provider competency in privileging resource · ms. matzka has authored a number of books related to...

Provider Competency in Privileging

Kathy Matzka, CPMSM, CPCS Consultant/Speaker

1304 Scott Troy Road Lebanon, IL 62254

[email protected] website: www.kathymatzka.com

Phone (618) 624-8124

BIOGRAPHICAL SKETCH, KATHY MATZKA, CPMSM, CPCS

Kathy Matzka, CPMSM, CPCS is a speaker, consultant, and writer with over 20 years of experience in credentialing, privileging, and medical staff services. She holds certification by the National Association Medical Staff Services (NAMSS) in both Medical Staff Management and Provider Credentialing. Ms. Matzka worked for 13 years as a hospital medical staff coordinator before venturing out on her own as a consultant, writer, and speaker. Ms. Matzka has authored a number of books related to medical staff services including both the fifth and sixth editions of the Compliance Guide to Joint Commission Medical Staff Standards, and The Medical Staff Meeting

Companion Tools and Techniques for Effective Presentations. For the past eight years, she has been the contributing editor for the credentialing industry’s premier credentialing publication, The Credentials Verification Desk Reference and, recently, its companion website The Credentialing and Privileging Desktop Reference. She has performed extensive work with NAMSS’ Library Team developing and editing educational materials related to the field including CPCS Certification Exam Preparatory Course, NAMSS Core Curriculum, PMSM and PCS Professional Development Workshops, and Independent Study Programs. These programs are essential educational tools for both new and seasoned medical services professionals. She also serves as a speaker and instructor for NAMSS. Ms. Matzka shares her expertise by serving on the editorial advisory boards for three publications - Briefings on Credentialing, Credentialing, Peer Review Legal Insider, and Advisor for Medical and Professional Staff Services. Ms. Matzka is a highly-regarded industry speaker, and in this role has developed and presented numerous programs for professional associations, hospitals, and hospital associations on a wide range of topics including provider credentialing and privileging, medical staff meeting management, peer review, negligent credentialing, provider competency, and accreditation standards.

In her spare time, Ms. Matzka takes pleasure in spending time with her family, listening to music, singing with her church worship team, traveling, hiking, fishing, and other outdoor activities.

Table of Contents Overview and Introduction...............................................................................................1

Definitions of Credentialing and Recredentialing .........................................................1 Why Do We Do It? .......................................................................................................1 What Do Accrediting and Regulatory Bodies Require?................................................2 Primary Source ..........................................................................................................14

Developing an Effective Privileging Process .................................................................16 Clinical Privileges.......................................................................................................16 History of Privileging ..................................................................................................16 Medicare CoPs Regarding Privileges ........................................................................16 Joint Commission Standards Regarding Privileges ...................................................17 Privileging Systems....................................................................................................20 Sample Privilege Forms.............................................................................................21 Category Example .....................................................................................................22 Core Privileges Example............................................................................................23 Requests for New Privileges ......................................................................................42

Evaluating and Documenting Practitioner Competency.................................................44 What Is Competence? ...............................................................................................44 Current Competence..................................................................................................44 Work History and Affiliations ......................................................................................45 Sample Letter: Facility Privileges and Competency Validation ..................................46 Sample Letter for Verification of Training...................................................................48 Peer Recommendations ............................................................................................51 Provisional Appointment ............................................................................................54 Joint Commission Standards for FPPE/OPPE...........................................................55 Sample Ongoing and Focused Professional Practice Evaluation Policy....................67

Documenting Recommendations...................................................................................71 Sample language for medical staff minutes: ..............................................................71 Sample language for Board minutes:.........................................................................71 Recommendation and Approval Form for Medical Staff Appointment and Clinical Privileges ...................................................................................................................72

Proctoring ......................................................................................................................73 Peer Review Policy: Definition of Peer.......................................................................75 Sample Policy Regarding Proctoring .........................................................................76 Sample Proctorship Forms.........................................................................................79 Proctoring Summary Report.......................................................................................81 Medical Proctor’s Report Sample 1............................................................................82 Medical Proctor’s Report Sample 2............................................................................83

Provider Competency in Privileging - Kathy Matzka, CPMSM, CPCS 1

Provider Competency in Privileging

OVERVIEW AND INTRODUCTION

Definitions of Credentialing and Recredentialing

NAMSS

Credentialing is the process of obtaining, verifying and assessing the qualifications of a healthcare practitioner to provide patient care services in or for a healthcare entity. Recredentialing is the process of obtaining and evaluating data to support the continued competence of the healthcare practitioner to provide patient care services in or for a healthcare organization. Source NAMSS Core Curriculum

Joint Commission

The Glossary in Joint Commission manual defines credentialing as the process of obtaining, verifying and assessing the qualifications of a healthcare practitioner to provide patient care services in or for a healthcare entity. The introduction to the credentialing standards includes more detail: “Credentialing involves the collection, verification, and assessment of information regarding three critical parameters; current licensure; education and relevant training; and experience, ability, and current competence to perform the requested privilege(s). Verification is sought to minimize the possibility of granting privilege(s) based on the review of fraudulent documents.”

Why Do We Do It? There are a number of reasons for credentialing providers. Patient Protection This is the number one concern. The patient is put before anything else. If you look at the mission statement of any healthcare organization, you will find language that refers to providing high quality patient care. This can only be accomplished by allowing only those providers who meet certain high standards to treat patients. Risk Management Concerns If the patient suffers an adverse outcome at the hospital, the hospital can be held liable. If the provider has problems that would have been revealed by credentialing, but credentialing was not performed, the hospital may be liable for any patient harm caused by the substandard clinician.


The case Darling v. Charleston Community Memorial Hospital, 211 N.E.2d 253 (Ill. 1965) set the precedent that a hospital can be held directly liable for negligent failure to properly credential a provider. In this case, the patient alleged that the hospital was negligent in the following areas:

• permitting the physician to treat his orthopedic injuries:

• not requiring the physician to update operative procedures;

• failing, through it’s medical staff, to exercise adequate supervision, especially since Dr. Alexander had been placed on emergency duty by the hospital; and

• not requiring consultation especially after complications set in. The hospital’s defense was that only the physician can practice medicine, therefore the hospital cannot be liable for the acts of a physician where reasonable care was exercised in selecting the physician. The Illinois Supreme Court sided with the patient noting that hospitals do more than just provide facilities for treatment, but assume certain responsibilities for the care of the patient. Required by accrediting and regulatory agencies Another reason healthcare organizations credential is that it is required by accrediting bodies and regulatory agencies. The Joint Commission (Joint Commission) and the National Committee for Quality Assurance (NCQA) standards require credentialing of providers.

What Do Accrediting and Regulatory Bodies Require?

Joint Commission

Joint Commission medical staff standards require any individual permitted by law and by the organization to provide care, treatment, and services without direction or supervision to be credentialed and privileged. These individuals are known as licensed independent practitioners (LIP). Although the granting of clinical privileges to these LIPs is required, Joint Commission does not require that they be appointed to the medical staff. This is left up to the hospital and varies by organization dependent upon the services provided by the facility, state regulations, and the mind-set of the medical staff and community. The credentialing process for non-physician LIPs is usually similar to that of a physician appointee due to the degree of patient care provided without direct supervision.


Medicare Conditions of Participation

§482.12 CONDITION OF PARTICIPATION: GOVERNING BODY The hospital must have an effective governing body legally responsible for the conduct of the hospital as an institution. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body. Interpretive Guidelines §482.12 The hospital must have only one governing body and this governing body is responsible for the conduct of the hospital as an institution. In the absence of an organized governing body, there must be written documentation that identifies the individual or individuals that are responsible for the conduct of the hospital operations. §482.12(a) Standard: Medical Staff The governing body must ensure the medical staff requirements are met. §482.12(a)(1) [The governing body must:] Determine, in accordance with State law, which categories of practitioners are eligible candidates for appointment to the medical staff; Interpretive Guidelines §482.12(a)(1) The medical staff must, at a minimum, be composed of physicians who are doctors of medicine or doctors of osteopathy. In addition, the medical staff may include other practitioners included in the definition in Section 1861(r) of the Social Security Act of a physician:

• Doctor of medicine or osteopathy; • Doctor of dental surgery or of dental medicine; • Doctor of podiatric medicine; • Doctor of optometry; and • a Chiropractor.

In all cases, the practitioners included in the definition of a physician must be legally authorized to practice within the State where the hospital is located and providing services within their authorized scope of practice. In addition, in certain instances the Social Security Act and regulations attach further limitations as to the type of hospital services for which a practitioner may be considered to be a “physician.” See 42 CFR 482.12(c)(1) for more detail on these limitations. The governing body has the flexibility to determine whether other types of practitioners included in the definition of a physician are eligible for appointment to the medical staff.


Furthermore, the governing body has the authority, in accordance with State law, to appoint some types of non-physician practitioners, such as nurse practitioners, physician assistants, certified registered nurse anesthetists, and midwives, to the medical staff. Practitioners, both physicians and non-physicians, may be granted privileges to practice at the hospital by the governing body for practice activities authorized within their State scope of practice without being appointed a member of the medical staff. §482.12(a)(2) [The governing body must:] Appoint members of the medical staff after considering the recommendations of the existing members of the medical staff; Interpretive Guidelines §482.12(a)(2) The governing body determines whether to grant, deny, continue, revise, discontinue, limit, or revoke specified privileges, including medical staff membership, for a specific practitioner after considering the recommendation of the medical staff. In all instances, the governing body’s determination must be consistent with established hospital medical staff criteria, as well as with State and Federal law and regulations. Only the hospital’s governing body has the authority to grant a practitioner privileges to provide care in the hospital. §482.12(a)(3) [The governing body must:] Assure that the medical staff has bylaws; Interpretive Guidelines §482.12(a)(3) The governing body must assure that the medical staff has bylaws and that those bylaws comply with State and Federal law and the requirements of the Medicare hospital Conditions of Participation. §482.12(a)(4) [The governing body must:] Approve medical staff bylaws and other medical staff rules and regulations;

Interpretive Guidelines §482.12(a)(4) The governing body decides whether or not to approve medical staff bylaws submitted by the medical staff. The medical staff bylaws and any revisions must be approved by the governing body before they are considered effective.

§482.12(a)(5) [The governing body must:] Ensure that the medical staff is accountable to the governing body for the quality of care provided to patients; Interpretive Guidelines §482.12(a)(5) The governing body must ensure that the medical staff as a group is accountable to the governing body for the quality of care provided to patients. The governing body is


responsible for the conduct of the hospital and this conduct includes the quality of care provided to patients. All hospital patients must be under the care of a practitioner who meets the criteria of 42 CFR 482.12(c)(1)and who has been granted medical staff privileges, or under the care of a practitioner who is directly under the supervision of a member of the medical staff. All patient care is provided by or in accordance with the orders of a practitioner who has been granted privileges in accordance with the criteria established by the governing body, and who is working within the scope of those granted privileges. §482.12(a)(6) [The governing body must:] Ensure the criteria for selection are individual character, competence, training, experience, and judgment; and Interpretive Guidelines §482.12(a)(6) The governing body must assure that the medical staff bylaws describe the privileging process to be used by the hospital. The process articulated in the medical staff bylaws, rules, or regulations must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners that considers:

• Individual character; • Individual competence; • Individual training; • Individual experience; and • Individual judgment.

The governing body must ensure that the hospital’s bylaws governing medical staff membership or the granting of privileges apply equally to all practitioners in each professional category of practitioners.

§482.12(a)(7) [The governing body must:] Ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship or membership in a specialty body or society.

Interpretive Guidelines §482.12(a)(7) In making a judgment on medical staff membership, a hospital may not rely solely on the fact that a MD/DO is, or is not, board-certified. This does not mean that a hospital is prohibited from requiring board certification when considering a MD/DO for medical staff membership, but only that such certification must not be the only factor that the hospital considers. In addition to matters of board certification, a hospital must also consider other criteria such as training, character, competence and judgment. After analysis of all of the criteria, if all criteria are met except for board certification, the hospital has the discretion to decide not to select that individual to the medical staff.


§482.22 CONDITION OF PARTICIPATION: MEDICAL STAFF

The hospital must have an organized medical staff that operates under bylaws approved by the governing body and is responsible for the quality of medical care provided to patients by the hospital. Interpretive Guidelines §482.22 The hospital may have only one medical staff for the entire hospital (including all campuses, provider -based locations, satellites, remote locations, etc.). The medical staff must be organized and integrated as one body that operates under one set of bylaws approved by the governing body. These medical staff bylaws must apply equally to all practitioners within each category of practitioners at all locations of the hospital and to the care provided at all locations of the hospital. The single medical staff is responsible for the quality of medical care provided to patients by the hospital. §482.22(a) Standard: Composition of the Medical Staff The medical staff must be composed of doctors of medicine or osteopathy and, in accordance with State law, may also be composed of other practitioners appointed by the governing body. Interpretive Guidelines §482.22(a): The medical staff must at a minimum be composed of physicians who are doctors of medicine or doctors of osteopathy. In addition, the medical staff may include other practitioners included in the definition in Section 1861(r) of the Social Security Act of a physician:

• Doctor of medicine or osteopathy; • Doctor of dental surgery or of dental medicine; • Doctor of podiatric medicine; • Doctor of optometry; and a • Chiropractor.

In all cases the practitioners included in the definition of a physician must be legally authorized to practice within the State where the hospital is located and providing services within their authorized scope of practice. In addition, in certain instances the Social Security Act and regulations attach further limitations as to the type of hospital services for which a practitioner may be considered to be a “physician.” See §482.12(c)(1) for more detail on these limitations. The governing body has the flexibility to determine whether other types of practitioners included in the definition of a physician are eligible for appointment to the medical staff. Furthermore, the governing body has the authority, in accordance with State law, to appoint some types of non-physician practitioners, such as nurse practitioners, physician assistants, certified registered nurse anesthetists, and midwives, to the medical staff. Practitioners, both physicians and non-physicians, may be granted


privileges to practice at the hospital by the governing body for practice activities authorized within their State scope of practice without being appointed a member of the medical staff.

§482.22(a)(1) The medical staff must periodically conduct appraisals of its members. Interpretive Guidelines §482.22(a)(1) The medical staff must at regular intervals appraise the qualifications of all practitioners appointed to the medical staff/granted medical staff privileges. In the absence of a State law that establishes a timeframe for periodic reappraisal, a hospital’s medical staff must conduct a periodic appraisal of each practitioner. CMS recommends that an appraisal be conducted at least every 24 months for each practitioner. The purpose of the appraisal is for the medical staff to determine the suitability of continuing the medical staff membership or privileges of each individual practitioner, to determine if that individual practitioner’s membership or privileges should be continued, discontinued, revised, or otherwise changed. The medical staff appraisal procedures must evaluate each individual practitioner’s qualifications and demonstrated competencies to perform each task or activity within the applicable scope of practice or privileges for that type of practitioner for which he/she has been granted privileges. Components of practitioner qualifications and demonstrated competencies would include at least: current work practice, special training, quality of specific work, patient outcomes, education, maintenance of continuing education, adherence to medical staff rules, certifications, appropriate licensure, and currency of compliance with licensure requirements. In addition to the periodic appraisal of members, any Procedure/task/activity/privilege requested by a practitioner that goes beyond the specified list of privileges for that particular category of practitioner requires an appraisal by the medical staff and approval by the governing body. The appraisal must consider evidence of qualifications and competencies specific to the nature of the request. It must also consider whether the activity/task/procedure is one that the hospital can support when it is conducted within the hospital. Privileges cannot be granted for tasks/procedures/activities that are not conducted within the hospital, regardless of the individual practitioner’s ability to perform them. After the medical staff conducts its reappraisal of individual members, the medical staff makes recommendations to the governing body to continue, revise, discontinue, limit, or revoke some or all of the practitioner’s privileges, and the governing body takes final appropriate action. A separate credentials file must be maintained for each medical staff member. The hospital must ensure that the practitioner and appropriate hospital patient care areas/departments are informed of the privileges granted to the practitioner, as well as of any revisions or revocations of the practitioner’s privileges. Furthermore, whenever a


practitioner’s privileges are limited, revoked, or in any way constrained, the hospital must, in accordance with State and/or Federal laws or regulations, report those constraints to the appropriate State and Federal authorities, registries, and/or data bases, such as the National Practitioner Data Bank. §482.22(a)(2) The medical staff must examine credentials of candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates. Interpretive Guidelines §482.22(a)(2) There must be a mechanism established to examine credentials of individual prospective members (new appointments or reappointments) by the medical staff. The individual’s credentials to be examined must include at least:

• A request for clinical privileges; • Evidence of current licensure; • Evidence of training and professional education; • Documented experience; and • Supporting references of competence.

