefits?

Example

Project: Purchase and installation of “Software Solution”

66



Page 6

Purpose: To reduce paperwork, increase storage, eliminate stand-alone equipment and improve employee productivity.

Unintended impacts: Increased demand for technology from other departments, increased training needs, potential increased maintenance costs.

Benefits: Reduce paper consumption, improve environmental awareness, eliminate “hard” storage needs, and reduce specific maintenance/replacement requirements.

The nature of the problem or goal will determine its intended benefits and intended recipients. But significant unintended impacts, whether negative or positive, must also be included in the analysis. Impacts on other departments or people may or may not be included in the CBA, but they should be identified, because they will be potential sources of support for - or opposition to - the project. Level of Effort The appropriate level of effort to be invested in the analysis depends on its cost and expected benefit. Resources (time, materials, and expertise) needed to perform the cost –benefit analysis should be weighed against the value of the analysis in determining the most cost-effective project or approach. If the proposed project has very high costs, it is clearly worth considerable effort to determine whether benefits exceed costs and to identify the most economically advantageous alternative. Conversely, the analytical effort should not be greater than what would be lost by pursuing a project that was not cost-beneficial or selecting the less cost-effective of two projects. In most situations, the incremental payoff from choosing the right alternative far exceeds the resources consumed in doing the cost-benefit analysis

Example

Designing and building a Physicians Lounge This project has very high monetary costs and significant environmental, economic, and noise effects. A thorough cost-benefit analysis including all of these effects and comparing the project to operational modifications that could provide similar benefits is justified.

In any analysis, effort should be concentrated on estimating and valuing the benefits and costs that are largest and that differ the most between alternative or competing projects.

67



Page 7

Project Information

Project Description and Timing What will be done? Where? How? By whom? When? The project must be described in sufficient detail for its benefits and costs to be estimated. The description may change during the course of the analysis if it is seen that a more extensive (or less extensive) project or a different way of doing it may be more cost-effective.

Example

What will be done: The Dragon will be purchased and installed. It will permit rapid scanning, electronic faxing, printing, storage and copying of medical staff documents, minutes, applications, and forms.

Where: It is anticipated that the Dragon will be located in the Medical Staff Office, northwest corner, replacing the existing stand-alone photocopier.

How: the vendor will handle all installation, as well as all initial employee training.

By whom: Vendor

When: The Technology will be operational by June 15, 2008. Sometimes the optimum timing for a project and its alternatives can only be established after costs and benefits have been estimated. At that stage the timing of an option can be tested through sensitivity analysis, using different dates, to reveal the impact of project timing on the outcome. Basis for Analysis: Base Case The impacts of a project are measured in comparison to some base case that is a realistic representation of current and expected future conditions. The base case is the situation that will prevail if the project is not undertaken. The base case could be "no build/no buy," maintain existing technology or "some build," or "degradation."

Examples

"No Build" A decision not to build a Medical Staff lounge. The base case is continuation of the current situation which might be a simple medical staff coat/mail room with a few outdated journals and an unused computer station.

68



Page 8

"Some Build" Attempt to renovate a small space so that physicians will have greater space and access to a modest assortment of chairs and a television.

"Degradation" Phase out all consideration of a Medical Staff lounge and discontinue support for the existing Coat Room and mail center.

Alternatives A CBA describes alternative actions that might be taken to achieve results similar to those of the project, or alternative actions for which the project's funds might be used. Both the base case and alternatives should be described in as much detail as the actual proposed project, and should include all the actions necessary to make it work. For example, the benefits of building a modern medical staff lounge or purchasing video conferencing technology might not be fully realized unless there was simultaneous development of a medical staff leadership program. Furthermore, each alternative should include only incremental benefits and costs attributable solely to that alternative, over and above those resulting from other approved projects. Including the costs or benefits of other projects misrepresents actual benefits and/or costs. If cost-benefit analysis is being used to decide how, where, or when to do something that has already been decided on, there may be no base case. Project alternatives will be compared against each other. In some cases no alternatives are considered, and the project is compared only to the base case.

Know Your Audience: Departmental Perspective

Whose costs and benefits should be considered in the evaluation of the project? Some people would argue that a cost-benefit analysis should consider all benefits and costs that accrue to anyone. But sometimes management gives greater weight to the costs and benefits that accrue to physicians on the Medical Staff. The perspective of management should be established before the analysis is begun. Other groups to whom significant benefits and costs accrue should also be identified and their costs and benefits estimated because they are potential sources of support or opposition to the project. If a particular group has much higher costs than benefits, some means of compensating it might be considered; conversely, if a group has much higher benefits than costs, it might be possible to find a way to obtain compensation for those benefits.

