the joint commission medical staff standards and fppe/oppe compliance

11

The Joint Commission The Joint Commission Medical Staff Standards Medical Staff Standards

and FPPE/OPPE and FPPE/OPPE ComplianceCompliance

Stephen M. Dorman, M.D.Stephen M. Dorman, M.D.

www.redandgold.comwww.redandgold.com

22

2013 Scoring andAccreditation Decision Model

33

StandardStandard

A statement that defines the performance expectations and/or structures or processes that must be in place in order for a healthcare organization to provide safe, high quality care, treatment, and services.

An organization is either “compliant” or “not compliant” with a standard.

44

Element of PerformanceElement of Performance

The specific performance expectation and/or structure or process that must be in place in order for a healthcare organization to provide safe, high quality care, treatment, and services.

The scoring of EP compliance determines an organization’s overall compliance with a standard.

55

2013 Scoring/Accreditation Decision Model -Summary

Elements of Performance (EP): types:

A: one observation to cite: 100% compliance

C: two observations to cite: 90% compliance

(D): requires a document or documentation

66


Elements of Performance and other accreditation requirements will be tagged based on their “criticality” – immediacy of impact on quality of care and patient safety as the result of noncompliance.

77


SITUATION DECISION (2): PDASITUATION DECISION (2): PDA

DIRECT impact: (3): 45 days for ESCDIRECT impact: (3): 45 days for ESC

INDIRECT impact: (4): 60 days for ESCINDIRECT impact: (4): 60 days for ESC

88


If partial compliance or insufficient compliance is not resolved, a progressively more adverse accreditation decision may result:

Provisional, Contingent, Preliminary Denial of Accreditation.

2013 Scoring/Accreditation Decision Model

Accreditation Follow Up Survey:Accreditation Follow Up Survey:– If any element of performance is cited twice in If any element of performance is cited twice in

subsequent surveys, a 45 day follow up subsequent surveys, a 45 day follow up survey will occur: AFS 02survey will occur: AFS 02

– Affects both direct and indirect findingsAffects both direct and indirect findings

99

1010


Critical Levels:Critical Levels:

Immediate threat to life: no a single Immediate threat to life: no a single standard, but condition (APR)standard, but condition (APR)

Falsification (APR)Falsification (APR)

Situational Decision Rule: immediate Situational Decision Rule: immediate recommendation of Denial of Accreditation recommendation of Denial of Accreditation or Contingent accreditation alone.or Contingent accreditation alone.

1111


DIRECT impact standard: SedationDIRECT impact standard: Sedation

INDIRECT impact standard: PoliciesINDIRECT impact standard: Policies

Labels on standards:Labels on standards:

(D): Documentation required

(2): Situational Decision Rule

(3): Direct Impact Requirements

(4): Indirect Impact Requirements

1212

MS Chapter OutlineMS Chapter Outline

I. Medical Staff Bylaws

A. Bylaws (revised MS.01.01.01) (36 A/4)

B. Unilateral Amendment (revised MS.01.01.03) (1 A/4)

II. Structure and Role of Medical Staff Executive Committee (revised MS.02.01.01) (12 A/4)

1313


III. Medical Staff Role in Oversight of Care, Treatment, and Services

A. Oversight of Quality of Care (revised MS.03.01.01) (16 A/4, 1 A/3)

B. Management and Coordination of Care (revised MS.03.01.03) (10 A/4, 2 A/3)

1414


IV. Medical Staff Role in Graduate Education Programs (revised MS.04.01.01) (8 A/4, 1 C/4).

V. Medical Staff Role in Performance Improvement

A. Role in Performance Improvement Activities (revised MS.05.01.01) (12 A/4)

B. Participation in Performance Improvement Activities (revised MS.05.01.03) (5 A/4)

1515


VI. Credentialing and Privileging A. Determining Resource Availability (revised

MS.06.01.01) (2 A/4)

B. Collecting Information (revised MS.06.01.03)(10 A/4, 1 A/3)

C. Decision Process (revised MS.06.01.05) (One A/2, 10 A/4, 1 C/4)


D. Reviewing Information (revised MS.06.01.07) (8 A/4), 1 C/4)

E. Communicating Decision (revised MS.06.01.09) (5 A/4)

F. Expedited Process (revised MS.06.01.11) (7 A/4)

G. Temporary Privileges (revised MS.06.01.13) (6 A/4)

1616

1717


VII. Appointment to Medical Staff

A. Recommending Appointment (revised MS.07.01.01) (5 A/4)

B. Peer Recommendations (revised MS.07.01.03) (4 A/4).

1818


VIII. Evaluation of Practitioners

A. Monitoring Performance (revised MS.08.01.01) (9 A/4)

B. Use of Monitoring Information (revised MS.08.01.03) (3 A/4)

1919


IX. Acting on Reported Concerns About a Practitioner (revised MS.09.01.01) (2 A/4)

X. Fair Hearing and Appeal Process (revised MS.10.01.01) (5 A/4)

XI. Licensed Independent Practitioner Health (revised MS.11.01.01) (10 A/4)

2020


XII. Continuing Education for Practitioners (revised MS.12.01.01) (5 A/4)

XIII. Medical Staff Role in Telemedicine A. Credentialing and Privileging of

Licensed Independent Practitioners (revised MS.13.01.01) (1 A/4)