The medical staff may not make its recommendation solely on the basis of the presence or absence of board certification, but must consider all of the elements above. However, this does not mean that the medical staff is prohibited from requiring in its bylaws board certification when considering a MD/DO for medical staff membership or privileges; only that such certification may not be the only factor that the medical staff considers. The medical staff makes recommendations to the governing body for each candidate for medical staff membership/privileges that are specific to type of appointment and extent of the individual practitioner’s specific clinical privileges, and then the governing body takes final appropriate action. A separate credentials file must be maintained for each individual medical staff member or applicant. The hospital must ensure that the practitioner and appropriate hospital patient care areas/departments are informed of the privileges granted to the practitioner. §482.22(b) Standard: Medical Staff Organization and Accountability The Medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing

body. (2) If the medical staff has an executive committee, a majority of the members of the

committee must be doctors of medicine or osteopathy.


(3) The responsibility for organization and conduct of the medical staff must be assigned only to an individual doctor of medicine or osteopathy or, when permitted by State law of the State in which the hospital is located, a doctor of dental surgery or dental medicine.

Interpretive Guidelines §482.22(b) The medical staff must be accountable to the hospital’s governing body for the quality of medical care provided to the patients. The organization of the medical staff must comply with these requirements. §482.22(c) Standard: Medical Staff Bylaws

The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: Interpretive Guidelines §482.22(c) The medical staff must regulate itself by bylaws that are consistent with the requirements of this and other CoPs that mention medical staff bylaws, as well as State laws. The bylaws must be enforced and revised as necessary. §482.22(c)(1) [The bylaws must] Be approved by the governing body. Interpretive Guidelines §482.22(c)(1) Medical staff bylaws and any revisions of those bylaws must be submitted to the governing body for approval. The governing body has the authority to approve or disapprove bylaws suggested by the medical staff. The bylaws and any revisions must be approved by the governing body before they are considered effective. §482.22(c)(2) [The bylaws must] Include a statement of the duties and privileges of each category of medical staff (e.g., active, courtesy, etc.) Interpretive Guidelines §482.22(c)(2) The medical staff bylaws must state the duties and scope of medical staff privileges each category of practitioner may be granted. Specific privileges for each category must clearly and completely list the specific privileges or limitations for that category of practitioner. The specific privileges must reflect activities that the majority of practitioners in that category can perform competently and that the hospital can support. Although the medical staff bylaws must address the duties and scope for each category of practitioner, this does not mean that each individual practitioner within the category may automatically be granted the full range of privileges. It cannot be assumed that every practitioner can perform every task/activity/privilege that is specified for the


applicable category of practitioner. The individual practitioner’s ability to perform each task/activity/privilege must be individually assessed. §482.22(c)(3) [The bylaws must] Describe the organization of the medical staff. Interpretive Guidelines §482.22(c)(3) The medical staff bylaws must describe the organizational structure of the medical staff, and lay out the rules and regulations of the medical staff to make clear what are acceptable standards of patient care for all diagnostic, medical, surgical, and rehabilitative services. §482.22(c)(4) [The bylaws must] Describe the qualifications to be met by a candidate in order for the medical staff to recommend that the candidate be appointed by the governing body. Interpretive Guidelines §482.22(c)(4) The medical staff bylaws must describe the qualifications to be met by a candidate for medical staff membership/privileges in order for the medical staff to recommend the candidate be approved by the governing body. The bylaws must describe the privileging process to be used in the hospital. The process articulated in the medical staff bylaws must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners that considers:

• Individual character; • Individual competence; • Individual training; • Individual experience; and • Individual judgment.

The medical staff may not rely solely on the fact that a MD/DO is, or is not, board-certified in making a judgment on medical staff membership. This does not mean that the medical staff is prohibited from requiring board certification when considering a MD/DO for medical staff membership; only that such certification is not the only factor that the hospital considers. After analysis of all of the criteria, if all criteria are met except for board certification, the medical staff has the discretion to not recommend that individual for medical staff membership/privileges. The bylaws must apply equally to all practitioners in each professional category of practitioners. The medical staff then recommends individual candidates that meet those requirements to the governing body for appointment to the medical staff.


482.22(c)(5) [The bylaws must] Include a requirement that – (i) A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy. Interpretive Guidelines §482.22(c)(5)(i) The purpose of a medical history and physical examination (H&P) is to determine whether there is anything in the patient's overall condition that would affect the planned course of the patient's treatment, such as a medication allergy, or a new or existing co-morbid condition that requires additional interventions to reduce risk to the patient. The Medical Staff bylaws must include a requirement that an H&P be completed and documented for each patient no more than 30 days prior to or 24 hours after hospital admission or registration, but prior to surgery or a procedure requiring anesthesia services. The H&P may be handwritten or transcribed, but always must be placed within the patient’s medical record within 24 hours of admission or registration, or prior to surgery or a procedure requiring anesthesia services, whichever comes first. An H&P is required prior to surgery and prior to procedures requiring anesthesia services, regardless of whether care is being provided on an inpatient or outpatient basis. (71 FR 68676) An H&P that is completed within 24 hours of the patient’s admission or registration, but after the surgical procedure, procedure requiring anesthesia, or other procedure requiring an H&P would not be in compliance with this requirement. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy. Section 1861(r) defines a physician as a:

• Doctor of medicine or osteopathy; • Doctor of dental surgery or of dental medicine; • Doctor of podiatric medicine; • Doctor of optometry; or a • Chiropractor.

In all cases the practitioners included in the definition of a physician must be legally authorized to practice within the State where the hospital is located and providing services within their authorized scope of practice. In addition, in certain instances the Social Security Act attaches further limitations as to the type of hospital services for which a practitioner is considered to be a “physician.”


Other qualified licensed individuals are those licensed practitioners who are authorized in accordance with their State scope of practice laws or regulations to perform an H&P and who are also formally authorized by the hospital to conduct an H&P. Other qualified licensed practitioners could include nurse practitioners and physician assistants. More than one qualified practitioner can participate in performing, documenting, and authenticating an H&P for a single patient. When performance, documentation, and authentication are split among qualified practitioners, the practitioner who authenticates the H&P will be held responsible for its contents. (71 FR 68675) A hospital may adopt a policy allowing submission of an H&P prior to the patient’s hospital admission or registration by a physician who may not be a member of the hospital's medical staff or who does not have admitting privileges at that hospital, or by a qualified licensed individual who does not practice at that hospital but is acting within his/her scope of practice under State law or regulations. Generally, this occurs where the H&P is completed in advance by the patient’s primary care practitioner. (71 FR 68675) When the H&P is conducted within 30 days before admission or registration, an update must be completed and documented by a licensed practitioner who is credentialed and privileged by the hospital’s medical staff to perform an H&P. 482.22(c)(5) – The Bylaws must include a requirement that (ii) An updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration. The updated examination of the patient, including any changes in the patient's condition, must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy. Interpretive Guidelines 482.22(c)(5)(ii) The Medical Staff bylaws must include a requirement that when a medical history and physical examination has been completed within 30 days before admission or registration, an updated medical record entry must be completed and documented in the patient's medical record within 24 hours after admission or registration. The examination must be conducted by a licensed practitioner who is credentialed and privileged by the hospital’s medical staff to perform an H&P. In all cases, the update must take place prior to surgery or a procedure requiring anesthesia services. The update note must document an examination for any changes in the patient's condition since the patient's H&P was performed that might be significant for the planned course of treatment. The physician or qualified licensed individual uses his/her clinical


judgment, based upon his/her assessment of the patient’s condition and co-morbidities, if any, in relation to the patient’s planned course of treatment to decide the extent of the update assessment needed as well as the information to be included in the update note in the patient’s medical record. If, upon examination, the licensed practitioner finds no change in the patient's condition since the H&P was completed, he/she may indicate in the patient's medical record that the H&P was reviewed, the patient was examined, and that "no change" has occurred in the patient's condition since the H&P was completed (71 FR 68676). Any changes in the patient’s condition must be documented by the practitioner in the update note and placed in the patient’s medical record within 24 hours of admission or registration, but prior to surgery or a procedure requirement anesthesia services. Additionally, if the practitioner finds that the H&P done before admission is incomplete, inaccurate, or otherwise unacceptable, the practitioner reviewing the H&P, examining the patient, and completing the update may disregard the existing H&P, and conduct and document in the medical record a new H&P within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia. §482.22(c)(6) [The bylaws must] Include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges. Interpretive Guidelines §482.22(c)(6) All patient care is provided by or in accordance with the orders of a practitioner who meets the medical staff criteria and procedures for the privileges granted, who has been granted privileges in accordance with those criteria by the governing body, and who is working within the scope of those granted privileges. Privileges are granted by the hospital’s governing body to individual practitioners based on the medical staff’s review of that individual practitioner’s qualifications and the medical staff’s recommendations for that individual practitioner to the governing body. §482.22(d) Standard: Autopsies The medical staff should attempt to secure autopsies in all cases of unusual deaths and of medical-legal and educational interest. The mechanism for documenting permission to perform an autopsy must be defined. There must be a system for notifying the medical staff, and specifically the attending practitioner, when an autopsy is being performed. §482.51(a)(4) - Surgical Privileges Surgical privileges must be delineated for all practitioners performing surgery in accordance with the competencies of each practitioner. The surgical service must maintain a roster of practitioners specifying the surgical privileges of each practitioner. Interpretive Guidelines §482.51(a)(4)


Surgical privileges should be reviewed and updated at least every 2 years. A current roster listing each practitioner’s specific surgical privileges must be available in the surgical suite and area/location where the scheduling of surgical procedures is done. A current list of surgeons suspended from surgical privileges or whose surgical privileges have been restricted must also be retained in these areas/locations. The hospital must delineate the surgical privileges of all practitioners performing surgery and surgical procedures. The medical staff is accountable to the governing body for the quality of care provided to patients. The medical staff bylaws must include criteria for determining the privileges to be granted to an individual practitioner and a procedure for applying the criteria to individuals requesting privileges. Surgical privileges are granted in accordance with the competencies of each practitioner. The medical staff appraisal procedures must evaluate each individual practitioner’s training, education, experience, and demonstrated competence as established by the hospital’s QAPI program, credentialing process, the practitioner’s adherence to hospital policies and procedures, and in accordance with scope of practice and other State laws and regulations. The hospital must specify the surgical privileges for each practitioner that performs surgical tasks. This would include practitioners such as MD/DO, dentists, oral surgeons, podiatrists, RN first assistants, nurse practitioners, surgical physician assistants, surgical technicians, etc. When a practitioner may perform certain surgical procedures under supervision, the specific tasks/procedures and the degree of supervision (to include whether or not the supervising practitioner is physically present in the same OR, in line of sight of the practitioner being supervised) be delineated in that practitioner’s surgical privileges and included on the surgical roster. If the hospital utilizes RN First Assistants, surgical PA, or other non-MD/DO surgical assistants, the hospital must establish criteria, qualifications and a credentialing process to grant specific privileges to individual practitioners based on each individual practitioner’s compliance with the privileging/credentialing criteria and in accordance with Federal and State laws and regulations. This would include surgical services tasks conducted by these practitioners while under the supervision of an MD/DO. When practitioners whose scope of practice for conducting surgical procedures requires the direct supervision of an MD/DO surgeon, the term “supervision” would mean the supervising MD/DO surgeon is present in the same room, working with the same patient. Surgery and all surgical procedures must be conducted by a practitioner who meets the medical staff criteria and procedures for the privileges granted, who has been granted specific surgical privileges by the governing body in accordance with those criteria, and who is working within the scope of those granted and documented privileges.

Primary Source The healthcare organization is obligated to assure that only competent practitioners provide treatment and services to its patients. This is accomplished through verification of the information provided by the practitioner and assuring that the practitioner meets the requirements for membership and privileges.


A primary source is the original source that can verify the accuracy of a credential, qualification, or other information reported by the practitioner. For instance, when seeking to verify completion of a residency program, the organization contacts the residency program and asks for this verification. Primary source verification can be performed via letter, fax, approved official website, or well-documented telephone call. If verifying by phone, include the name of the organization called, the date, the person contacted, the questions asked, the response, the name of the person receiving the response.

Both the Joint Commission on the Accreditation of Healthcare Organizations and the National Committee on Quality Assurance have standards regarding primary source verification at the time of initial credentialing and recredentialing.

Joint Commission Standards Regarding PSV

Joint Commission allows primary source verification to be obtained through written documentation, secure electronic communication, or by phone contact with the primary source. According to the Joint Commission, a documented telephone conversation can be utilized as primary-source verification for all information including licensure, education, training, experience, competence, and peer references. When verifying information via telephone, documentation should include the date of the conversation, the name and title of the person providing the information, the name of the organization when appropriate, e.g., the school, certifying board, employing organization, etc., the specific information provided, and the date and signature of the person receiving the information.


DEVELOPING AN EFFECTIVE PRIVILEGING PROCESS

Clinical Privileges Privileging is the process used to determine the specific procedures and treatments that healthcare practitioners may perform. They are granted within an area of practice. Privileges are not a right. The applicant must prove qualifications through documentation of training and/or experience.

History of Privileging In days past, only admitting privileges were granted and these privileges were granted only to physicians. There were fewer treatment options available so most practitioners could competently perform all or most included in privileges. In the 1950’s, the American College of Surgeons recommended the laundry list approach which included a detailed listing of all privileges and procedures that a physician or surgeon may wish to perform. At that time, many physicians had not completed residencies, and many states allowed licensure to physicians who had completed medical school only. As such, skills varied. As technology advanced, this changed. Residencies began to clearly delineate what needed to be included in the training programs. This standardization helped greatly in establishing privilege lists. Hospitals began establishing lists of all procedures that could conceivably be performed. Because of technology changing rapidly, these lists became quickly outdated and required constant maintenance in order to clearly reflect the physicians’ practice within the hospital. Today, privileges are granted within area of practice. They are not a right. The applicant must prove qualifications through documentation of training and/or experience. It is important to carefully review privilege requests to make sure the applicant is only requesting privileges for which he/she is qualified and that the hospital can provide these services. Remember! THE BURDEN OF PROOF IS ON THE APPLICANT! Privileges must be setting-specific, meaning they are based, not only on the applicant's qualifications, but also on consideration of the procedures and types of care, treatment, and services that can be performed or provided within the setting. A hospital must have the necessary equipment and trained staff to support procedures and/or treatments.

Medicare CoPs Regarding Privileges §482.22(c)(2) - [The bylaws must:] Include a statement of the duties and privileges of each category of medical staff (e.g., active, courtesy, etc.) Interpretive Guidelines §482.22(c)(2)


The medical staff bylaws must state the duties and scope of medical staff privileges each category of practitioner may be granted. Specific privileges for each category must clearly and completely list the specific privileges or limitations for that category of practitioner. The specific privileges must reflect activities that the majority of practitioners in that category can perform competently and that the hospital can support. Although the medical staff bylaws must address the duties and scope for each category of practitioner, this does not mean that each individual practitioner within the category may automatically be granted the full range of privileges. It cannot be assumed that every practitioner can perform every task/activity/privilege that is specified for the applicable category of practitioner. The individual practitioner’s ability to perform each task/activity/privilege must be individually assessed.

Joint Commission Standards Regarding Privileges Joint Commission requires privileges delineation, but does not specify how this must be done. The privilege delineation system must be hospital specific and must take into account the hospital’s technical and staff capability of supporting the procedures. Standards require all LIPs (defined as individuals who are permitted by law and the hospital to provide care, treatment, or services without direction or supervision) to be privileged through the medical staff process. The hospital must have a mechanism that ensures the quality of patient care by all individuals with delineated clinical privileges, whether or not they are medical staff appointees. The process used to grant or deny privileges and/or renew existing privileges must be objective and evidenced-based. This means that privileges can’t be based on arbitrary criteria, such as random number of admissions or procedures, but must be scientifically developed, consensus driven, and based on current literature. The hospital must establish criteria to determine a practitioner’s ability to provide patient care, treatment, and services within the scope of the requested privileges. These criteria must be consistently evaluated for all practitioners with like privileges, must be based on the medical staff’s recommendations, and must be approved by the governing body. Criteria must include evaluation of current licensure or certification, relevant training, evidence of physical ability to perform the requested privilege, data from professional practice review from other organization where the applicant currently has privileges (if available), recommendations from peers and/or faculty. On renewal, there must be a review of the applicant’s performance within the hospital. Criteria utilized to make decisions on medical staff membership and clinical privileges must be directly related to the quality of health care, treatment, and services. If privileging criteria are used that are unrelated to quality of care, treatment, and services or professional competence, evidence exists that the impact of resulting decisions on the quality of care, treatment, and services is evaluated. There must be a clearly-documented procedure for the processing of requests for initial grants, renewal, or revision of privileges which is approved by the medical staff.