69



Page 9

Timetables

Project Schedule Because benefits and costs will be summed (added) over future years, a project's schedule can affect the outcome of the cost-benefit analysis. Schedules for both the proposed project and its alternatives should maximize benefits relative to costs. In some situations, project schedules can be very complex, such as where project alternatives involve staged construction or major rehabilitation during the period covered by the analysis. The optimum timing for each can be established after costs and benefits have been estimated. Then the timing of each option can be tested through sensitivity analysis, using different dates. This reveals the impact of project timing on the outcome. Less than optimal timing can distort results. For example, a comparison of technological upgrade vs. total replacement might be distorted if a premature replacement date is assumed. Time Period of Analysis The time period starts with the first project expenditures, and extends through the useful life of the project or its most long-lived alternative, or some future time at which meaningful estimates of effects are no longer possible. Examples Purchase of voice recognition software (VRS) technology: For an analysis of VRS to be purchased for a medical staff leadership group, the time period of the analysis might extend until the time at which the oldest Medical Staff leader would no longer be on the Medical Executive Committee. The analysis would include the residual value of the software beyond that point in time unless new medical staff leaders would be reasonably expected to become proficient in the use of the VRS. Alternatives with very different schedules — The time period of analysis is particularly important when one project has a very different schedule from another, such as a new digital document/data storage system and an alternative fixed space saving filing cabinet system. The digital storage system could be implemented sooner and would have lower initial capital costs, but might have higher operating and maintenance costs. In this case the period of analysis should extend until operational and maintenance

70



Page 10

costs cease to be reliable. Sensitivity analysis can be used to determine how the relative performance of the alternatives is affected by the time period of the analysis.

CBA Types and Templates

To maximize its value a compelling cost benefit analysis must present sufficient financial information so as to permit an evaluation of all costs and assumed benefits. This is often referred to as a Cost Benefit Ratio. The Cost Benefit Ratio is a mathematical computation that permits reviewers and decision makers to determine if the cost is justified based upon the return or benefit. Generally a cost benefit ratio above 1 suggests that the benefit outweighs the cost. Below 1 suggests the opposite.

Or CBR=b/c

Where c=cost, b=benefit, and r=ratio

Example: Purchase of credentialing software with a total project cost $22,000.00 and estimated actual lifetime benefit $34,000.00. Cost benefit ratio=1.54 Generally a “go” decision will be made if the true ratio is 1.5. However, other compelling projects with CB ratios greater than this may win the day. Alternatively a project with a lower CB ratio but a higher overall gain may be selected if resources are tight. Computing Total Project Costs Remember to include every detail. When computing total project costs, don’t neglect the following: Assessment costs: these are costs associated with evaluation of various available alternative technologies or inputs, software, hardware, building plans, human resources, site visits, etc.

Cost Benefit = Total Computed Benefit

Total Projected Costs

71



Page 11

Acquisition costs: actual cost of project (technology, construction, employment etc.)

Installation costs: disposal of existing technology (if any cost is associated with this aspect of the project.)

Orientation and training costs

Ongoing maintenance costs

Utilities costs: electricity, light heat etc.

Cost Benefit Analysis Template When attempting to acquire new expensive technology or mount a new but expensive project with the medical staff (such as reorganization, a MS leadership development university, new but “needed” personnel, or a Medical Staff lounge renovation/development) take a few hours and answer these fundamental questions. Compute a valid Cost/Benefit ratio. Rehearse and then take a big breath and present with confidence to the CEO/COO or your immediate supervisor. You may be amazed at the power inherent in a well-drafted Cost Benefit Analysis.

Purpose of the project: What is the problem or goal that the project is intended to address? What are its intended benefits?

Project description: What will be done? Where? When? How? By whom?

Purpose of the analysis: Will the analysis be used to determine if the project should be undertaken? Will it be used to determine which of a group of projects should be selected or which should have highest priority?

Appropriate level of effort for the analysis: Given the cost of the project, how much effort should be devoted to benefit-cost analysis and which aspects should receive the most attention?

Departmental perspective: What is the constituency that will benefit from the project? For whom are benefits being sought? Who will incur the direct and indirect costs?

Basis for the analysis:

o Base case: What will happen if there is no project?

o Alternatives to be considered: Through what other means could the desired benefit be achieved?

Project schedule: When will costs be incurred? When will benefits be realized?

72



Page 12

Type of cost –benefit analysis to be used: Should the project be evaluated on the basis of its benefit-cost ratio, net present value, internal rate of return or some combination of these?

Geographic scope of the analysis: What departments will be affected by the project? By its alternatives?

Time period of analysis: Over what period of time should the project be evaluated?

Cost-Benefit ratio and Departmental recommendation based upon the Cost-Benefit Analysis.