According to Joint Commission, the privileging process typically includes:

• Development and approval of a privilege form or procedures list

• Processing the application according to an approved procedure

• Evaluation of the information regarding the applicant that is accumulated during the credentialing and privileging process

• Medical staff making and submitting of recommendations to the governing body

• Governing body action

• Notifying relevant personnel of the decision including the applicant and external organizations required by law; and

• Continuous monitoring of privileges and any quality of care issues The privileging process must include a statement that the applicant must attest that there are no existing health problems that could affect his or her ability to perform the requested privileges. The hospital must query the National Practitioner Data Bank (NPDB) as required by law, on initial grants of privileges, on renewal of privileges, and when new privileges are requested. Before recommending privileges, medical staff must evaluate all of the following:

• Challenges to any licensure or registration

• Voluntary and/or involuntary relinquishment of any license or registration

• Voluntary and/or involuntary termination of medical staff membership

• Voluntary and/or involuntary limitation, reduction, or loss of clinical privileges

• Evidence of an excessive number or an unusual pattern of professional lawsuits that result in a final judgment against the applicant.

• Documentation as to the applicant’s health status

• Relevant practitioner-specific data as compared to aggregate data, when available

• Morbidity and mortality data, when available The hospital must have process to determine whether it has adequate clinical performance information to make its decision regarding the granting, limiting, or denial of privileges. The credentialing and privileging process must be completed in a timely fashion and completed privilege applications must be acted on within the time period specified in the bylaws. When changes in clinical privileges are made, information regarding the practitioner’s scope of privileges must be updated. The medical staff must review and analyze the information collected by the hospital during the credentialing and privileging process and use it to come to its decisions. The process used for review and analysis of information must be clearly defined. Final authority for granting, renewing, or denying privileges rests with the governing body or a committee to which the governing body has delegated this function. PAs and APRNs who practice within the organization are credentialed, privileged, and reprivileged through the medical staff process or an equivalent process that has been approved by the governing body.


Joint Commission FAQ Regarding Core/Bundled Privileges - 4/1/2008

Q: Does the Joint Commission endorse or recommend the use of the core/bundle privileging format.

A: Joint Commission's credentialing and privileging standards in all accreditation

manuals do not reference the concept of core privileges nor do they suggest or promote a particular format for granting privileges.

Q: Are they any specific issues with using the core/bundle privileging format? A: The definition of the activities that are being covered by the core/bundle

terminology; and the implementation of an evaluation to determine that the applicant can be granted each of the activities listed the core privileges.

Definition:

• the core/bundled privilege must be clearly and accurately defined to reflect specific activities/procedures/privileges to be included in the core terminology, and those activities/procedures/privileges that are outside the core

• the core/bundled privilege must be clearly and accurately defined to reflect only activities/procedures/privileges actually performed at the organization

• the core/bundled privilege must be clearly defined to reflect activities that the organization believes a majority applicants should be able to perform

Implementation:

• before the core/bundle is granted the organization must evaluate each applicant's education, training and current competence to perform each activity listed in the core/bundle, and any that are assigned outside the core/bundle.

It cannot be assumed that every applicant can do every activity listed. • there needs to be a clearly defined method for the applicant to request deletion of

specific activities if they don't wish for them to be granted • if organization's evaluation determines that the applicant is not competent to

perform certain activities, then the organization must modify the core/bundle that is granted to the applicant

• in accordance with the medical staff standards the applicant and all appropriate internal and/or external persons or entities (as defined by the organization and applicable law) are notified as to the granting decision, i.e., whether the full core/bundle or a modified bundle has been granted. If the core/bundle was modified, the notification must detail the specific modifications. Note: The expectation for the evaluation of each applicant's education, training, and current competence to perform each specific activity would be the same if


the organization were to use a "laundry list" format for the applicant to select activities

Q: Is the Joint Commission aware of any issue that CMS might have with the

use of core/bundle privileging? A: In November 2004 CMS issued their position on privileging which addresses the concept of core/bundle privileging. It is in line with the Joint Commission expectation outlined above.

Privileging Systems There are various methods for delineating clinical privileges. Some examples include:

• Laundry list - an exhaustive list of individual procedures or conditions

• Core privileges - encompass treatment of medical conditions or performance of invasive procedures for which the applicant has been trained in the residency or fellowship program. Privileges for procedures or treatment of conditions for which training is obtained over and above residency or fellowship training require meeting additional criteria.

• Category or levels - describe privileges in terms of hierarchy of levels based either on treatment groupings or the level of training and experience

Privilege forms should include a statement that notifies the applicant that competency will be verified. In addition, core privilege forms should note that the applicant must cross off those privileges they do not want.


Sample Privilege Forms

“Laundry List” Example

Family Practice Privileges

� amniocentesis

� androscopy

� anoscopy

� arterial puncture

� arthrocentesis

� aspiration of bladder: suprapubic

� bartholin’s cyst: drainage

� biopsy skin and subcutaneous

� biopsy: vulva or vagina

� bladder catheterization

� breast: needle aspiration of cyst

� burns: partial; full thickness

� casting, splinting, and bracing

� cervix: biopsy and polypectomy

� cervix: cryosurgery

� chemotherapy, adult and child

� colonoscopy w /biopsy

� colonoscopy w/o biopsy

� colposcopy and biopsy

� culdocentesis

� dilatation and curettage

� dilatation and curettage

� dislocations: simple/closed reduction

� ECG interpretation

� ectopic pregnancy: medical management

� EGD w/ biopsy

� EGD w/o biopsy

� endometrial bx/aspiration curettage

� endoscopy: w/ foreign body removal

� epistaxis: anterior

� extensor tendon repair: simple/primary

� fine needle biopsy: superficial lymph node or thyroid

�

foreign body removal, eye, ear, nose, throat

� fracture care closed reduction

� fracture care non-operative/non-displaced

� frenulum release

� ganglion: aspiration/drainage

� hemorrhoidectomy: banding or infrared

� hemorrhoidectomy: external surgical

� history and physical exam

� holter monitoring

� hymenotomy

� hysterosalpingogram

� I & D abscess

� injection: joint, tendon, or bursa

� intrauterine demis management

� IU insertion/removal

� laceration: simple repair

� laceration: intermediate repair

� laryngoscopy: direct

� laryngoscopy: indirect

� LEEP biopsy or cone

� lumbar puncture

� lymph node superficial biopsy or excision

� lymph node excision or biopsy

� meatotomy

� morton’s neurom injection

� nail matrix destruction

� nail plate removal

� nasal fractur undisplaced

� neoplasia of skin: thermal or surgical treatment

� NG tube placement

� non-stress testing

� oral lesions: biopsy and excision; simple

� osteopathic manipulative therapy

� paracervical block

� pilonidal cyst I & D or excision

� proctosigmoidoscopy: flexible w/ biopsy

� proctosigmoidoscopy: flexible w/o biopsy

� proctosigmoidoscopy: rigid w/ biopsy

� proctosigmoidoscopy: rigid w/o biopsy

� pudendal block

� pulmonary function testing

� removal of cerumen impaction

� rhinolaryngoscopy: fiberoptic

� sebaceous cyst excision

� skin biopsy: shave, punch, incisional or excisional

� slit lamp exam

� stress testin exercise treadmill

� sub-cutaneous contraceptive devic insertion/removal

� thoracentesis: needle/catheter

� thoracentesis: needle/catheter

� tonometry

� ultrasound

� urethra dilation of female

� urethra dilation of male

� vacuum curette incomplete abortion

� vasectomy

� venereal warts: treatment

� venereal warts: treatment

� venipuncture

Signature___________________________________________ Date________________________________________________


Category Example

Privileges for Family Practice Category I This category includes privileges for uncomplicated, basic procedures and cognitive skills. Physicians applying for privileges in this category will be graduates of approved medical/osteopathic schools who are properly licensed, and who have demonstrated skills in family medicine. Category II Privileges in this category include privileges in Category I as well as privileges for those procedures and cognitive skills involving more serious medical problems and which normally are acquired during successful completion of a family practice residency program. This category may include procedures and cognitive skills also acquired by physicians trained in other specialty residency programs. Physicians requesting privileges in this category will have completed training in a family practice residency program, be qualified to take the family practice board exam and/or be board certified in family practice by the American Board of Family Practice (ABFP), or the American Osteopathic Board of Family Practice (AOBFP); or will have documented experience, demonstrated abilities and current competence in family medicine. Category III Privileges in this category require special skills and knowledge and, therefore, require documentation of such training and experience which may have been acquired in a family practice residency, in a post residency fellowship program, in a special course, or by practice experience.

Source: American Academy of Family Physicians These categories would include listings of procedures that can be performed in each category.

CLINICAL PRIVILEGE REQUEST FOR FAMILY MEDICINE WITH MATERNITY CARE

SOURCE: AMERICAN ACADEMY OF FAMILY PHYSICIANS


Core Privileges Example

Name: Effective from __/__/__ to __/__/__

INTRODUCTION OF CORE PRIVILEGES

Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity. Core privileges within the department of family medicine should reflect the core curriculum and training offered in accredited family medicine residency programs. The categories and core privileges listed are based on the “Program Requirements for Graduate Medical Education in Family Medicine,” a publication by The Accreditation Council for Graduate Medical Education (ACGME) (http://www.acgme.org/acWebsite/downloads/RRC_progReq/120pr706.pdf), and the “Recommended Curriculum Guidelines for Family Medicine Residents” endorsed by the American Academy of Family Physicians (http://www.aafp.org/x16524.xml). Resources for family physicians and hospitals for special non-core privileges can be found at the AAFP website at aafp.org, including the AAFP position paper on colonoscopy found at http://www.aafp.org/online/en/home/policy/policies/c/colonoscopypositionpaper.html.

ELIGIBILITY

To be eligible to apply for core privileges in family medicine, the applicant must meet the following criteria:

• Current certification or active participation in the examination process leading to certification in family medicine by the American Board of Family Medicine or the American Osteopathic Board of Family Physicians

And/or

• Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited post-graduate training program in family medicine.

FAMILY MEDICINE CORE PRIVILEGES

� Requested Admission, evaluation, diagnosis, treatment and management of infants and children, adolescents and adults for most illnesses, disorders and injuries. Core privileges include but are not limited to:

• The care of neonates and infants, including both well-baby and ill newborns.

• Illnesses, disorders and injuries of childhood, such as pneumonia, asthma, gastrointestinal infections, dehydration and urinary tract infections.

• Illnesses, disorders and injuries of adolescence.

• Illnesses, disorders and injuries of the adult, including but not limited to conditions of the heart, kidney, lung, musculoskeletal system, skin, eye, and nervous system, and including multi-system




diseases such as diabetes mellitus, HIV/AIDS and cancer, and including the care of patients requiring admission to intensive care.

• Women’s health, including illnesses, disorders and injuries of the female reproductive and genitourinary systems.

• Pre- and post-operative evaluation and care.

• Acute and chronic diseases of the elderly, including dementias, as well as functional assessment, physiologic and psychologic aspects of senescence and end-of-life care.

• Psychiatric disorders in children and adults, emotional aspects of non-psychiatric disorders, psychopharmacology, alcoholism and other substance abuse.

• The care for patients of all ages with acute illnesses, disorders and injuries in an emergency care setting.

• Community issues, such as child abuse and neglect, domestic violence, elder abuse and neglect, disease prevention and disaster preparedness.

• Procedures such as suturing lacerations, removal of non-penetrating corneal foreign bodies, simple skin biopsies or excisions, incision and drainage of abscesses, burn care, the management of uncomplicated minor closed fractures and uncomplicated dislocations, and such other procedures that are extensions of the same techniques and skills.

Exclusions: Though considered core privileges for Family Medicine, the following privileges will be excluded for this applicant at their request. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MATERNITY CORE PRIVILEGES

� Requested Admit, evaluate and manage pregnancy, labor and delivery, post-partum care, and other procedures related to maternity care, including medical diseases that are complicating factors in pregnancy (with consultation as appropriate). Applicant must provide documentation of at least 2 months obstetrical rotation during family practice residency with 40 patients delivered.

SPECIAL NON-CORE PRIVILEGES

To be eligible to apply for special non-core privileges, the applicant must have documented training and/or experience and current competence in performing the requested procedure(s) consistent with criteria set forth in medical staff policies governing the exercise of specific privileges. This may be accomplished by providing documentation of acceptable supervised training and experience during residency and/or fellowship training, or successful completion of an approved, recognized course when such exists.

C-Section

� Requested Application Criteria: Successful completion of an ACGME or AOA accredited residency training program in family medicine or obstetrics and gynecology. Required Previous Experience: A minimum of 30 Cesarean births as primary operator.




Acknowledgement of Practitioner

I acknowledge that I have requested only those privileges for which by current competence, training and/or experience, I am qualified to perform and for which I wish to exercise at the Hospital. I understand that I am bound by the applicable bylaws or policies of the Hospital. Signed: Date: Typed or printed name:

Department Chair’s Recommendation

I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and make the following recommendation(s):

� Recommend all requested privileges

� Recommend privileges with the following conditions/modifications:

� Do not recommend the following requested privileges:

Privilege Condition/Modification/Explanation

1.

2.

3.

4.

Notes:

Department Chair Signature: Date:




FAMILY MEDICINE CORE: APPENDIX A

CORE PROCEDURES

The following are a few examples of procedures from the Family Medicine CORE, illustrating the depth of Family Medicine training. As with other specialties, not every applicant for privileges will choose to do all procedures within the core, and may elect to exclude those procedures from their privilege request. It remains the responsibility of the Family Medicine department chair to forward credentialing/privileging applications to the credentials committee that have been appropriately vetted at the department level. General

• Arthrocentesis

• Incision and drainage (I & D) abscess

• Incision and drainage (I & D) hemorrhoids

• Breast cyst aspiration

• Burn care

• Excision of skin and subcutaneous lesions

• Excision of cutaneous and subcutaneous tumors and nodules

• Local anesthetic techniques

• Lumbar puncture

• Management of uncomplicated closed fractures and dislocations

• Needle biopsies

• Placement of anterior and posterior nasal hemostatic packing

• Perform skin biopsy or excision

• Peripheral nerve blocks

• Interpretation of electrocardiograms

• Management of non-penetrating corneal foreign body, nasal foreign body

• Repair of lacerations, including those requiring layer closure

• Suprapubic bladder aspiration

• Exercise Treadmill testing

• Vascular access and intubation of newborns

• Management of abnormal Pap, including colposcopy, cryotherapy and LEEP

• Insertion and removal of intrauterine devices

• Tracheal Intubation

• Circumcision

• Central venous line placement

• Paracentesis/Thoracentesis




Maternity Care

• Amniotomy

• Normal spontaneous vaginal delivery of a term vertex presentation, including ante- and postpartum care

• Dilation and curettage (D&C), including suction and postpartum

• Excision of vulvar lesions at delivery

• External and internal fetal monitoring

• Augmentation of labor

• Induction of labor

• Management of uncomplicated labor

• Manual removal of placenta, post delivery

• Operative or assisted vaginal delivery

• Oxytocin challenge test

• Post partum hemorrhage (PPH)

• Post partum endometritis

• Pudendal anesthesia

• Repair of episiotomy, including lacerations/extensions

• Repair of vaginal and cervical lacerations

• Dilation and Curettage for Incomplete Abortion Note: Appendix A is NOT incorporated by reference into the Core document but instead is to be used by an applicant when seeking privileges when they determine it would be to their benefit. There is no expectation that every physician graduating from a Family Medicine program will have been trained/be competent in all listed procedures. It is the responsibility of the Family Medicine department chair to forward only those requests for privileges that have been appropriately reviewed and vetted at the department level. Alternatively, Appendix A does not represent the entire scope of family medicine. Utilizing Appendix A as a mechanism to restrict privileges for family physicians by interpreting the appendix as a comprehensive delineation of services offered by family physicians would be incorrect.

General Surgery Clinical Privileges


Name:___________________________________________________________

Qualifications

To be eligible to apply for privileges in general surgery, the applicant must meet the following criteria:

Training:

MD or DO with successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited residency in general surgery. For advanced procedures, see additional qualification criteria.

Board Certification

One of the following requirements must be met:

1. Current certification in general surgery by the American Board of Surgery or the American Osteopathic Board of Surgery;

2. adequate progress toward Board certification (the determination of adequacy shall be made by the MEC and must be approved by the Board of Trustees); or

3. demonstration to the satisfaction of the MEC and the Board of Trustees, that the applicant has competency and training equal or equivalent to that required for Board certification.

Required previous experience Applicants for initial appointment or initial privileges must be able to demonstrate adequate experience reflective of the scope of privileges requested in order for the medical staff to make a reasoned decision regarding the competency of the practitioner. For advanced procedures, see additional qualification criteria. Reappointment requirements To be eligible to renew privileges in general surgery, the applicant must demonstrate current demonstrated competence and an adequate volume of experience with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation, monitoring through the Medical Staff Quality Improvement Program, and patient care outcomes. For advanced procedures, see additional qualification criteria.



Privileges Requested

Applicant Instructions: Check off the “Requested” box for each privilege requested. Applicants have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving any doubts related to qualifications for requested privileges. Requests for privileges not included on this form should be made in writing and include documentation of training and experience. Please check only the boxes reflective of your practice specific to this hospital.

Active Staff Privileges - > 2 patient admissions per month or > 24 per year

Courtesy Staff Privileges - < 2 patient admissions per month or < 24 per year

General Surgery Privileges/Procedures � Admit, evaluate, diagnose, consult, and provide pre-, intra-, and postoperative care and perform

surgical procedures to patients of all ages to correct or treat various conditions, diseases, disorders, and injuries of the alimentary tract, abdomen, and its contents, extremities, breast, skin and soft tissue, head and neck, and endocrine systems; assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services; provide care to patients in the intensive care setting; performance of history and physical exam.

� Abdominoperineal resection � Amputations, above the knee, below knee;

toe, transmetatarsal, digits � Anoscopy � Appendectomy � Breast: complete mastectomy with or

without axillary lymph node dissection; excision of breast lesion, breast biopsy, incision and drainage of abscess, modified radical mastectomy, operation for gynecomastia, partial mastectomy with or without lymph node dissection, radical mastectomy, subcutaneous mastectomy

� Circumcision � Colectomy (abdominal) � Colon surgery for benign or malignant

disease � Colonoscopy with polypectomy � Colotomy, colostomy � Correction of intestinal obstruction � Drainage of intra abdominal, deep

ischiorectal abscess � EGD with and without biopsy � Emergency thoracostomy � Endoscopy (intraoperative) � Enteric fistulae, management � Enterostomy (feeding or decompression) � Esophageal resection and reconstruction

� Distal esophagogastrectomy � Excision of fistula in ano/fistulotomy, rectal

lesion � Excision of pilonidal cyst/marsupialization � Excision of thyroid tumors � Excision of thyroglossal duct cyst � Gastric operations for cancer (radical,

partial, or total gastrectomy) � Gastroduodenal surgery � Gastrostomy (feeding or decompression) � Genitourinary procedures incidental to

malignancy or trauma � Gynecological procedure incidental to

abdominal exploration � Hepatic resection � Hemodialysis access procedures � Hemorrhoidectomy, including stapled

hemorrhoidectomy � Incision and drainage of abscesses and

cysts � Incision and drainage of pelvic abscess � Incision, excision, resection and

enterostomy of small intestine � Incision/drainage and debridement,

perirectal abscess � Insertion and management of pulmonary

artery catheters [determine core or noncore]



� IV access procedures, central venous catheter, and ports

� Laparoscopy, diagnostic, appendectomy, cholecystectomy, lysis of adhesions, mobilization and catheter positioning

� Laparotomy for diagnostic or exploratory purposes or for management of intra-abdominal sepsis or trauma

� Liver biopsy (intraoperative), liver resection � Management of burns � Management of intra-abdominal trauma,

including injury, observation, paracentesis, lavage

� Management of multiple trauma � Management of soft-tissue tumors,

inflammations and infection � Operations on gallbladder, biliary tract, bile

ducts, hepatic ducts, including biliary tract reconstruction

� Osteopathic manipulative treatment using isotonic, isometric forces

� Pancreatectomy, total or partial � Pancreatic sphincteroplasty � Parathyroidectomy � Peritoneal venous shunts, shunt procedure

for portal hypertension � Peritoneovenous drainage procedures for

relief or ascites � Proctosigmoidoscopy, rigid with biopsy, with

polypectomy/tumor excision

� Pulmonary artery catheters, � Pyloromyotomy � Radical regional lymph node dissections � Removal of ganglion (palm or wrist, flexor

sheath) � Repair of perforated viscus (gastric, small

intestine, large intestine) � Scalene node biopsy � Sclerotherapy � Selective vagotomy � Sigmoidoscopy, fiberoptic with or without

biopsy, with polypectomy � Skin grafts (partial thickness, simple) � Small bowel surgery for benign or malignant

disease � Splenectomy (trauma, staging, therapeutic) � Surgery of the abdominal wall, including

management of all forms of hernias, including diaphragmatic hernias, inguinal hernias, and orchiectomy in association with hernia repair

� Thoracentesis � Thoracoabdominal exploration � Thyroidectomy and neck dissection � Tracheostomy � Transhiatal esophagectomy � Tube thoracostomy � Vein ligation and stripping

� Administration of Conscious Sedation and Analgesia

Additional Qualifications for Conscious Sedation and Analgesia:

• Initial applicants must complete Qualifying Examination for Sedation/Analgesia

• For recredentialing, must have performed a minimum of ten (10) cases per year within the two (2) year reappointment period (total of 20 cases) OR must retake and successfully pass the Qualifying Examination for Sedation/Anesthesia.


Provider Competency in Privileging 31

Advanced Procedures

Laparoscopic Nissen Fundoplication (Antireflux Surgery)

Criteria: Successful completion of an accredited residency in general surgery that included advanced laparoscopic training; and a formal course in laparoscopic Nissen fundoplication that included preceptorship by a surgeon experience in the procedure.

Required previous experience: Demonstrated current competence and evidence of the performance of at least ____ laparoscopic Nissen fundoplication procedures in the past 12 months.

Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least ____laparoscopic Nissen fundoplication procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

� Requested

advanced Laparoscopic procedures (e.g. colectomy; splenectomy; adrenalectomy; common duct; exploration/stone extraction)

Criteria: Successful completion of an accredited residency in general surgery that included advanced laparoscopic training or completion of a hands-on CME course.

Required previous experience: Demonstrated current competence and evidence of the performance of at least ____ advanced laparoscopic procedures in the past 12 months.

Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least ___advanced laparoscopic procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

� Requested

Breast Cryoablation

Criteria: Successful completion of an ACGME- or AOA-accredited residency-training program in general surgery that included formal training in ultrasound and breast cryoablation.

Required previous experience: Demonstrated current competence and evidence of the performance of at least _____ breast cryoablation procedures in the past 12 months.

Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least _____ breast cryoablation procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

� Requested



Endovenous ablative Therapy (ELVT) via all energy sources

Criteria: Successful completion of an ACGME OR AOA accredited residency or fellowship program which included supervised training in the diagnosis and treatment of varicose veins and training in interpreting ultrasound examinations of the legs. Applicants must demonstrate completion of training in ELVT, which included the performance/interpretation of ____ ELVT procedures. Applicant must demonstrate training and experience with the specific energy source to be used.

Required previous experience: Demonstrated current competence and evidence of the performance of at least ____ ELVT procedures in the past 12 months.

Maintenance of privilege: Applicant must be able to show maintenance of competence with evidence of the performance and or interpretation of at least ____ ELVT procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

� Requested

Use of Laser

Criteria: Successful completion of an approved residency in a specialty or subspecialty that included training in laser principles or completion of an approved eight to 10 hour minimum CME course which includes training in laser principles and a minimum of six hours observation and hands-on experience with lasers. Practitioner agrees to limit practice to only the specific laser types for which they have provided documentation of training and experience. Required previous experience: Demonstrated current competence and evidence of the performance of at least _____ laser procedures in the past 24 months.

Maintenance of privilege: Laser privileges must be reviewed with each renewal of clinical privileges. A physician must document that a minimum of ____ procedures have been performed over the past 24 months in order to maintain active privileges for laser use.

� Requested




I have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform, for which my professional liability insurance will cover, and that I wish to exercise at _______ Hospital. I understand that:

a. In exercising any clinical privileges granted, I am constrained by Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation.

b. Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the Medical Staff Bylaws or related documents.

c. If any privileges are covered by an exclusive contract or an employment contract, practitioners who are not a party to the contract are not eligible to request the privilege(s), regardless of education, training, and experience.

Signature: _______________________________ Date: _________________

Department Chair's Recommendation


I recommend all requested privileges.

I recommend privileges with the following conditions/modifications (include explanation):

Privilege Condition(s)/Modification(s)/Explanation

I do not recommend the following requested privileges (include explanation):


_______________________________________ ___________________ Department Chair Signature Date

Orthopedic Surgery Privileges


Name:___________________________________________________________

Qualifications

To be eligible to apply for privileges in orthopedic surgery, the applicant must meet the following criteria:

Training:

MD or DO with successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited residency in orthopedic surgery. For advanced procedures, see additional qualification criteria.

Board Certification

One of the following requirements must be met:

1. Current certification in general surgery by the American Board of Orthopedic Surgery or the American Osteopathic Board of Orthopedic Surgery;

2. adequate progress toward Board certification (the determination of adequacy shall be made by the MEC and must be approved by the Board of Trustees); or

3. demonstration to the satisfaction of the MEC and the Board of Trustees, that the applicant has competency and training equal or equivalent to that required for Board certification.

Required previous experience Applicants for initial appointment or initial privileges must be able to demonstrate adequate experience reflective of the scope of privileges requested in order for the medical staff to make a reasoned decision regarding the competency of the practitioner. For advanced procedures, see additional qualification criteria. Reappointment requirements To be eligible to renew privileges in general surgery, the applicant must demonstrate current demonstrated competence and an adequate volume of experience with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation, monitoring through the Medical Staff Quality Improvement Program, and patient care outcomes. For advanced procedures, see additional qualification criteria.

Privileges Requested

Applicant Instructions: Check off the “Requested” box for each privilege requested. Applicants have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving any doubts related to qualifications for requested privileges. Requests for privileges not included on this form should be made in writing and include documentation of training and experience. Please check only the boxes reflective of your practice specific to this hospital.



Applicants for Refer and Follow category are not eligible to request additional privileges. Stop here and review and sign the Acknowledgment section of this form. � Active Staff Privileges - > 2 patient admissions per month or > 24 per year � Courtesy Staff Privileges - < 2 patient admissions per month or < 24 per year

Orthopedic Surgery Privileges/Procedures � Admit, evaluate, diagnose, treat, and provide consultation to patients of all ages to correct or treat

various conditions, illnesses and injuries of the extremities, spine, and associated structures by medical, surgical, and physical means including but not limited to congenital deformities, trauma, infections, tumors, metabolic disturbances of the musculoskeletal system, deformities, injuries, and degenerative diseases of the spine, hands, feet, knee, hip, shoulder, and elbow, including primary and secondary muscular problems and the effects of central or peripheral nervous system lesions of the musculoskeletal system. Perform history and physical exam. Provide care to patients in the intensive care setting. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services.

� Amputation surgery including immediate

prosthetic fitting in the operating room � Arthrocentesis, diagnostic � Arthrodesis, osteotomy and ligament

reconstruction of the major peripheral joints, excluding total replacement of joint

� Arthrography � Arthroscopic surgery � Biopsy and excision of tumors involving

bone and adjacent soft tissues � Bone grafts and allografts � Carpal tunnel decompression � Closed reduction of fractures and

dislocations of the skeleton � Debridement of soft tissue � Excision of soft tissue/bony masses � Fasciotomy and fasciectomy � Fracture fixation � Growth disturbances such as injuries

involving growth plates with a high percentage of growth arrest, growth inequality, epiphysiodesis, stapling, bone shortening or lengthening procedures

� Ligament reconstruction

� Major arthroplasty, including total replacement of knee joint, hip joint, shoulder

� Major cancer procedures involving major proximal amputation (i.e., forequarter, hindquarter) or extensive segmental tumor resections

� Management of infectious and inflammations of bones, joints and tendon sheaths

� Muscle and tendon repair � Open and closed reduction of fractures � Open reduction and internal/external fixation

of fractures and dislocations of the skeleton [in/excluding spine]

� Orthotripsy � Reconstruction of nonspinal congenital

musculoskeletal anomalies � Removal of ganglion (palm or wrist; flexor

sheath) � Total joint replacement revision � Total joint surgery � Treatment of extensive trauma, excluding

spine

� Administration of Conscious Sedation and Analgesia

Additional Qualifications for Conscious Sedation and Analgesia:

• Initial applicants must complete Qualifying Examination for Sedation/Analgesia

• For recredentialing, must have performed a minimum of ten (10) cases per year within the two (2) year reappointment period (total of 20 cases) OR must retake and successfully pass the Qualifying Examination for Sedation/Anesthesia.



Surgery of the Hand Qualifications: To be eligible to apply for privileges in surgery of the hand, the initial applicant must meet the following additional criteria: Successful completion of an Accreditation Council for Graduate Medical Education (ACGME)– or American Osteopathic Association (AOA)–accredited residency in orthopedic surgery and successful completion of an accredited fellowship in surgery of the hand. Hand Surgery Privileges/Procedures � Admit, evaluate, diagnose, treat, and provide consultation to patients of all ages,

presenting with injuries and disorders of all structures of the upper extremity directly affecting the form and function of the hand and wrist by medical, surgical and rehabilitative means. Perform history and physical exam. Provide care to patients in the intensive care setting. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services.

� Arthroplasty of large and small joints,

wrist or hand, including implants � Bone graft pertaining to the hand � Carpal tunnel decompression � Fasciotomy and fasciectomy � Fracture fixation with compression

plates or wires � Microvascular procedures excluding

replantation � Nerve graft � Neurorrhaphy � Open and closed reductions of

fractures � Perform history and physical exam � Removal of soft tissue mass,

ganglion palm or wrist, flexor sheath, etc

� Repair of lacerations � Repair of rheumatoid arthritis

deformity � Skin grafts � Tendon reconstruction (free graft,

staged) � Tendon release, repair and fixation � Tendon transfers � Treatment of infections



Surgery of the Spine Qualifications: To be eligible to apply for privileges in surgery of the hand, the initial applicant must meet the following additional criteria: Successful completion of an Accreditation Council for Graduate Medical Education (ACGME)– or American Osteopathic Association (AOA)–accredited residency in orthopedic surgery and successful completion of an accredited fellowship in orthopedic surgery of the spine.

Spine Surgery Privileges/Procedures Admit, evaluate, diagnose, treat, and provide consultation to patients of all ages, with spinal column diseases, disorders, and injuries by medical, physical, and surgical methods including the provision of consultation. Perform history and physical exam. Provide care to patients in the intensive care setting. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. � Assessment of the neurologic function of the spinal cord and nerve roots � Endoscopic minimally invasive spinal surgery � Interpretation of imaging studies of the spine � Laminectomies, laminotomies, and fixation and reconstructive procedures of the

spine and its contents including instrumentation � Lumbar puncture � Management of traumatic, congenital, developmental, infectious, metabolic,

degenerative, and rheumatologic disorders of the spine � Scoliosis and kyphosis instrumentation � Spinal cord surgery for decompression of spinal cord or spinal canal, rhizotomy,

cordotomy, dorsal root entry zone lesion, tethered spinal cord or other congenital anomalies

� Treatment of extensive trauma



ADVANCED PROCEDURES Minimally Invasive Total Joint Arthroplasty

Criteria: Applicants must have completed an ACGME- or AOA-accredited training program in orthopedic surgery followed by completion of specialized training in minimally invasive total hip arthroplasty (THA).

Required previous experience: Demonstrated current competence and evidence of the performance of at least ____ minimally invasive THAs in the past 12 months.

Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least ___ minimally invasive THAs in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

� Requested Minimally Invasive Total Hip Arthroplasty

Minimally Invasive Total Knee Arthroplasty

Criteria: Applicants must have completed an ACGME- or AOA-accredited training program in orthopedic surgery followed by completion of specialized training in minimally invasive total knee arthroplasty (TKA).

Required previous experience: Demonstrated current competence and evidence of the performance of at least ____ minimally invasive TKAs in the past 12 months.

Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least ____ minimally invasive TKAs in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

� Requested Minimally Invasive Total Knee Arthroplasty

Percutaneous Lumbar Discectomy (PLD)

Criteria: Successful completion of an ACGME or AOA residency or fellowship training program in that included percutaneous lumber discetomy; or completion of an approved training course in percutaneous lumber discectomy that included proctoring. Applicants must provide evidence that the training program included fluoroscopy and discography. In addition, applicants should have completed a training course in the PLD method for which privileges are requested.