73

_____ Health System

Credentialing Verification Methods and Requirements

For Licensed Independent Practitioners and Advanced Practice Allied Health Professionals

Date: ____________________________ PRACTITIONERS WHO MUST BE CREDENTIALED AND/OR PRIVILEGED Practitioners and Advanced Practice AHPs who must be credentialed and/or privileged are:

Type of Practitioner

Licensed Independent Practitioners (LIPs)

Physician (M.D. or D.O.)

Dentist

Oral Maxillofacial Surgeon

Podiatrist

Psychologist

Advanced Practice AHPs

Audiologist

Chiropractor

Clinical Nurse Specialist

LCSW (therapist)

Nurse Anesthetist (CRNA)

Nurse Midwife

Nurse Practitioner

Optometrist

Physician Assistant

Radiologist Assistant

Registered Nurse First Assistant (RNFA) and/or Certified First Assistant

74

Type of Practitioner Note: These practitioners must be privileged IF they perform surgical tasks as defined by CMS. If a surgical assistant’s or RNFA’s duties are limited to holding retractors or instruments as directed by the surgeon, applying electrocautery at direction of the surgeon, passing instruments, sponging, suction, and other non-invasive tasks performed at the direction of and under supervision of the surgeon, these tasks do not meet the definition of performing “surgery” and the practitioner would not need to be granted privileges. However, if the assistant will be suturing or cutting tissue (even if done under direction by and under supervision of the surgeon) this would be “structurally altering the human body by the incision or destruction of tissues, meaning it meets the definition of “surgery” and would thus require privileges to be granted. CMS Definition of Surgery (from Medicare Conditions of Participation for Hospitals – Interpretive Guidelines):

“Surgery is performed for the purpose of structurally altering the human body by the incision or destruction of tissues and is part of the practice of medicine. Surgery also is the diagnostic or therapeutic treatment of conditions or disease processes by any instruments causing localized alteration or transposition of live human tissue which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles. The tissue can be cut, burned, vaporized, frozen, sutured, probed, or manipulated by closed reductions for major dislocations or fractures, or otherwise altered by mechanical, thermal, light-based, electromagnetic, or chemical means. Injection of diagnostic or therapeutic substances into body cavities, internal organs, joints, sensory organs, and the central nervous system also is considered to be surgery (this does not include the administration by nursing personnel of some injections, subcutaneous, intramuscular, and intravenous, when ordered by a physician). All of these surgical procedures are invasive, including those that are performed with lasers, and the risks of any surgical procedure are not eliminated by using a light knife or laser in place of a metal knife, or scalpel. Patient safety and quality of care are paramount and, therefore, patients should be assured that individuals who perform these types of surgery are licensed physicians (physicians as defined in 482.12(c)(1)) who are working within their scope of practice, hospital privileges, and who meet appropriate professional standards.”

Minimum Verification Requirements: It should be noted that the Verification Methods and Requirements document list verification elements that apply to all practitioners and Advanced Practice-AHPs. There may be additional items to verify (or to obtain), depending upon the privileges that an applicant has requested. These verifications should be incorporated into the process at the appropriate time.

75

Primary Source: In this document, primary source means the issuing or originating organization or an organization that is determined to be “equivalent” to the primary source for specific information (for example, the AMA Profile is considered to be a primary source for physician education – medical school, residency programs and fellowship programs). Documents to be provided or signed by LIPs being credentialed:

Membership Only – No Privileges

Initial Privileges Reappointment At Expiration New Privileges

Documents to be provided by Advanced Practice AHPs being credentialed:

Initial Privileges Reappointment At Expiration New Privileges

76

# CREDENTIALING ITEM METHOD OF

VERIFICATION METHOD OF

DOCUMENTATION

CREDENTIALING EVENT

MEMBERSHIP

ONLY INITIAL

APPOINTMENT REAPPOINTMENT

UPDATE AS

EXPIRES NEW

PRIVILEGE(S) TEMPORARY

PRIVILEGES

1 License to Practice in State Where Organization is Located Verify current license, expiration date and sanctions and/or limitations. Required by Joint Commission to be verified via primary source.

X X X X X X

2 Licenses to Practice in Other States Verify current license, expiration date and sanctions and/or limitations. Note: It is not required by Joint Commission or CMS that licenses (current/past) be verified. However, many organizations have determined that this is a best credentialing practice.

77



DOCUMENTATION

CREDENTIALING EVENT

MEMBERSHIP

ONLY INITIAL


UPDATE AS

EXPIRES NEW


PRIVILEGES

3 DEA Registration (if applicable) Obtain DEA Registration number, expiration date, schedules.

X X X

4 State Narcotics License (If applicable)

X X X

5 Medical School (Domestic Graduates) Or Other Professional Schooling Relevant to Privileges Requested (non-physician applicants) Verify institution, completion date and degree received. Required by Joint Commission to be verified via primary source.