Required previous experience: Demonstrated current competence and evidence of the performance of at least _____ procedures in the PLD method for which privileges are requested in the past 12 months.

Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least ____ procedures in the PLD method for which privileges are requested in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

� Requested Percutaneous Lumbar Discectomy



Percutaneous Vertebroplasty

Criteria: Successful completion of an ACGME- or AOA-accredited residency program in orthopedic surgery that included percutaneous vertebroplasty; or have completed an approved training course in percutaneous vertebroplasty that included proctoring. Applicants must also have completed training in radiation safety.

Required previous experience: Demonstrated current competence and evidence of the performance of at least ____ percutaneous vertebroplasty procedures in the past 12 months.

Maintenance of privilege: Applicant must be able to demonstrate maintenance of competence by evidence of the performance of at least ____ percutaneous vertebroplasty procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

� Requested Percutaneous Vertebroplasty

Balloon Kyphoplasty

Criteria: Successful completion of an ACGME- or AOA-accredited residency program in orthopedic surgery that included training in balloon kyphoplasty. Applicants must also have completed an approved training course in the use of the inflatable bone tamp and have been proctored in their initial cases by a Kyphon company representative. Applicants must also have completed training in radiation safety.

Required previous experience: Demonstrated current competence and evidence of the performance of at least ____ balloon kyphoplasty procedures in the past 12 months.

Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least ____ balloon kyphoplasty procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

� Requested Balloon Kyphoplasty

Artificial Disc Replacement (ADR)

Criteria: Successful completion of an ACGME- or AOA-accredited residency program in orthopedic surgery that included insertion of artificial discs; or completion of an approved training program in the insertion of artificial discs.

Required previous experience: Demonstrated current competence and evidence of the performance of at least ___ ADR surgery procedures in the past 12 months.

Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least ___ ADR surgery procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

� Requested Artificial Disc Replacement




I have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform, for which my professional liability insurance will cover, and that I wish to exercise at Mineral Area Regional Medical Center. I understand that:

a. In exercising any clinical privileges granted, I am constrained by Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation.

b. Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the Medical Staff Bylaws or related documents.

c. If any privileges are covered by an exclusive contract or an employment contract, practitioners who are not a party to the contract are not eligible to request the privilege(s), regardless of education, training, and experience.

Signature: _______________________________ Date: _________________

Department Chair's Recommendation


I recommend all requested privileges.

I recommend privileges with the following conditions/modifications (include explanation):


I do not recommend the following requested privileges (include explanation):


_______________________________________ ___________________ Department Chair Signature Date



Core Privileges form for Orthopedic Surgery and General Surgery Modified and Adapted from Core Privileges for Physicians: A Practical Approach to Developing and Implementing Criteria-based Privileges, 4th Edition; an HCPro Publication. www.HCPro.com.


Requests for New Privileges Things to be considered when evaluating requests for new procedures:

√ Should be based on services currently provided or to be provided by the organization

√ Must have the necessary equipment and trained staff to support new procedures and/or treatments that applicants request

√ Must have enough qualified physicians

√ Medical needs of community

√ Will there be enough volume to support program?

√ Determine if there is a transference of skill

Transference of Skill

A transference of skill occurs when the same skills are utilized for different procedures. If a physician has not performed a specific procedure, but has performed another procedure where those skills would transfer these can be grouped together. This may not apply to surgeries requiring more specialized skills or for complex surgeries not regularly performed.


Work Sheet for Consideration of New Privilege

Name of procedure/privilege_________________________________________ Education required to request privilege (check all that apply)

MD - Medical Doctor DO - Osteopathic Physician) DDS - Oral and Maxillofacial Surgeon DMD - Dentist DPM - Podiatrist APN – Advance Practice Nurse (specify specialty)______________________________ PA – Physician Assistant (specify specialty) ___________________________________ DC – Chiropractic Other (specify) __________________________________________________________

Training Required:

Experience required

Additional Requirements:

CME Board Certification Manufacturer’s Training Course/Certificate Peer Recommendations

Is monitoring or proctoring required?

No Yes. If yes, specify the following:

Number of procedures ___________ Length of time __________________ In order to complete proctorship/monitoring requirements, the applicant must perform

_______ (number) procedures within _____________(time frame). What type of review or follow up will be conducted?


EVALUATING AND DOCUMENTING PRACTITIONER COMPETENCY

What Is Competence? Competence refers to a person’s ability to do a particular activity to a prescribed standard or a desirable outcome. There are particular qualities on which competency is based, including, knowledge (education/training), traits, skills, and abilities. Knowledge involves understanding certain facts and procedures. This is evidenced by completion of educational and training requirements. On-the-job experience—including feedback from peers, in-service training, and continuing education – enhance knowledge. Traits are characteristics that predispose a person to behave or respond in a certain way. For instance, self-control, self-confidence, the ability to take criticism, the ability to get along with others. Skill is the capacity to perform specific privileges/procedures. Skill is based on both knowledge and the ability to apply the knowledge. Skills can be gained by hands-on training using anatomic models or real patients, or through role plays. For instance, a surgeon learning to use the laser may use animal tissue in hands-on training rather than a human subject. Abilities are the attributes that a person has acquired through previous experience. Since abilities are gained or developed over time, they are more easily retained than knowledge and skills. They also include “God-given” abilities with which a person is born. Healthcare providers acquire competence over time. When a physician completes medical school, he/she is not competent to practice medicine. Additional training and hands-on experience is necessary to reach a level that can be certified as competent.

Current Competence During the credentialing and recredentialing processes, an assessment of the applicant’s current competence is obtained through a variety of different sources including:

• references from residency directors, department chairs, and others who have first-hand knowledge of clinical abilities and technical skills;

• evaluation of professional standing as reflected by information on malpractice claims, peer review attestations, and maintenance of a valid and unrestricted license;

• evidence of lifelong specialty-specific learning; and

• practice performance assessments including assessment by peers, patient assessments, quality improvement data on current performance and comparative


data, chart audits and patient satisfaction questionnaires, and measurement of patient outcomes.

patient is in house or retrospectively on discharge.

Work History and Affiliations Some organizations verify all current and past hospital affiliations, while some verify only the past 5 -10 years. There are several reasons for performing this verification.

One reason is to make sure there are no unexplained gaps. Many hospitals feel it is important to document the provider’s whereabouts and clinical activity for the period from medical school to the date of application. This is done to make sure that there are no unaccounted for periods of time. For example, a provider who spent time in prison or in a drug/alcohol rehabilitation facility may attempt to hide this by stating he/she was on staff at a hospital during this time. Verification of the dates on staff may turn up the discrepancy. Another reason work history and affiliations are verified is to ascertain current clinical competence. This is particularly important in the hospital. Typically, such requests will include dates on staff, current staff status or category, disciplinary actions, and whether the privileges requested are consistent with those held at the facility being queried. Some managed care plans require a provider to have medical staff appointment at a hospital that contracts with the managed care plan. The MCO will verify this appointment. Some MCOs will ask the hospital to provide a list of providers on a routine basis in lieu of individual verification letters.

Joint Commission Standards Regarding Work History

There is no specific standard that specifically addresses verification of work history. The standards require, at the time of appointment to membership and initial granting of privileges, verification of relevant training or experience must be obtained from the primary source(s), whenever feasible. Relevant training or experience is defined by the specific circumstances of the applicant. This may vary among specialties. The hospital must believe there is sufficient information on which to base a reasoned decision.


Sample Letter: Facility Privileges and Competency Validation Date Facility Name Facility Address Regarding applicant: John Doe, M.D. Specialty: General Surgery Dear Medical Services Professional: We have received an application from the above-named provider for medical staff appointment and privileges. A copy of the privileges requested is attached. The applicant noted that s/he currently, or has in the past, held privileges at your facility. In order to process the application we require documentation experience, ability, and current competence on the six areas of “General Competencies” adopted from the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) joint initiative. These competencies include assessment of patient care, interpersonal and communication skills, professionalism, medical knowledge, practice-based learning and improvement, and systems-based practice. Our policies require completion of the enclosed form. Failure to receive this form will delay consideration of the applicant’s request for privileges. Also, our policies require the physician to document competency in performing specific procedures by allowing our organization to obtain a copy of his/her privilege form from your hospital as well as a list of the actual procedures performed in the past 12 months and the outcomes for those procedures. The applicant has authorized you to provide this information to our organization via signature on the attached Authorization and Release Form. Sincerely,

Medical Staff Coordinator


CONFIDENTIAL Evaluation of Privileges and Competency Validation

Name of Facility Providing Information:___________________________________________________________ Name of Practitioner for which Information is Provided:_______________________________________________

Dates on Staff: From ________________________________ To ____________________________________

Has the practitioner been subject to any disciplinary action, restrictions, modifications, or loss of Yes No privileges or medical staff appointment either voluntary or involuntary at your facility? Are you aware of any restrictions, modifications, or loss of privileges or medical staff appointment, Yes No either voluntary or involuntary, at any another facility? Are you aware of any physical or mental condition that could affect this practitioner’s Yes No ability to exercise clinical privileges as requested, or would require accommodation to perform privileges safely and competently? If the answer to any of the above questions is “YES”, please explain:

_________________________________________________________________________ _________________________________________________________________________

Evaluation: Please rate the practitioner in the following areas.

• Patient Care is compassionate, appropriate, and effective for the treatment of health problems and promotion of health

• Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care

• Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

• Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals

• Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

• Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.

Excellent Good Fair Poor Unable to evaluate

Patient care

Medical knowledge

Practice-based learning and improvement

Interpersonal and communication skills

Professionalism

Systems-based practice

_______________________________________ _____________________________ Signature Date

_______________________________________ _____________________________ Name, Position/Title (Please Print) Phone Number

Please return this form within 2 weeks along with a copy of the applicant’s privilege list for your hospital and a list of the actual procedures performed in the past 12 months and the outcomes for those procedures.


Sample Letter for Verification of Training [Date] Re: [Applicant’s full name, Title] Training: [Residency/fellowship] Specialty: [Specialty] Dates: [From/to] Dear [Program Director name]: We have received an application from the above-named provider for medical staff appointment and/or privileges. A copy of the privileges requested is attached. The applicant noted that the above-specified training took place at your institution. In order to process the application we require verification of completion of training and documentation of experience, ability, and current competence on the six areas of “General Competencies” adopted from the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) joint initiative. Our policies require completion of the enclosed form. Failure to receive this form will delay consideration of the applicant’s request for privileges. Also, our policies require the physician to document competency in performing specific procedures by allowing our organization to obtain a copy of his/her procedure list from your program and the outcomes for those procedures (if outcomes are available). The applicant has authorized you to provide this information to our organization via signature on the attached Authorization and Release Form. Enclosed is a copy of a release and immunity statement signed by the applicant consenting to this inquiry and your response. The immunity statement releases from liability any individual who provides the requested information. Thank you for your assistance. We look forward to hearing from you. Sincerely, Director Enclosures


Residency Program Director’s Evaluation and Recommendation

Page 1 Re: [Applicant’s full name] Training: [Residency/fellowship] Specialty: [Specialty] Dates: [From/to]

Area of Evaluation Please use comment section below to provide additional information noting

question number for which information is provided.

YES NO Unable to

Evaluate

1 Were you the director of the program at the time of this applicant’s training?

2 Was the applicant at your institution in the above program for the stated period of time?

3 Was the program fully accredited throughout the applicant’s participation in it?

4 Did the applicant successfully complete the program?

5 Did the applicant receive satisfactory ratings for all aspects of his/her training in the program?

6 Was the applicant ever subject to or considered for disciplinary action?

7 Did the applicant ever attempt procedures beyond his/her assigned training protocols?

8 Was the applicant’s status and/or authority to provide services ever revoked, suspended, reduced, restricted, not renewed, or was he/she placed on probationary status or reprimanded at any time or were proceedings ever initiated that could have led to any of the actions?

9 Did the applicant ever voluntarily terminate his/her status in the program or restrict his/her activities in the program in lieu of formal action or to avoid an investigation?

10 In reviewing the attached request for privileges, do you feel that the applicant’s training and experience included these procedures?

11 In reviewing the attached request for privileges, do you feel that the applicant is currently competent to carry out these procedures?

12 Are you aware of any physical or mental condition that could affect this practitioner’s ability to exercise clinical privileges in his/her specialty area, or would require an accommodation to exercise those privileges safely and competently?

Comments: Question Comment _______ __________________________________________________________ _______ __________________________________________________________ _______ __________________________________________________________ _______ __________________________________________________________ _______ __________________________________________________________ _______ __________________________________________________________ _______ __________________________________________________________ _______ __________________________________________________________ _______ __________________________________________________________ _______ __________________________________________________________ _______ __________________________________________________________


Residency Program Director’s Evaluation and Recommendation Page 2

Re: [Applicant’s full name] Training: [Residency/fellowship] Specialty: [Specialty] Dates: [From/to] Please rate the applicant in each of the following areas:

Excellent Good Fair Poor Unable to evaluate

Patient care

Medical knowledge

Practice-based learning and improvement

Interpersonal and communication skills

Professionalism

Systems-based practice

This evaluation is based upon: Personal knowledge of the applicant.

Review of file.

Other _____________________________________________________________________________

Overall Recommendation (check ONE): I recommend privileges as requested without reservation.

I recommend privileges as requested with the following reservation(s) (use back of form, if necessary

_____________________________________________________________________________________________

_____________________________________________________________________________________________

I do not recommend this applicant for the following reason(s)

_____________________________________________________________________________________________ _____________________________________________________________________________________________ _______________________________________ _____________________________ Signature Date

_______________________________________ _____________________________ Name, Position/Title (Please Print) Phone Number

Please return this form within 2 weeks. Failure to receive the form will delay consideration of the applicant’s request for privileges.


Peer Recommendations A peer recommendation is a statement provided in support of an applicant’s request for appointment/ reappointment and/or privileges by a practitioner in the same professional discipline as the applicant. Peer recommendations are typically obtained from prior training program directors, department chairs, chiefs of staff, or others familiar with the applicant’s professional history and current clinical competence. Friends, neighbors, and relatives are not appropriate sources for peer recommendations. Peer recommendations should include reference to the applicant’s competence and ability to perform the privileges requested.

Joint Commission Requirements for Peer Recommendations

The medical staff must use peer recommendations in its consideration of recommendations for appointment and initial granting of privileges and in consideration of termination from the medical staff or revision/revocation of clinical privileges. Peer recommendations may be used to recommend individuals for the renewal of clinical privileges when insufficient practitioner-specific data are available. The peer must be an appropriate practitioner in the same professional discipline as the applicant with personal knowledge of the applicant. In situations where there is no peer available for a specific category or LIP, it may be necessary to obtain a reference from a physician with essentially equal qualifications who is familiar with the LIP’s performance. For example, a pediatrician could provide a reference for a pediatric nurse practitioner, or an internist could provide a reference for an adult nurse practitioner. The recommendation should come from someone in the same clinical specialty. Peer recommendations must address the practitioner’s relevant training and experience, current competence, and any effects of health status on privileges being requested Approved sources for peer recommendations include: • a hospital performance improvement committee, the majority of whose members are

the applicant's peers; • a reference letter(s), written documentation, or documented telephone

conversation(s) about the applicant from a peer(s) who is knowledgeable about the applicant's professional performance and competence;

• a department or major clinical service chairperson who is a peer; or • the medical staff executive committee.

Additionally, peer recommendations must include evaluation of the applicant’s medical knowledge, technical and clinical skills, clinical judgment, communication skills, interpersonal skills, professionalism. See sample peer reference letter and form on the following pages.


Sample Peer Recommendation Letter

Date Facility Name Facility Address Regarding applicant: John Doe, M.D. Specialty: General Surgery Dear ______________: We have received an application from the above-named provider for medical staff appointment and privileges. A copy of the privileges requested is attached. The applicant has listed you as a peer who will be willing to provide a recommendation. In order to process the application we require your evaluation of the applicant’s experience, ability, and current competence in the areas of medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism. Our policies require completion of the enclosed form. Failure to receive this form will delay consideration of the applicant’s request for privileges. You may supplement the form with additional information, if you so desire. The applicant has authorized you to provide this information to our organization via signature on the attached Authorization and Release Form. Sincerely,

Medical Staff Coordinator


Sample Peer Recommendation Form

CONFIDENTIAL Professional Peer Reference & Competency Validation Page 1 of 2

Name of Applicant:________________________________________________________________________________ Name of Evaluator:____________________________________ Relationship to Applicant:________________________

How well do you know the applicant? not well casual personal acquaintance professional acquaintance very well Do you refer your patients to the applicant? yes no. If no, list reason(s) why not ___________________________________ _________________________________________________________________________________________________________

PLEASE RATE THE PRACTITIONER IN THE FOLLOWING AREAS

Excellent Good Fair Poor Unable to

evaluate

Medical knowledge - Practitioner should have a good knowledge of established and evolving biomedical, clinical, and cognate sciences, and how to apply this knowledge to patient care. This is evidenced by completion of educational and training requirements as well as on-the-job experience, inservice training, and continuing education.