X X

X

6 ECFMG (Foreign Graduates) Graduation from a foreign medical school (does not cover internships and

X X X

78



DOCUMENTATION

CREDENTIALING EVENT

MEMBERSHIP

ONLY INITIAL


UPDATE AS

EXPIRES NEW


PRIVILEGES

fellowships) Verify ECFMG number and date issued. Required by Joint Commission to be verified via primary source.

79



DOCUMENTATION

CREDENTIALING EVENT

MEMBERSHIP

ONLY INITIAL


UPDATE AS

EXPIRES NEW


PRIVILEGES

7 Internship/Other Professional Training Completed after Medical School/Professional School Graduation OR post receipt of ECFMG Verify institution, begin/end dates, type of internship, successful completion. Required by Joint Commission to be verified via primary source.

X X

X Verify any

new education or professional training that

may be required for

the privilege(s)

requested or may provide information about the applicant’s

competency to perform

the requested

new privilege(s)

X

8 Residency/Other Professional Training Completed after Medical School/Professional School Graduation OR post receipt of ECFMG Verify institution, begin/end dates, type of residency, successful completion.

X X

X Verify any


may be required for

the privilege(s) requested

or may provide

X

80



DOCUMENTATION

CREDENTIALING EVENT

MEMBERSHIP

ONLY INITIAL


UPDATE AS

EXPIRES NEW


PRIVILEGES

Required by Joint Commission to be verified via primary source.

information about the applicant’s


the requested

new privilege(s)

9 Fellowship/Other Professional Training Completed after Medical School/Professional School Graduation OR post receipt of ECFMG Verify institution, begin/end dates, type of fellowship, successful completion. Required by Joint Commission to be verified via primary source.

X X

X Verify any


may be required for

the privilege(s) requested

or may provide

information about the applicant’s


the requested

new privilege(s)

X

10 Board Certification or other professional certification or

X X X X

X If any new certification

X

81



DOCUMENTATION

CREDENTIALING EVENT

MEMBERSHIP

ONLY INITIAL


UPDATE AS

EXPIRES NEW


PRIVILEGES

registration All specialty board certifications (may be multiple) which are ABMS (American Board of Medical Specialties) or AOA (American Osteopathic Association) approved (for physicians). Verify certifying Board, specialty of certification, date certified and expiration date, if applicable. Include whether or not the practitioner is in the Maintenance of Certification program (if verified by ABMS board). Required by Joint Commission to be verified via primary source if the organization requires board certification.

s have been obtained since the previous

appointment period that

would qualify the

applicant for the new

privilege(s)

82



DOCUMENTATION

CREDENTIALING EVENT

MEMBERSHIP

ONLY INITIAL


UPDATE AS

EXPIRES NEW


PRIVILEGES

11

Military Service Only if needed to account for time and if there is any bearing on practitioner's current competence at initial appointment.

12 Healthcare Organization Affiliations Hospitals, ambulatory facilities, etc. Ideally - verify current status, begin/end dates of affiliation, adverse actions, performance or behavior problems, range/scope of privileges, in good standing if current affiliation or when affiliation ended. Note: Joint Commission does not require that all current/past affiliations be verified. Organization needs to set an

83



DOCUMENTATION

CREDENTIALING EVENT

MEMBERSHIP

ONLY INITIAL


UPDATE AS

EXPIRES NEW


PRIVILEGES

internal standard. Organization should also address how to handle practitioners who provide locum tenens services and may have hundreds of past affiliations. It is important for an organization to determine what it wants to learn from verification of hospital affiliations. If it is to account for all time since a certain point, be cognizant that the hospital that supplies an affiliation verification may not have “seen” the practitioner at all (for example, the practitioner was on the courtesy staff – the hospital may verify that the practitioner was on staff in and “good standing” even if the practitioner never used the facility).

13 Work History Note: Organization needs to set internal standard of what constitutes a gap. Usually, hospitals define a gap as anywhere from one month to six months, with two to three months being the most frequently identified.

14 Professional Liability

84



DOCUMENTATION

CREDENTIALING EVENT

MEMBERSHIP

ONLY INITIAL


UPDATE AS

EXPIRES NEW


PRIVILEGES

Insurance – Confirmation that practitioner has coverage Joint Commission does not require verification of insurance. NCQA does require that the practitioner provide (and attest to) information about current malpractice coverage.

15 Professional Liability Claims History Joint Commission requires information related to settlements and judgments. Current pending claims is optional.

16 Continuing Medical Education/CEUs CME activity should relate to privileges requested/held. Joint Commission standards require that participation in continuing education be considered in decisions about reappointment.