Technical and clinical skills - Skill involves the capacity to perform specific privileges/procedures. It is based on both knowledge and the ability to apply the knowledge.

Clinical judgment - Clinical judgment refers to the observations, perceptions, impressions, recollections, intuitions, beliefs, feelings, inferences of providers. These clinical judgments are used to reach decisions, individually and/or collectively with other providers, about a patient’s diagnosis and treatment.

Communication skills - The provider should create and sustain a therapeutic and ethically sound relationship with other care givers, patients, and their families. He/she should be able to communicate effectively and demonstrates caring, compassionate, and respectful behavior. This also includes effective listening skills, effective nonverbal communication, eliciting/providing information, and good writing skills

Interpersonal skills - Areas of evaluation include how the provider works effectively with other professional associates, including those from other disciplines, to provide patient-focused care as a member of a healthcare team.

Professionalism - Professionalism is demonstrated by respect, compassion, and integrity. It means being responsive and accountable to the needs of the patient, society, and the profession. It means being committed to providing high-quality patient care and continuous professional development as well as being ethical in issues related to clinical care, patient confidentiality, informed consent, and business practices.


Provisional Appointment For the hospital medical staff, when initial appointment or privileges are “provisional”, the appointee’s performance is subject to additional evaluation for a provisional period, typically 6 to 12 months. This evaluation usually consists of review of the quality of the clinical aspect of care and citizenship aspects such as, conduct, meeting attendance, records completion, use of the hospital, and other bylaws requirements. At the end of this period, a formal recommendation for discontinuation or continuation of the provisional period is made and medical staff appointment and privileges are continued or modified. The provisional period is also extended to additional privileges approved for current medical staff appointees. Some medical staff bylaws appoint providers to an actual staff status of “Provisional”, while others appoint providers to a category such as Active or Associate staff, but make privileges provisional for a period of time. The idea of the provisional review is to protect patients by assuring that providers are competent to carry out the privileges they request and to make sure a new provider does not have quality of care or behavioral concerns that were not identified during the initial credentialing process. Unfortunately, the credentialing process does not always give a clear indication of behavioral issues or the quality of care provided. Often, hospitals provide only basic demographic information concerning dates on staff, staff status, number of patients treated, etc. It is often difficult to obtain detailed information such as numbers of procedures performed, complication rates, and behavioral aspects of performance, even with a signed consent and release form. By having a provisional period of appointment, hospitals and medical staffs are compelled to evaluate these aspects in more detail. Even if a hospital has a strong quality monitoring program, it is often a challenge to come up with significant provider-specific data for every new applicant. In some cases, the provisional period becomes more of a paperwork exercise than an actual quality monitoring tool. Most hospital medical staffs participate in ongoing quality improvement programs that continually evaluate provider quality of care. Some feel that having a strong monitoring program in place makes provisional staff monitoring redundant. Others feel that this added level of review is important. Provisional staff sometimes carries a requirement that, if the provider has not admitted or treated a sufficient number of patients to be able to evaluate competence, the provider can be deemed to have relinquished medical staff appointment or clinical privileges. Under some State regulations, the provisional category cannot be treated differently in regards to appellate review and hearing rights. Provisional staff monitoring may provide for retrospective or concurrent review -- or a combination of both -- depending on the privileges requested and the specialty of the provider. A surgeon or physician performing interventional procedures may be assigned a proctor to actually observe a number of procedures. A family practice physician who does not perform any procedures may have patient charts reviewed either while the patient is in house, or retrospectively, on discharge.


Joint Commission Standards for FPPE/OPPE In the past, Joint Commission standards required all initial grants of privileges to be for a provisional period of time. This standard was later replaced with a comment that, if the hospital utilized a provisional period of appointment, it was spelled out in the privileging process. In 2007, Joint Commission reinstated the standard requiring provisional appointment of privileges and introduced a new concept – focused professional practice evaluation. According to Joint Commission, focused professional practice evaluation is a process that applies to a practitioner for which the hospital does not have documented evidence of competently performing the requested privileges at the organization. It can also apply when a question arises concerning the ability of a practitioner with current privileges to provide safe, high quality patient care. Using this documented, time-limited process, the organization evaluates competence of the practitioner regarding the specific privileges requested. The hospital has the responsibility to protect patients by assuring that all providers can carry out the privileges they request in a competent, safe manner. There may be times when quality of care or behavioral concerns are not identified during the initial credentialing process, but unfortunately, the credentialing process does not always give a clear indication of behavioral issues or the quality of care provided. Often, hospitals receive only basic demographic information concerning dates on staff, staff status, number of patients treated, etc. Detailed information, such as numbers of procedures performed, complication rates, and behavioral aspects of performance, are difficult to obtain. Focused professional practice evaluation compels the hospital to evaluate these aspects in more detail. Joint Commission requires that the medical staff defines the circumstances that require monitoring and evaluation of a practitioner’s professional performance. If necessary, this monitoring can be extended beyond the defined time frame or additional monitoring and evaluation can be conducted.

A period of focused professional practice evaluation must be implemented for all initially requested privileges. The medical staff must develops criteria for evaluating the performance of practitioners credentialed and privileged through the medical staff process when a question about whether safe, high quality patient care is identified. When initiating a focused review, the following components should be identified:

• The issue

• Start date

• Means of identifying and documenting the issue

• Periodic reporting as the review progresses

• Interventions taken during the review to correct problematic issues

• Completion date or endpoints of the review

• Final analysis

• Mechanism for reporting results to the PI Committee


Ongoing Professional Practice Evaluation

Ongoing professional practice evaluation is the process the hospital and medical staff use to identify negative practice trends that may impact quality of care and patient safety. When negative trends or isolated incidents are identified, the medical staff needs to determine what intervention should be taken. Prior to or at the time of renewal/reappointment of privileges, information collected as a result of the organization’s ongoing professional practice evaluation is utilized in the decision to maintain current privileges, or revise/revoke an existing privilege. The ongoing professional practice evaluation process must be clearly defined and must contribute to and support the evaluation of each practitioner’s professional practice. This means there must be a written policy and procedure. The hospital and/or medicals staff’s performance improvement plan should include this process. The medical staff must determine and approve what performance data to be collected. Information required by Joint Commission to be evaluated as part of the medical staff’s PI include medical assessment and treatment of patients, use of medications, use of blood and blood components, operative and other procedures, appropriateness of clinical practice patterns, significant departures from established patterns of clinical practice, autopsy criteria, sentinel events, and patient safety data. The medical staff must use the information it receives from ongoing professional practice evaluation in its determination as whether to continue, limit, or revoke any existing privileges.


Ongoing Professional Practice Evaluation Report (To be included in Credentials File)

Practitioner Name:______________________________________________________ Department:___________________________________________________________ Time Period for Review: From:_____________________ To:__________________ The information from Ongoing Professional Practice Evaluation has been reviewed and based on this review:

The practitioner is performing well or within desired expectations and no further action is warranted. It is recommended that current privileges continue.

Issue(s) exist or trigger(s) met requiring a focused evaluation. The specific issue(s) is

(are)___________________________________________________ ________________________________________________________________ ________________________________________________________________

Practitioner has had no patient contact for _____ months, notify practitioner and initiate focused review.

Other__________________________________________________________ _______________________________________________________________ __________________________________ _________________________ Signature, Department Chair Date __________________________________ Name Department Chair


Focused Professional Practice Evaluation (FPPE) Report (To be included in Credentials File)

Practitioner Name:______________________________________________________ Department:___________________________________________________________ Time Period for Review: From:_____________________ To:__________________ The information from Focused Professional Practice Evaluation has been reviewed and based on this review:

The practitioner is performing well or within desired expectations and it is recommended that current privileges continue and FPPE cease.

Issue(s) exist or trigger(s) met requiring continuation of Focused Evaluation. The specific

issue(s) is (are)_____________________________________________ ________________________________________________________________ ________________________________________________________________

Practitioner has not had sufficient patient volume or has not met assigned FPPE requirements. Continue FPPE for ______ months.

Other__________________________________________________________ _______________________________________________________________ __________________________________ _________________________ Signature, Department Chair Date __________________________________ Name Department Chair


Admit and Follow Privilege Form Print Name: ___________________ __________________________ ____________________ First Last Degree Admit and Follow privileges include admitting a patient to the hospital and immediately referring patients to a Hospitalist or other Medical Staff member for inpatient care, following patients during the hospital stay, reviewing the medical record of referred patients and conversing with attending physician, consultants and hospital staff concerning referred patients. Privileges do not include ordering tests, consultations, drugs or therapies for inpatients or entries in the medical record other than admitting orders.

I request Admit and Follow Privileges. I certify that I have requested only those privileges for which I am qualified by education, training, current experience and demonstrated competence. I understand that by making these requests that I am bound by the applicable Bylaws and policies of the Medical Staff and hospital. I also attest that my professional liability insurance covers the privileges I have requested. _______________________________________________ _____________________ Applicant Signature Date _______________________________________________ ______________________ Department Chairperson Date


Joint Commission FAQ regarding OPPE

Page 1 Q. What is the intent of the requirement for Ongoing Professional Practice Evaluation? Answer: 1. The intent of the standard is that organizations are looking at data on performance for all

practitioners with privileges on an ongoing basis rather than at the two year reappointment process, to allow them to take steps to improve performance on a more timely basis.

2. A clearly defined process would include but not be limited to:

• who will be responsible for reviewing performance data? For example, in smaller organizations the department chair or the department as a whole at their department meetings might be able to review all department members. In larger organizations it could be the responsibility of the credentials committee, the MEC, or a special committee of the organized Medical Staff.

• how often the data will be reviewed. The frequency of such evaluation can be defined by the organized Medical Staff, e.g., three months, six months, nine, months, etc. However, as noted in the teleconferences during 2007, twelve months would be periodic rather than ongoing.

• the process to be implemented to use the data to make decision as to whether to continue, limit or revoke privileges. This could include defining who can make and approve a recommendation for action, e.g., the department chair when no action is required, the MEC and governing body for limitation or revocations.

• how data will be incorporated into the credentials files. There needs to be a defined process for the data to be in the record and for the review to occur. This can include storing the data out of the record and making it available with the record at the time of the review. There is no requirement that the data be continuously stored in the credentials file.

The decision resulting from the review, whether it be to take an action or to continue the privilege would need to be documented along with the supporting data. 3. The type of data to be collected would need to be defined by individual Medical Staff

departments and approved by the organized Medical Staff. The standards require an evaluation for all practitioners not just those with performance issues. The departments will know best what type of data will reflect both good and problem performance for the various practitioners in their departments. The organized Medical Staff will then determine if the correct type and amount of data is being collected.


Joint Commission FAQ regarding OPPE Page 2 The standard's rationale outlines suggested data that the organization may choose to collect along with the following suggestions for methodologies for collecting information:

• periodic chart review • direct observation • monitoring of diagnostic and treatment techniques • discussion with other individuals involved in the care of each patient including

consulting physicians, assistants at surgery, nursing, and administrative personnel. While some types of data apply to all practitioners, since performance is different for different practitioner, e.g., cardiologist vs. orthopedists, vs. obstetricians, there may need to be specific data. In addition since most practitioners perform well, there would need to be data on their actual performance as well as those with performance issues. The fact that a practitioner doesn't fall out on pre-defined screening criteria, is not sufficient to meet the requirement for performance data on every practitioner. It is also important to remember that zero data is in fact data. Zero data can actually be evidence of good performance, e.g., no returns to the OR, no complications, no complaints, no infections, etc. It is also important to know when someone is not performing certain privileges over a given period of time. It would not be acceptable to find at the two year reappointment that someone has not performed a privilege for two years. 4. The information resulting from the evaluation needs to be used to determine whether to

continue, limit, or revoke any existing privilege(s) at the time the information is analyzed. Based on analysis, several possible actions could occur, including but not limited to: • determining that the practitioner is performing well or within desired expectations and

that no further action is warranted • determining that issue exist that require a focused evaluation • revoking the privilege because it is no longer required • suspending the privilege, which suspends the data collection, and notifying the

practitioner that if they wish to reactivate it they must request a reactivation • determining that the zero performance should trigger a focused review (MS.4.30 EP

5) whenever the practitioner actually performs the privilege. • determining that the privilege should be continued because the organization's mission

is to be able to provide the privilege to its patients Evidence of these determinations would need to be included in each practitioner's credentials files at the time of each review of the data.


Joint Commission FAQ regarding OPPE for Medical/Cognitive Specialties Q. Medical and Cognitive specialties (IM, FP, psychiatry, other med specialties, etc...) are very tough to identify meaningful data that can be evaluated. Is there any guidance that The Joint Commission can offer to assist organized Medical Staffs? Answer: Cognitive specialties (IM, FP, med specialties ...) are very difficult to identify meaningful data that can be evaluated. The most difficult is probably psychiatry due to the confidential nature of psychiatry, if is often not possible to observe the provision off care, treatment, and services by the psychiatrist. It is important to start with the type of privileges that are granted. For the medical specialists. For medical specialties in addition to managing medical conditions, they also often perform procedures. The Joint Commission Resources Publication "Credentialing, Privileging, Competency, and Peer Review: Examples of Compliance for the Medical Staff" has some excellent detailed privilege forms for a wide variety of specialties including but not limited to: internal medicine, family practice, OB/GYN, cardiac, cardiovascular disease, clinical psychology, dentistry, emergency medicine, gastroenterology, medical imaging. As you look at the way the privileges are detailed you can begin to identify data to collect including, but not limited to, numbers of activities, length of stay, complications, management of complications, reasons for readmissions, use of diagnostics, medications or other modalities, etc. Other data to be considered would include, but not be limited to:

• compliance with The Joint Commission Core Measures (for the applicable practitioners) • compliance with organization specific clinical practice guidelines • medication prescribing practices, e.g., number of times a drug is prescribed,

appropriateness to diagnosis, appropriateness of dosing, appropriateness of medication monitoring practices

• use of diagnostic, i.e., appropriateness, overuse/underuse, appropriateness of therapeutic interventions in response to diagnostic testing result

• patient readmissions either inpatient or outpatient for the same diagnosis/problem which may such inadequate or inappropriate initial treatment

• patient complaints


Joint Commission FAQ regarding FPPE

Page 1 Q. What is the intent of the Focused Professional Practice Evaluation requirement? A. There are essentially two components:

1. Element of Performance 1 which requires "A period of focused professional practice evaluation is implemented for all initially requested privileges." This would mean all privileges for new practitioners and all new privileges for existing practitioners. The EP was published in January 2007 with an effective date of January 1/2008.

2. Elements of Performance 2 - 9 which were relocated from the 2006 standard MS.4.90. These elements address what had previously been termed "Peer Review".

Focused Professional Practice Evaluation for New Privileges Q. What is the requirement for new privileges? A. A period of focused review is required for all new privileges meaning all privileges for new applicants and all new privileges for existing practitioners. There will be no exemption for board certification, documented experience, or reputation. All applicants for new privileges must have a period of focused review. Q. Must the process be pre-defined or can it be determined for each specific applicant for the new privilege? A. The components for design are listed in EP 3 and would include, but not be limited to:

• criteria for conducting performance evaluations • method for establishing the monitoring plan specific to the requested privilege • method to determining the duration of performance monitoring • circumstances under which monitoring by an external source is required

The organization may choose to use the methodologies for collecting information such as those outlined at MS.4.40 for ongoing professional practice evaluation:

• periodic chart review • direct observation • monitoring of diagnostic and treatment techniques • discussion with other individuals involved in the care of each patient including consulting

physicians, assistants at surgery, nursing, and administrative personnel. There is nothing in EP 3 that would prevent the design of a multi tiered/level approach. The type of review can certainly be different, especially for different privileges, e.g. for some direct observation is appropriate but for other chart audits are more appropriate.


Joint Commission FAQ regarding FPPE Page 2 Q. Must the process be defined in writing or defined in the Medical Staff Bylaws? A. The process would need to be pre-defined as EP 4 requires that focused professional

practice evaluation be consistently implemented in accordance with the criteria and requirements defined by the organized Medical Staff. Since the process must be consistently implemented (EP 4), the organization may wish to put it in writing. There is no requirement that it be in the Medical Staff Bylaws.