X

17 National Practitioner Data Bank (NPDB)

X X X X X

X (One-time

query)

85



DOCUMENTATION

CREDENTIALING EVENT

MEMBERSHIP

ONLY INITIAL


UPDATE AS

EXPIRES NEW


PRIVILEGES

Required by Federal law to query the NPDB for membership and privileging requests/decisions.

18 Medicare/Medicaid and Other Sanctions Includes exclusions from Federal Health Care programs, loss or restrictions of membership, privileges, licenses to practice, board certification, etc. Essentially any type of restriction that would have a bearing on an applicant’s competency or conduct.

19 Background Check Some states require background checks. It is estimated that approximately 50-60% of hospitals are conducting background checks at the time of initial appointment.

86



DOCUMENTATION

CREDENTIALING EVENT

MEMBERSHIP

ONLY INITIAL


UPDATE AS

EXPIRES NEW


PRIVILEGES

20 Peer/Professional References/ Recommendations Joint Commission requires that peer recommendations be obtained for initial appointment/privileging and reappointment. The number of peer recommendations is organization-specific, but usually ranges from 2 to 4 for initial appointment.

Peer means an individual in the same professional discipline (same type of license) with essentially the same privileges.

X X X X X

87



DOCUMENTATION

CREDENTIALING EVENT

MEMBERSHIP

ONLY INITIAL


UPDATE AS

EXPIRES NEW


PRIVILEGES

22 Identity of Applicant The Joint Commission requires that during the credentialing process, there is a mechanism to insure that the individual requesting privileges is in fact the same individual that is identified in the credentialing documents. Viewing of government-issued identification is required.

X X X

88

XXX Medical Center

MANAGEMENT OF MEDICAL STAFF COMMITTEE MEETINGS

DATE: BYLAWS AND MEDICAL STAFF DOCUMENTS REFERENCES: Articles XIII and XIV OTHER CROSS-REFERENCES: See “Policy on Confidentiality of Medical Staff Records”

POLICY It is the policy of the medical staff organization that medical staff committee meetings will be appropriately managed by the medical staff office (MSO) in order to make optimal use of all participants' time and increase the effectiveness of all committee activities. Concise, but complete minutes of medical staff committee meetings will be prepared that reflect the actions taken and deliberations of the committee, and the discussions and actions pertinent to quality improvement activities. Documentation requirements of regulatory and licensing agencies will also be met. A master listing of all medical staff organization committees for each organization is attached (Attachment A). This listing includes details related to room assignments, ordering of food and equipment, etc. PROCEDURE

AGENDA PREPARATION A draft of the agenda will be prepared by MSO personnel seven calendar days prior to a scheduled meeting. All agenda items, reports and any other information that is to be submitted to the committee for review and/or evaluation must be submitted ten calendar days prior to a scheduled meeting. An agenda planning session will be scheduled and facilitated by the MSO. This agenda planning session will include, at a minimum, the following individuals:

the chair of the committee

the quality management representative (if applicable)

the medical staff coordinator The agenda planning meeting may include other representatives as appropriate to the function(s) of the committee for which the agenda is being prepared. For example, the agenda planning session for the P & T Committee should always include a pharmacy representative.

89

XXX Medical Center Management of Medical Staff Committee Meetings Page 2 The agenda will include all follow-up business, even if responses to requests for information have not been received. The final agenda will be prepared, along with all attachments by the MSO after the agenda planning session (see attached agenda format – Attachment B). No agenda items may be added prior to a meeting unless approved by the chair of the committee.

MEETING NOTICES All committee members will be provided with access to the agenda or will be provided with access to a meeting notice (see attached meeting notice – Attachment C) at least five business days prior to a scheduled meeting. The decision regarding whether to use a meeting notice or a copy of the agenda to inform committee members of a meeting will be made by the medical staff coordinator who supports the specific committee and the chair of the committee. The decision will be based upon timing issues and confidentiality of information on the agenda. Access to related information will be provided in advance of the meeting when appropriate. Meeting notices and/or agendas will clearly identify individuals who are responsible for follow-up or presentation of information.

CONDUCT DURING THE MEETING A representative from the MSO will attend medical staff committee meetings in order to take the minutes. The MSO representative will sit next to the committee chair during the meeting to facilitate exchange of information and must ask for clarification of actions taken when necessary to assure proper documentation in the minutes. Meetings will not be tape recorded.

MINUTES PREPARATION A draft of the minutes will be prepared by the MSO within two business days following a meeting and submitted for input to all the individuals who attended the agenda planning session (i.e., committee chair, quality management representative, pharmacy director, etc.). These individuals will be given five business days for review and input. Once the MSO has finalized the minutes, they will be submitted to the chair for approval. The final version of the minutes, including all follow-up, must be completed no later than ten business days following a meeting. Follow-up must include a communication (via email) to all members and other involved individuals detailing assignments made for the next meeting.