Q. What is the duration of the monitoring, e.g. can it be a twelve-month provisional period? A. With regard to establishing the monitoring plan specific to the requested privilege, and the possibility of using a twelve month provisional period, it is important to remember that there is no required provisional period. The provisional period when it was required related to appointment to the Medical Staff and not to privileges. Using a 12-month provisional period for focused review might be burdensome when the volume of activity is very large. It may be more appropriate to consider a different approach for high volume vs. low volume privileges or high risk vs. low risk privileges for example performing a focused review for a defined number of admissions such as the first 5, 10, 20, etc, or a defined number of procedures, such as 5, 10, 20, etc, or for a short period of time such as 1 month or 3 months. For an infrequently performed privilege numbers might work better than a time period especially if the privilege isn't performed in that time period. While the EP would require an evaluation of each new privilege it could be possible to group very similar activities together and then evaluate a set number of any mix of the privileges for example, any ten from the group will be evaluated to determine competence for the whole group, but you cannot just look at one privilege from the group. The duration could also be different for different levels of documented training and experience, e.g.

• practitioners coming directly from an outside residency program • practitioners coming directly from the organization’s residency program • practitioners coming with a documented record of performance of the privilege and its

associated outcomes • practitioners coming with no record of performance of the privilege and its associated

outcomes Q. Can the focused review for new privileges be only for performance issues or when triggers occur? A. A focused review/peer review process for new privileges, which is triggered by practice indicators which only relate to untoward outcomes, would not meet EP 1 for a focused practice review for all privileges for new applicants and new privileges for existing practitioners. The bottom line principles are:

• The process must be defined • The process must be consistently implemented as defined


Joint Commission FAQ regarding FPPE Page 3

• All new privileges (new applicants and new privileges for existing applicants) must be

reviewed in accordance with the defined process Focused Professional Practice Evaluation for Performance issues Q. What is the distinction between performance issues and triggers and are there any examples? A. The standard requires that organized Medical Staff develops criteria to be used for evaluating the performance of practitioners when issues affecting the provision of safe, high quality patient care are identified (EP 2). In addition, the triggers that indicate the need for performance monitoring are clearly defined (EP 5). Triggers can be single incidents or evidence of a clinical practice trend. There is a somewhat fine line between criteria and triggers but triggers are the very obvious issues, e.g., infection rates, sentinel events, perhaps complaints, other events that aren't sentinel like sponges left in during surgery, etc. Criteria for performance issues might include but not be limited to:

• small number of admissions or procedures over an extended period of time that raise the concern of continued competence

• a growing number of longer lengths of stay than other practitioners • returns to surgery • frequent or repeat readmission suggesting possibly poor or inadequate initial

management/treatment • patterns of unnecessary diagnostic testing/treatments • failure to follow approved clinical practice guidelines--may or may not indicate care

problems but why the variance Issues affecting the provision of safe, high quality patient care and indicate the need for performance monitoring may be identified as part of the ongoing practitioner performance evaluation at MS.4.40. They may also be that the negative or outlier data on a practitioner that will be used to identify the trigger that indicate the need for performance monitoring. Q. Are there any required components for design of the focused evaluation process? A. The four required components for design of the process are outlined in EP 3:

• criteria for conducting performance evaluations • method for establishing the monitoring plan specific to the requested privilege • method to determining the duration of performance monitoring • circumstances under which monitoring by an external source is required


Joint Commission FAQ regarding FPPE Page 4 Since the process must be consistently implemented (EP 9), the organization may wish to put it in writing. There is no standard requiring that it be in the Medical Staff Bylaws. With regard to establishing the monitoring plan specific to the requested privilege it could either be pre-defined for different type of performance issues or triggers or it could be appropriate to allow the reviewers to recommend to the organized Medical Staff the type of monitoring and duration based on the issue under review. Q. Are there any guidelines for how to collect information for evaluation? A. The organization may choose to use the methodologies for collecting information outlined at MS.4.40 for ongoing professional practice evaluation:

• periodic chart review • direct observation • monitoring of diagnostic and treatment techniques • discussion with other individuals involved in the care of each patient including consulting

physicians, assistants at surgery, nursing, and administrative personnel. Q. Is this really just the process that was historically called “Peer Review”? A. The Joint Commission renamed “peer review” to be termed “Focused Review of Practitioner Performance” in 2004. The current term is now Focused Professional Practice Evaluation. If an organization's current "peer review" process includes the criteria to be used for identified performance issue (EP 2), defined triggers that indicate the need for performance monitoring (EP 5),the four required components outlined in EP 3, and the remaining requirements at EP's 4 and 6 - 9, it would meet the intent for the existing focused professional practitioner evaluation covered by EP's 2 - 9.


Sample Ongoing and Focused Professional Practice Evaluation Policy Purpose: To assure that the Hospital, through the activities of its Medical Staff, assesses the ongoing professional practice and competence of its medical Staff, conducts professional practice evaluations, and uses the results of such assessments and evaluations to improve professional competency, practice and care. The focused efforts towards individuals complements but does not replace ongoing efforts to evaluate and improve performance of clinical groups and enterprise-based systems of care. “Professional Practice Evaluation” is considered an element of the peer review process and the records and proceedings relating to this policy are protected from discovery pursuant to [enter state regulation code addressing peer review]. Ongoing Professional Practice Evaluation Criteria utilized for the ongoing professional practice evaluation may include but is not limited to:

• Review of operative and other clinical procedure(s) performed and their outcomes

• Pattern of blood and pharmaceutical usage

• Requests for tests and procedures

• Length of stay patterns

• Morbidity and mortality data

• Appropriate use of consultants

• Sentinel events and/or near misses

• CMS Core Measures

• National Patient Safety Goals

(Add additional specific indicators as identified by each department) Methods utilized to identify reviews may include:

• Chart review

• Direct observation and/or proctoring

• Routine monitoring of indicators

• Complaints or concerns from patients, staff, medical staff members, etc.

• Failure to follow approved clinical practice guidelines

Rationale: It is the policy of [hospital name] its medical staff to comply with accreditation requirements regarding ongoing professional practice evaluation and focused professional practice evaluation. Ongoing data review and findings about practitioner practice and performance are evaluated by Departmental Chairmen [Medical Director] on a continual basis and utilized to assess the quality of care of each practitioner at time of reappointment. The Medical Executive Committee provides oversight of all monitoring activities for the medical staff. General Instructions: 1. Quality of care and patient safety indicators/criteria are developed by the medical staff

departments/committees and are approved by the Medical Executive Committee. 2. Indications/criteria are implemented and monitored by Hospital and quality analysts on an ongoing basis. 3. Results of monitored indicators/criteria are reported to the practitioner’s clinical department chairman on a

monthly basis. 4. Unusual patterns, trends, outliers or issues are to be brought to the Chairman immediately for review.

Patterns, trends, outliers or issues identified at department/committee review will be addressed for further review, corrective action and/or additional monitoring as necessary.

5. In conjunction with review by Department Chairman, those practitioners who fall below established targets may be recommended for implementation of additional proctoring, education of practitioner, focused review and/or restriction of privileges in accordance with Bylaws.


6. Monitoring results and department/committee recommendations are reported to the medical executive committee at least quarterly.

7. Process issues identified will be referred to the medical executive committee for recommendation and development of a corrective action plan

8. Cumulative or specific practitioner reports are reviewed [enter frequency], any time additional privileges are requested and at time of bi-annual reappointment.

Focused Professional Practice Evaluation

FPPE is defined as a time-limited period during which the organization evaluates and determines a practitioner’s professional performance. A period of FPPE is implemented for all initially requested privileges through the appropriate Service and when there are concerns regarding a practitioner’s professional performance, as recognized through the peer review and Ongoing Professional Practice Evaluation (OPPE) process. The Service Chief or designee shall be responsible for the oversight and development of the evaluation plan for all applicants or medical staff members assigned to their department. The following guidelines should be used to determine the extent of FPPE to be performed:

1. Initial Privilege Requests a. Evaluation of peer recommendations from previous institutions b. Ongoing monitoring of performance indicators and aggregate data within the department c. Input from colleagues, consultants, nursing personnel, and administration. d. Procedure and clinical activity logs will be reviewed from previous institutions and/or training

programs. If current competency and adequate clinical activity is not well documented from previous institution, then a higher level of focused evaluation may be assigned. Specifically, concurrent chart review or proctoring may occur to fully evaluate the ability to perform requested privileges.

e. At a minimum, the medical records of the first 5 patients will be reviewed by the Service Chief or his/her designee either prospectively (while patient is in house) or retrospectively (on patient discharge). Based on review of information received in the credentialing and privileging process, the Service Chief may require additional review, proctoring, or monitoring.

2. Additional privilege request – The privilege(s) requested will be reviewed by the Service Chief. If

the additional privilege(s) requested is significantly different from the requesting physician’s current practice and there is no transference of skill (as determined by the Service Chief), an FPPE plan will be established.

3. FPPE required as a result of peer review - The Service Chief will establish a plan on a case by

case basis when focused evaluation has been recommended as a result of peer review.

Triggers may include but are not limited to: � Significant variation from accepted standards of clinical performance; � Findings from a sentinel event, serious event, or “near miss” review in which one of the root

causes is determined to be related to practitioner performance; � Unexpected unfavorable patient care outcome; � Identified trends or variations; � Findings from investigation of a complaint/occurrence about practitioner performance; � Minimal threshold criteria has not been met to maintain proficiency for a specific privilege or

procedure as determined by the Service Chief. � Recommendation of the Executive Committee for additional monitoring of practitioner

performance. Information for FPPE may be derived from the following:


• Discussion with other individuals involved in the care of each patient (e.g. consulting physician, assistants in surgery, nursing, or administrative personnel)

• Chart review

• Monitoring clinical practice patterns

• Proctoring

• External peer review

A specific monitoring plan will be developed and will include the following as appropriate:

• Specific performance elements are to be monitored

• Number of cases or length of time or both to complete the monitoring plan

• Practitioners assigned to perform monitoring or proctoring

• Description of how the results of monitoring and any recommendations will be provided to the practitioner and to the appropriate monitoring body (Service Chief, Executive Committee, and/or Governing Board)

• In instances where there may be a lack of expertise within the medical staff to provide monitoring, or in which the available monitors with appropriate expertise may have a conflict of interest, a plan for monitoring by an external source will be developed by the Executive Committee. The plan will contain the elements defined above.

If either during the process of, or after completion of the specific FPPE monitoring plan a recommendation is made that would result in restriction, decrease, or revocation of specific privileges, or in suspension or revocation of medical staff membership, the processes pursuant to the Medical Staff Bylaws will apply. Procedures: A. Monitoring and evaluation are conducted as fairly as possible and are performed based on criteria of which

the Medical Staff members have prior knowledge. B. Initial review and identification of an indicator may be determined by the Quality Improvement Office, the

Risk Management Department or referred by a Medical Staff Department to determine if criteria for the indicator are met.

C. Cases will be forwarded to the appropriate Service Chief for review and recommendation. D. The Service Chief will determine the need for action or the need for additional review including the use of

external reviewers.

Pro

vid

er

Com

pete

ncy in

Pri

vile

gin

g

7

0

Focused Professional Practice Evaluation Plan

PRACTITIONER N

AME

BRANDON JONES, MD

MEDICAL STAFF D

EPARTMENT SURGERY

PRACTITIONER SPECIALTY

GENERAL SURGEON

REASONS/TRIGGER FOR R

EVIEW

In

itia

lly r

equeste

d p

rivile

ge(s

) N

ew

ly c

rede

ntiale

d p

ractitioner

P

eer

Revie

w / N

egative T

rends e

xce

edin

g t

hre

shold

s identified

O

ther:

_____

________

_______

_____

___________

___

_____

________

______

___________

________

________

_____

____________

________

________

______

___________

___

RATIONALE FOR M

ONITORING PLAN

AND D

URATION

Check all that have been considered:

L

evel of pri

vile

ge s

pecific

activity d

uri

ng the

past 24 m

onth

s

A

dditio

nal privile

ge s

pecific

tra

inin

g is a

vaila

ble

R

evie

w o

f available

aggre

gate

data

E

xis

ting p

eer

revie

w r

esults

DURATION OF FOCUSED R

EVIEW:

INITIATION D

ATE: ___1/12/10_________ END D

ATE:___________________ D

ESIGNATED #

OF CASES: SEE VOLUME BELOW

Privilege Under

Focused Review

Method

(Check all that apply)

Volume

(Number to be Reviewed/ Observed

/Proctored /Monitored /Simulated/Sent

Out/Etc

Specifics

(Specify key components for the review)

Individual (s) Assigned

(Individuals Assigned

Review

/Observation/M

onitoring/P

roctoring, Etc,

Responsibilities)

MONITORING PLAN

Example:

Surgical case review

for new applicant

Chart

revie

w

Retr

ospective

Concurr

ent

Dir

ect observ

ation

Monitori

ng o

f dia

gnostic a

nd

treatm

ent te

chniq

ues a

nd

clin

ical pra

ctice p

attern

s

Sim

ula

tion

Pro

cto

ring

Exte

rnal R

evie

w

Dis

cussio

ns w

ith o

ther

indiv

iduals

, in

volv

ed in the c

are

of th

e p

atient, inclu

din

g

consultin

g p

hysic

ians, assis

tants

at surg

ery

, nurs

ing a

nd

adm

inis

trative p

ers

onnel.

Example:

Charts of first 5 patient contacts

reviewed on discharge

First two surgical cases proctored with

direct observation

VPMA to discuss care provided with OR

staff and surgical nursing floor staff.

Charts of first 5 patient contacts

reviewed on discharge by Medical

Director and generic quality screen

applied.

First two surgical cases proctored with

direct observation

Example:

Dr. Smith (chart review)

Dr. Jacobs –proctor/direct

monitoring

ADDITIONAL D

ETAILS/

SPECIFICS OF PLAN

____________________________________________

DATE:_________________________

CHAIR OF CREDENTIALS COMMITTEE OR CHIEF OF STAFF

____________________________________________

DATE: ________________________

DEPARTMENTAL CHAIR

____________________________________________

DATE:_________________________

PRACTITIONER

OR


DOCUMENTING RECOMMENDATIONS

Sample language for medical staff minutes: “Committee members reviewed the applications, the supporting documentation, the Department Chairmen’s recommendations, and information received during the credentialing and privileging processes. Based on this review, it is the committee’s opinion that the following applicants meet the requirements for Medical Staff appointment and have documented appropriate education, training, experience, current competency, clinical judgment, professionalism, and health status to perform the privileges requested. It was moved, seconded, and carried to recommend to the [fill in Credentials Committee or MEC as appropriate] approval of the following appointments and clinical privileges:”

Sample language for Board minutes: “Board members reviewed the applications, the supporting documentation, the Department Chairmen’s recommendations, Medical Executive Committee’s recommendations, and information received during the credentialing and privileging processes. Based on this review, it is the Board’s opinion that the following applicants meet the requirements for Medical Staff appointment and clinical privileges as recommended and it was moved, seconded, and carried to approve of the following appointments and clinical privileges:”


Recommendation and Approval Form for Medical Staff Appointment and Clinical Privileges Practitioner Name:____________________________________________________________________ Staff Status:__________________ Department:________________________ Specialty:_________________________

Departmental Recommendation

Based on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant the following recommendations are made:

� Privileges be granted/renewed � Medical staff membership be granted/renewed � Additional privileges requested be granted � Privileges be modified as follows: _________________________________________________________________________ _____________________________________________________________________________________________________ � Privileges not be granted/renewed � Medical staff membership not be granted/renewed (comment below) � Additional privileges requested be denied (comment below) Comments: Department Chairman Date

Credentials Committee Recommendation Based on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant and on the evaluations and recommendations of the Department Chairman the following recommendations are made:

� Concur with recommendation(s) of the Department Chairman and forward these recommendations to the Medical Executive Committee � Do not concur with the recommendations of the Department Chairman, and instead make the following recommendations: ____________________________________________________________________________________________________________ Credentials Committee Representative Date

Medical Staff Executive Committee Recommendation

Based on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant, and on the evaluations and recommendations of the Department Chairman and Credentials Committee, the following recommendations are made:

� Concur with recommendation(s) of the Department Chairman and Credentials Committee and forward these recommendations to the governing body for consideration. � Do not agree with the recommendations of the Department Chairman, and Credentials Committee and instead make the following recommendations: ____________________________________________________________________________________________________________ Medical Staff Executive Committee Representative Date

Governing Body Approvals/Action Taken

Based on the evaluation of the education, training, current competence, health status, skill, character, and judgment data and information, and on the recommendations of the Medical Staff, the following action is taken:

� Concur with and approve the recommendation(s) of the Medical Staff. � Do not concur with the recommendations of the Medical Staff. Action taken is documented in Board minutes of __________________. (date) Board of Trustees Representative Date


PROCTORING

Medical staffs often associate proctoring - the evaluation of a physician's clinical competence by a proctor who represents, and is responsible to, the medical staff – with provisional status, when in fact, they are two separate and distinct processes. Proctoring can occur at any time a provider’s performance needs to be monitored, for instance, when a current medical staff appointee requests additional privileges. Physician organizations, such as the American Academy of Family Physicians (AAFP) support the use of clinical proctoring as an important peer review tool for physicians seeking privileges. The AMA Board of Trustees Report 30-A-94, “Clinical Proctoring,” defines clinical proctoring as an objective evaluation of a physician’s actual clinical competence by a monitor

or proctor, who represents the medical staff and is responsible to the medical staff. When an initial applicant seeks privileges or an existing medical staff member requests new privileges, they are proctored or observed while providing the services for which privileges are requested. WIn most instances, proctors act as monitors to evaluate the technical and cognitive skills of another physician, and do not directly participate in patient care, have no physician/patient relationship with the patient being treated, do not receive a fee from the patient, represent the medical staff and are responsible to the medical staff.”

AMA Policy 375.974, “Clinical Proctoring,” reinforces the role of proctoring: “AMA policy states that clinical proctoring is an important tool for peer review and

for evaluating clinical competence of new physicians seeking privileges or existing medical staff members requesting new privileges. Therefore, the AMA:

(1) encourages hospital medical staffs to develop proctoring programs, with

appropriate medical staff bylaws provisions, to evaluate the clinical competency of new physicians seeking privileges and existing medical staff members requesting new privileges; and

(2) encourages hospital medical staffs to consider including the following

provisions in their medical staff bylaws for use in their proctoring program: (a) Except as otherwise determined by the medical executive committee, all

initial appointees to the medical staff and all members granted new clinical privileges shall be subject to a period of proctoring.

(b) Each appointee or recipient of new clinical privileges shall be assigned to a department where performance of an appropriate number of cases as


established by the medical executive committee, or the department as designee of the medical executive committee, shall be observed by the chair of the department, or the chair's designee, during the period of proctoring specified in the department's rules and regulations, to determine the suitability to continue to exercise the clinical privileges granted in that department. The exercise of clinical privileges in any other department shall also be subject to direct observation by that department's chair or the chair's designee.

(c) The members shall remain subject to such proctoring until the medical executive committee has been furnished with: a report signed by the chair of the department(s) to which the member is assigned as well as other department(s) in which the appointee may exercise clinical privileges, describing the types and numbers of cases observed and the evaluation of the applicant's performance, a statement that the applicant appears to meet all of the qualifications for unsupervised practice in that department, has discharged all of the responsibilities of staff membership, and has not exceeded or abused the prerogative of the category to which the appointment was made, and that the member has satisfactorily demonstrated the ability to exercise the clinical privileges initially granted in those departments. (BOT Rep. 30-A-94)

.


Peer Review Policy: Definition of Peer For the purpose of this policy, a peer is an individual with subject matter expertise who is practicing in the same professional discipline (i.e. MD, DO, DPM, DDS) Reviewer Selection & Duties Reviews are completed by the designated Medical Staff Committee. (i.e. a chart will be reviewed by the committee where the privileges are monitored. Medical care will be reviewed by the Medical Care Review Committee, Surgical care by the Surgical Care Review Committee, etc.). However, in the case where a physician holds privileges in more than one specialty, any specific questions regarding the care involved will be forwarded to the appropriate medical staff committee for review. Physician members of the department or service shall be designated by the Committee Chairperson to review medical records prior to or during the Committee meeting. The physician reviewer will present the results to the Committee. The designated physician reviewer may not review a case where he/she participated in the care (including radiology and pathology). Members of the same physician groups cannot review the other members of the group. Reviewer Disqualification & Replacement If a reviewer does not feel he/she can adequately review a medical record due to a conflict of interest or believes he/she is not qualified to address a certain issue, the reviewer may discuss the issue with the Chairperson of the Committee. If the Chair concurs, the Chair shall reassign the record(s) to another reviewer. If a member has reviewed a record that needs to be presented but is unable to attend the meeting, the member shall report to the Chair so that the presentation may be reassigned to another Committee member or presented by the Chairperson. If the chairperson is the practitioner subject to review, the record review will be assigned to another Active Staff member by the Chief of Staff. If a determination is reached that no physician on the staff is qualified to conduct the review, the MEC or the Board of Trustees may request external peer review by a physician who is Board certified within the same specialty.


Sample Policy Regarding Proctoring PURPOSE:

The purpose of this policy is to define the __________ (“Hospital”) process and standards for evaluating the performance of Medical Staff members through direct observation. Definition of Proctoring: The personal presence of an assigned physician (hereafter referred to as “Proctor”) who does not have a treatment relationship with the patient, who is designated to provide clinical teaching or to monitor the clinical performance of another physician to facilitate quality of care to patients, as required for purposes of credentialing, reappointment, quality improvement, or corrective action.

POLICY: A. Candidates for Proctoring

1. Physicians who may require proctoring include new applicants seeking privileges, current Medical Staff members seeking new or additional clinical privileges, or sanctioned physicians in need of additional evaluation and/or training to have certain clinical privileges maintained or restored.

2. To be reportable to the National Practitioner Data Bank, the decision to assign a Proctor

must be based on an assessment of a physician’s professional competence or professional conduct and constitute a restriction on the physician’s privileges lasting more than thirty (30) days. Such a decision to assign a Proctor based on an assessment of the physician’s competence or conduct must follow the process in Article __ of the bylaws. All other proctoring is not reportable to the National Practitioner Data Bank. For example, if the Proctor is not required to grant approval before medical care is provided, if the Proctor is assigned to a physician recently granted new or additional clinical privileges, or if the Proctor is providing training or evaluation as part of a quality improvement or peer review process, the assignment of the Proctor is not reportable.

3. Nothing set forth in this policy shall: (i) operate to prevent the Hospital or Medical Staff

Committees from taking action as provided for in Article ___ bylaws or (ii) supersede the rights of the physician as provided for in the bylaws.

B. Assignment of a Proctor

The Proctor must be a member of the Medical Staff with appropriate unrestricted clinical privileges in good standing to perform the procedures that he/she will proctor. If no Medical Staff members who have the necessary qualifications are available to proctor, special arrangements may be made for selection of a Proctor who is not a current member of the Medical Staff or for the Medical Staff member to receive proctoring at another hospital. A prospective Proctor who is not a member of the Medical Staff must apply for appointment to the Medical Staff and for clinical privileges. In addition, he/she must have documented training, skill, and current competence in the service or procedure that is the subject of the proctoring. With regard to Medical Staff members applying for new or additional privileges, the physician is responsible for contacting potential Proctors and choosing his/her Proctor, but the Department Chairperson must approve the choice of Proctor.

1. If an assigned Proctor is unable to fulfill proctoring responsibilities, he or she shall notify the Vice President of Medical Affairs (“VPMA”), Department Chairperson, or appropriate Medical Staff Committee Chairperson who shall assign another Proctor.


2. The proctored physician shall have the option of requesting more than one Proctor who

will monitor a sequence of cases.

3. The Department Chairperson or the appropriate Medical Staff Committee will determine the appropriate number of procedures or observations the Proctor will evaluate.

a. Routine New or Additional Clinical Privilege Request. The Department

Chairperson may at any time determine that the physician has received sufficient proctoring and demonstrates competence in the clinical privileges under review and therefore may terminate the required proctoring program before the proctor has observed or reviewed the designated number of procedures. In such a case, the Department Chairperson will notify the physician of this determination and will make a report to the credentials committee for the physician’s file to be incorporated in the Board’s decision to grant the clinical privileges under review.

b. Other Proctoring. The proctored physician must complete the designated

number of procedures. C. Function and Responsibility of the Proctor

1. Competence is assessed by evaluation of a physician’s performance under clinical conditions. The proctor will complete a form for each procedure he or she monitors. The form will include documentation of the appropriateness of patient selection, appropriate education and discussion with patient and family, knowledge of equipment, skill in use of equipment, monitoring, technical expertise in performance, and management and knowledge of possible adverse outcomes.

2. If medical care is provided, the Proctor will evaluate the proctored physician’s

performance from the time of admission until discharge including the indications for admission, discharge, diagnostic work-up, and therapy management. The Proctor reviews the care of the patient utilizing the patient’s record, discussions with the physician, and actual observation as the basis for the review. Invasive medical procedures will be proctored by direct observation.

3. If a surgery or an invasive procedure is performed, the Proctor will evaluate the indication for the procedure, the technique for the procedure, how it is performed, and the preoperative, operative, and postoperative care of the patient. The Proctor may utilize the patient’s record, discussion with the physician, and actual observation as the basis for the review.

4. The Proctor’s primary responsibility is to evaluate the proctored physician’s performance. However, if the Proctor believes that immediate intervention is warranted in order to avert harm to a patient, the Proctor may take any action he/she finds reasonably necessary to protect the patient.

5. Proctors shall not receive compensation directly or indirectly from any patient for this

service. 6. Proctors shall complete the Verification of Proctored Procedure/Treatment Form for each

proctored case and a Proctoring Summary Report at the conclusion of the proctoring. The forms shall be provided to the Department Chairperson or appropriate Medical Staff Committee. The proctoring reports shall remain confidential in accord with other Medical Staff peer review information.


7. The Department Chairperson or appropriate Medical Staff Committee will review, acknowledge, and document the Proctor’s reports in its recommendation and report and place such report in the applicant’s file. If the purpose of the proctoring is for new or additional clinical privileges, the report will be provided to the Credentials Committee for recommendations concerning the requested clinical privileges.

D. Responsibility of the Proctored Physician

1. The proctored physician shall be responsible for notifying the assigned Proctor(s) of each patient whose care is to be evaluated. For surgical or invasive medical procedures to be observed, the proctored physician shall be responsible for arranging the time of the procedure with the Proctor.

2. The proctored physician shall provide the information that is requested by the Proctor

regarding the patient and the planned course of treatment. 3. The proctored physician shall inform the patient that another physician may observe and

assist in the procedure. Both the Proctor and the proctored physician’s name shall be included on the informed consent form.

E. Proctoring Duration

1. A Medical Staff member may request an extension of time to complete the proctoring if he or she has not had a sufficient number of cases to satisfy the proctoring requirements in whole or in part.

2. If a proctored physician completes the necessary number of proctored cases, but has not achieved satisfactory proficiency during proctoring, as concluded by the Proctor, Department Chairperson, VPMA, or the appropriate Medical Staff Committee, he or she may be proctored on additional cases.

3. Failure to satisfactorily complete the proctoring shall be reviewed and acted upon in

accordance with the procedures set forth in the bylaws. This provision does not preclude the initiation of corrective action pursuant to Article __ of the bylaws.


Sample Proctorship Forms

Verification of Proctored Procedure/Treatment

If a surgery or an invasive procedure is performed, the Proctor should evaluate the indication for the procedure, the technique for the procedure, how it is performed, and the preoperative, operative, and postoperative care of the patient. The Proctor may utilize the patient’s record, discussion with the physician, and actual observation as the basis for the review.

Proctored Physician: _____________________________ Date: ___________________ Proctor: ____________________________________________________________________ Procedure/Treatment:__________________________________________________________ Comments: _________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Areas of in need of Improvement: ________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Procedure Completed Successfully: _____ Yes _____ No _________________________________________ ____________________ Signature, Proctoring Physician Date _________________________________________ ____________________ Signature, Proctored Physician Date


CONCURRENT PROCTORING: Procedural / Surgical Evaluation Form

TO: Department Chair ____________________________ Date: ________________________ Confidential File for: ___________________________ By Assigned Proctor: _____________________

Patient Medical Record # ________________ Diagnosis: ____________________________________

Procedure(s):_________________________________________________________________________

Complications as applicable: ______________________________________________________________________________ _______________________________________________________________________________ Please answer all the following: If the answer to any of the following is “no”, attach an explanation sheet Mark a √ in the appropriate box Yes No NA

Was there pre-operative justification for the surgery documented?

Were patient rounds made daily?

Were calls answered promptly by the practitioner?

Did the practitioner cooperate with you (the proctor) concerning this review?

Was all necessary information (history, physical, progress notes, op note, etc.) recorded by the practitioner in a timely manner in the patient’s medical record?

Was the above information legible?

Were the entries made in the record informative?

Were the entries by the practitioner appropriate/

Was the practitioner’s use of diagnostic services (lab, imaging, etc.) appropriate?

Was the practitioner’s surgical technique appropriate?

Did the pre-operative diagnosis coincide with postoperative findings?

Was postoperative care adequate and within industry standards?

Was the operative report complete, accurate and timely?

Were complications, if any, recognized and managed appropriately?

Was there any evidence that the practitioner exhibited any disruptive or inappropriate behavior?

Was there any evidence of patient dissatisfaction?

BASIC ASSESSMENT Satisfactory Unsatisfactory 1. Basic medical knowledge 2. Clinical judgment 3. Communication skills 4. Use of consultants if indicated 5. Professional attitude 6. Recordkeeping 7. Relationship to patient

Generally, how would you rate this practitioner’s skill and competence in performing this examination? Outstanding Acceptable Unacceptable Unable to evaluate because: _______________________________________

COMMENTS: ______________________________________________________________________


Proctoring Summary Report Proctored Physician: ________________________________ Date: ___________________ Proctor: ____________________________________________________________________ Number of Procedures/Treatment Episodes Proctored: _______________________________ Comments: _________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Areas in need of Improvement: _________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________ Proctoring Completed Successfully: _____ Yes _____ No _________________________________________ ____________________ Signature, Proctoring Physician Date

Department Chair Recommendation

� The applicant appears to meet all of the qualifications for unsupervised practice in that department, has discharged all of the responsibilities of staff membership, and has not exceeded or abused the prerogative of the category to which the appointment was made, and that the member has satisfactorily demonstrated the ability to exercise the clinical privileges initially granted in those departments. It is recommended that proctoring cease.

� It is recommended that proctoring continue for ______________________________________ (list number of procedures and/or time frame)

Comments________________________________________________________________________ _________________________________________________________________________________ _________________________________________ ____________________ Signature, Department Chairperson Date


Medical Proctor’s Report Sample 1 Patient Name or M.R.#____________________________________________ Admission/Start Date_______________ Discharge/End Date_____________ Attending Physician________________________________________________ Proctoring Physician________________________________________________

APPEARS APPROPRIATE

Area of review Yes No N/A Comments

Diagnostic workup:

Necessity of admission(s)

Initial level of care/placement

History and physical examination (promptness, thoroughness, significant negative, problem-oriented, etc)

Problem formulation (initial impression(s), rule-outs, assessment, thoroughness, justification, etc)

Use of diagnostic tests, labs, x-rays, etc.

Initial orders (activity, diet, vital signs, parenteral, fluids, clarity, legibility, etc

Diagnostic procedures (especially invasive, such as endoscopy, arthroscopy, imaging, biopsies, catheterizations, etc

Patient Management:

Antibiotic drug use (prophylactic, therapeutic choice of drug, dosage, route, duration, combinations, toxicity monitoring, serum levels, etc.)

Use of other drugs (digitalis, glycosides, diuretics, psychotropics, corticosteroids, anticoagulants, etc.)

Use of blood and blood products

Use of ancillary services (P.T., Respiratory Therapy, Social Service, Dietary, etc.)

Monitoring patient’s condition (vital signs, weights, intake/output, follow-up lab tests, and x-rays, etc.)

Diet including parenteral alimentation

Level of care (include placement, such as ICU, Step Down, etc.), activity level, use of isolation, etc.

Length of stay

Progress notes

Complications (anticipated, recognized promptly, dealt with appropriately, etc)

Placement (transfer, home , ECF, home health, etc.)

Patient education/instruction (regarding diet, mediations, follow-up, level of activity, etc.)

Proctoring physician’s signature


Medical Proctor’s Report Sample 2 Patient Name or M.R.#____________________________________________ Admission/Start Date_______________ Discharge/End Date_____________ Attending Physician________________________________________________ Proctoring Physician________________________________________________

Generic Competencies - Rate on scale of 1 (poor) to 5 (excellent)

1 2 3 4 5 Basic medical knowledge

Clinical judgment

Procedural skills

Communication skills

Use of consultants

Professional attitude

Record-keeping

Relationship to patient

Cost-effectiveness

General comments on the handling of this case:

Proctoring physician’s signature

provider competency in privileging resource · ms. matzka has authored a number of books related to...

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