90

XXX Medical Center Management of Medical Staff Committee Meetings Page 3 All minutes of medical staff department/committee meetings will be prepared using the approved format (attached - Attachment D). Attendance of meetings will be maintained in the Medical Staff Office management software. The minutes, along with all attachments, will be retained in (specify computer location).

ACCESS TO MEETING MINUTES See policy on “Confidentiality of Medical Staff Documents.”

DOCUMENTATION OF PEER (CASE) REVIEW Case discussion should be documented consistently by all committees that are given authority to perform case review by the Medical Staff Executive Committee and should always include the following: • Medical Record Number (Patient Record Number) • Practitioner(s) Involved • Reason for Review Why did this case come to the committee for review? Examples might be: ER

patient left AMA; Unplanned return to the OR; Unexpected mortality; etc. • Description Brief description of the case. For example: 59 year old male with history of

diabetes presented to the ER ..... • Evaluation/Conclusion In the review of the case, to what conclusion did the reviewer(s) come - this

should be specific. • Systems/Process Issues Identified and/or Opportunity for Improvement If applicable • Action What action will be taken as a result of review of the case? Examples of action:

No action required; Letter to practitioner for information only; Department chair to speak personally with practitioner in regard to findings; etc.

• Follow-up What follow-up is required? Examples of follow-up: Involved practitioner is to

take a course and report back to department chair; involved practitioner is to

91

XXX Medical Center Management of Medical Staff Committee Meetings Page 4

present rationale for his/her management of the case to the committee; etc. This follow-up stays on the agenda until completed.

Follow-up case discussion must identify the case, reference to the minutes date/item

number of all previous discussion, the practitioner(s), response and action of the department/committee.

See “Peer Review Policy” for further information.

OTHER DOCUMENTATION ISSUES

1. Conclusions and actions taken will be documented for all reports presented to medical staff department/committee meetings. This includes statistical "quality" reports.

2. Minutes will generally indicate points of discussion and conclusions, actions and

recommendations and not include names of individuals who participated in discussion or made recommendations (avoid who said what about the subject or the individual being discussed).

3. Follow-up should include a specific deadline for the follow-up and should also

include the individual/group responsible for the follow-up.

REVIEWED BY: APPROVED BY:

DISTRIBUTION/COMMUNICATION:

DOCUMENT LOCATION:

92

CONSENT AGENDAS A TOOL TO HELP EXPEDITE THE WORK OF COMMITTEES

A consent agenda is a tool that can be used to save meeting time and to help assure that committee time is spent on items that require discussion. Consent agendas expedite approval of routine, non-controversial business brought before a committee (for example, the Medical Executive Committee). The use of a consent agenda places responsibility on committee members to prepare prior to a meeting. They also place responsibility on those responsible for preparation of the agenda – most typically, the President of the Medical Staff and the Medical Staff Professional that supports the meeting. In order to use a consent agenda the following should occur:

1. The committee members must understand how the consent agenda will work and must agree to the use of the consent agenda.

2. Consent agenda items must be distributed to committee members in advance of the meeting – well enough in advance for committee members to review all the consent agenda items (and any back-up documentation) and to determine if discussion at the meeting is necessary.

The types of information that may be included on a consent agenda might include the following:

minutes from the previous MEC meeting

factual reports that do not require any action

minor changes in policies and procedures

routine document updates

3. Any committee member may ask for any item listed on the consent agenda to be removed from the consent agenda and addressed separately. This can occur prior to the meeting (which is the optimal situation) or at the meeting.

Consent agenda items are usually addressed toward the beginning of the meeting. This allows any item removed from the consent agenda to be placed into the appropriate place on the agenda for discussion and/or action later in the meeting. Caveats about the use of consent agendas:

1. Do not use consent agendas to “hide” actions that are controversial or to push something through without discussion. If this occurs, the committee will usually never trust the items that are listed on a consent agenda again and may ban the practice!

2. Committee members must review items in advance of the meeting.

93

3. Committee members need to be committed to appropriate use of committee time. Items that are placed on a consent agenda are there because there is no need to spend valuable committee time on discussion. Sometimes committee members (or those attending a meeting) have submitted written reports for information – there is no action required. However, they feel compelled to speak about the report (or worse yet – read it to the committee). The committee members need to respect the time of all present and to refrain from discussion that serves no useful purpose.

4. It is beneficial for a committee that uses a consent agenda to have some “rules” about what can and cannot be placed on a consent agenda.

The use of consent agendas can be an effective way to improve and streamline Medical Executive Committee meetings and other meetings at which there is a lot of routine business. Consent agendas should only be used, however, when they are understood and properly implemented.

94

MEDICAL/PROFESSIONAL STAFF MEETING

AGENDA

MEETING: MEDICAL EXECUTIVE COMMITTEE DATE: TIME: PLACE:

ITEM

#

ITEM (SUBJECT/ISSUE)

RESPONSIBILITY SUPPORTING

INFORMATION ON AGENDA FOR:

TIME

ALLOWED

CALL TO ORDER CHAIR INSERT

WHETHER

ITEMS ARE ON

AGENDA FOR

ACTION, INFORMATION

OR DISCUSSION

1 MINUTE

CONSENT AGENDA ITEMS 1 MINUTE

PREVIOUS MINUTES (INSERT DATE) IDENTIFY HOW

SUPPORTING

INFORMATION

CAN BE

ACCESSED

(I.E., ATTACHED, AVAILABLE VIA

WEB SITE, ETC.)

ACTION

REVISED POLICY AND PROCEDURE ON MEDICAL RECORDS

COMPLETION ACTION

MINUTES FROM THE FOLLOWING DEPARTMENTS AND COMMITTEES

(NO ACTION ITEMS FROM THESE DEPARTMENTS/COMMITTEES WERE

ACTION

95

ITEM

#

ITEM (SUBJECT/ISSUE)

RESPONSIBILITY SUPPORTING

INFORMATION ON AGENDA FOR:

TIME

ALLOWED

FORWARDED TO THE MEC): INFECTION CONTROL; RADIATION

SAFETY; DEPARTMENT OF SURGERY; DEPARTMENT OF OB/GYN.

OLD BUSINESS

NEW BUSINESS

ANNOUNCEMENTS

GOLF OUTING: (INSERT DATE) INFORMATION

ADJOURNMENT

96

DESIGNING AN ANNUAL CREDENTIALING REPORT The following outline shows how an annual credentialing report might be organized. Title page • Name of report • Time period covered • Prepared by: (include names of credentials committee members and director,

medical staff services staff, etc.) Table of contents Major purpose of the report Comparison of actual performance or goals with target levels of performance State each goal (e.g., decreasing the length of time it takes to process applications, transitioning from paper applications to electronic applications, transitioning from laundry list privileges to core privileges, etc.) from the previous annual report and provide a synopsis of whether the goal was reached. Summary of audits and audit findings Include a list of the types of audits conducted, what was learned, and any changes made as a result of the audits (or refer to the recommendations section of the report if changes are proposed). Summary of important credentialing events Include information about denials that were made for appointment, reappointment, and privileges; hearings held and the outcome; negligent credentialing lawsuits filed and the current status; etc. Recommendations Include any recommendations made as a result of the analysis of the credentialing processes during the year. These might include the following suggestions: • Provide credentials committee members and department chairs with more education

about the credentialing process • Increase the number of credentialing staff • Purchase new credentialing software • Add resource information (e.g., newsletters, books, etc.) • Change the composition of the credentials committee • Add a required interview to the credentialing process Goals and objectives for the coming year (may include a work plan) You may need to defer part of this section, based on concurrence of the MEC, administration, and board, with recommendations made in the preceding section.

97

Include here any goals and objectives that the committee can implement without “permission” of the MEC and board, as well as those actions that can be taken after first securing funds that will have to be included in the next budget. An annual report that contains the elements identified above lends itself to a high-impact presentation to the MEC and the board. The report can be put together in a binder and can be accompanied by a PowerPoint presentation to communicate important points when presenting to the MEC and the board. Again, consider that the credentials committee seeks precision and concise language—and the report may eventually serve as the primary resource for important recommendations that are made.

98

_____ Medical Center Annual Credentials Report

2011

Dashboard Report A dashboard report is a concise snapshot of key indicators – in this case, related to credentialing and privileging processes. Dashboard reports are used to flag potential quality and/or process issues. Indicators serve as “pointers” to direct the Medical Executive Committee’s and the Board’s attention and resources to target areas for improvement in the process of credentialing. Dashboards establish expectations (via the targets), and facilitate evaluation of performance.

Purpose To identify key indicators of quality for issues that directly affect the success of the credentialing and privileging program. To facilitate evaluation of performance to lead to improvements in credentialing.

Performance Measures (Indicators) In credentialing as in other functions, that which cannot be measured is difficult to improve. Performance measures have been selected which are key measures of volume and quality that can serve as the starting point for further investigation.

Target Established by _____Medical Center. National standards or benchmarks are useful to help organizations establish their own targets. National standards or benchmarks may be difficult to find in the credentialing arena, but are identified when used.

99

Measure Target

(If Applicable)

Q1 Q2 Q3 Q4 TOTAL

Total # of credentialed and/or privileged practitioners

# of Active

# of Associate (no privileges)

# of Courtesy

# of Consulting

# of Honorary (no privileges)

# of Advanced Practice Allied Health Professionals

# of Resignations

Retired

Relocation

Stayed practicing in the community

# of practitioners on leave of absence

Initial appointment summary

# of initial applications received

# of initial applications completed

# of initial applications withdrawn by applicant prior to review by the Board

# of initial applications terminated prior to review by the Board

# of appointments approved by the Board with no changes in the privileges requested by applicant

# of denials of appointment

# of appointments approved by the Board with partial rejection of privileges requested by applicant

Average # of days from submission of application to Board appointment

Average # of days from submission of application to file declared complete for Department Chair review/evaluation

Reappointment Summary

Total # of reappointment applications received

100

Measure Target (If

Applicable)

Q1 Q2 Q3 Q4 TOTAL

# received 90 days or more prior to expiration of current appointment

# received within 30 days of expiration of current appointment

# of reappointment applications completed

# of reappointment applications withdrawn by applicant prior to review by the Board

# of reappointment applications terminated prior to review by the Board

# of reappointments approved by the Board with no changes in the privileges requested by applicant

# of denials of reappointment

# of reappointments approved by the Board with partial rejection of privileges requested by applicant

# of reappointments that were not approved by the Board prior to expiration date of current appointment

Temporary Privileges

Number of requests for temporary privileges (excludes TPs while pending initial appointment)

# approved as requested

# approved with some modification

# denied

Increased Privileges

# of requests for increased privileges

# approved

# approved with some modification

# denied

Other Issues

Number of files sent back to the Medical Staff Office from the Credentials Committee for additional information/research

101

Measure Target (If

Applicable)

Q1 Q2 Q3 Q4 TOTAL

Number of files sent back to the Department Chair from the Credentials Committee for additional information/documentation

# of instances of practitioners who exercised privileges that had not been granted

# of hearings

# of corporate negligence claims alleging credentials failure

# settled in favor of plaintiff

# dropped or settled in favor of healthcare organization

# of privilege clarifications requested of Medical Staff Office (e.g., asking if a practitioner has been granted privileges to perform a specific procedure)

102

UNDERSTANDING COMMITTEES AND THEIR ROLES

A TOOL FOR EVALUATING EFFECTIVENESS OF COMMITTEES

# ISSUE ANALYSIS

1 COMMITTEE PURPOSE What is the purpose of the

committee? Is it clearly articulated? Where is the purpose of the

committee described? Do the committee members know

the purpose? How do we determine if the purpose

is being fulfilled?

2 COMMITTEE MEMBERS Who are members of the committee? In what document are the members

specified (and their roles, if any)? Which members are voting members

vs. “ex-officio”?

3 MINUTES Where are the complete sets of

minutes and records kept? Who/what department is responsible

for maintaining the minutes? How long must minutes be retained?

Is there a policy on retention of minutes of this committee?

4 FREQUENCY OF MEETINGS (Review Attendance Records) How often is the committee

supposed to meet? How often did the committee meet

during the past 12 months (go back two years, if possible)?

Was a meeting ever canceled because of a lack of quorum?

Was a meeting ever held despite not having a quorum?

Do physicians regularly attend this

103

# ISSUE ANALYSIS

meeting? What percentage of meeting are

attended by each 1. Physician? 2. Other key individuals?

5 COMMITTEE RELATIONSHIPS How does this committee relate to

other medical staff organization (or non-medical staff organization) committees?

Is this committee a sub-committee of another committee?

To what committee/group does this committee report?

How does the committee report (send a copy of minutes somewhere, give a verbal report at another meeting, etc.)?

How does the committee receive feedback?

(When the committee reports something to another committee or group, how does the committee hear back what happened?)

6 INFORMATION FLOW What information (reports) does the

committee regularly receive? What does the committee do with

the information? (Analyze, make decision, refer somewhere else?)

7 REGULATORY REQUIREMENTS Who will be reading the minutes? What will “they” be looking for in the minutes? What are the external requirements

of the committee? Are there specific regulations that pertain to the functioning of the committee?

Do we have a copy of these regulations?

Who is responsible to assure that

104

# ISSUE ANALYSIS

requirements are being met when there are regulatory requirements that pertain to the workings of the committee?

What are the possible consequences of not performing the functions in accordance with regulatory agency requirements?

8 COMMITTEE COST What is the cost of the committee?

Figure: Number of physicians who attend meetings times an hourly rate (average $___/hr per physician) for their time; number of non-physician personnel (average $__/hr) who attend meetings times an hourly rate for their time; number of support personnel who support the meeting times an hourly rate for their time (this number is usually higher than for the other people because they make arrangements, write minutes, prepare follow-up, etc.) food; copying costs; meeting room costs; etc.

9 KEY ACCOMPLISHMENTS What are the committee’s key

accomplishments during the past 12 months?

105