B. Recommending Clinical Services to be Provided (revised MS.13.01.03) (2 A/4)

LEADERSHIPLEADERSHIP

The medical staff has been defined as one The medical staff has been defined as one of the three components of “leadership”. of the three components of “leadership”. There is no longer a medical staff There is no longer a medical staff leadership interview. When the standards leadership interview. When the standards address “leaders”, it is up to the address “leaders”, it is up to the organization to determine which leaders organization to determine which leaders are involved.are involved.

2121

LD.01.02.01LD.01.02.01

1: Senior managers and leaders of the 1: Senior managers and leaders of the organized medical staff work with the organized medical staff work with the governing body to define their shared and governing body to define their shared and unique responsibilities and unique responsibilities and accountabilities. (A/4)accountabilities. (A/4)

2222

2323

LD.01.05.01 (A/4)LD.01.05.01 (A/4)

1: NO EP1: NO EP

2: Self-governing2: Self-governing

3: Conforms to guiding principles3: Conforms to guiding principles

4: Governing body approves structure4: Governing body approves structure

5: Medical staff oversees quality care 5: Medical staff oversees quality care provided by individuals with clinical provided by individuals with clinical privilegesprivileges

6: Accountable to governing body6: Accountable to governing body

LD.01.05.01LD.01.05.01

7: MD/DO/Dentist/Podiatrist responsible 7: MD/DO/Dentist/Podiatrist responsible for the organization and conduct of the for the organization and conduct of the medical staff.medical staff.

8: There is a SINGLE organized medical 8: There is a SINGLE organized medical staff.staff.

2424

LD.01.07.01LD.01.07.01

1. Governing body, senior managers, and 1. Governing body, senior managers, and leaders of the organization medical staff leaders of the organization medical staff work together to identify the skills requires work together to identify the skills requires of individual leaders.of individual leaders.

2525

LD.01.07.01LD.01.07.01

2: …leaders of the organized medical staff 2: …leaders of the organized medical staff are oriented to:are oriented to:– Mission/ValuesMission/Values– Safety and Quality goalsSafety and Quality goals– Structure and decision making processStructure and decision making process– BudgetBudget– Population servedPopulation served– ResponsibilityResponsibility– Law and RegulationLaw and Regulation

2626

LD.02.02.01LD.02.02.01

1. Define conflict of interest.1. Define conflict of interest.

2. Policy on management of conflict of 2. Policy on management of conflict of interest.interest.

3. Obtain disclosures of conflicts of 3. Obtain disclosures of conflicts of interest.interest.

This standard applies to LEADERSHIPThis standard applies to LEADERSHIP

2727

LD.02.04.01LD.02.04.01

1: Ongoing process for conflict 1: Ongoing process for conflict management.management.

2828

LD.04.01.05LD.04.01.05

CMS REQUIRED PHYSICIAN CMS REQUIRED PHYSICIAN DEPARTMENT DIRECTORS:DEPARTMENT DIRECTORS:– AnesthesiaAnesthesia– Emergency Medicine ServicesEmergency Medicine Services– Respiratory Care ServiceRespiratory Care Service– RadiologyRadiology– Nuclear MedicineNuclear Medicine

2929

LD.04.01.05LD.04.01.05

6: Emergency services are directed and 6: Emergency services are directed and supervised by a qualified member of the supervised by a qualified member of the medical staff.medical staff.

7: Physicians direct: anesthesia, nuclear 7: Physicians direct: anesthesia, nuclear medicine, respiratory care.medicine, respiratory care.

9: Anesthesia responsible for ALL 9: Anesthesia responsible for ALL anesthesia services (ref. deep sedation)anesthesia services (ref. deep sedation)

3030

LD.04.02.01LD.04.02.01

1. Define conflict of interest1. Define conflict of interest

2. Policy on conflict of interest2. Policy on conflict of interest

3. Disclosures of conflicts of interest.3. Disclosures of conflicts of interest.

3131

LD.04.03.09LD.04.03.09

1: Clinical leaders and medical staff have 1: Clinical leaders and medical staff have an opportunity to provide advice about an opportunity to provide advice about sources of clinical services to be provided sources of clinical services to be provided through contractual agreement.through contractual agreement.

3232

3333

MS.01.01.01MS.01.01.01

What is required in the bylaws What is required in the bylaws and new Medical staff and new Medical staff

communication processescommunication processes

3434

The doctors of medicine and osteopathy and, in accordance with medical staff bylaws, other practitioners are organized into a self-governing medical staff that oversees the quality of care provided by all physicians and by other practitioners who are privileged through a medical staff process.

3535

The organized medical staff and the governing body collaborate in a well-functioning relationship, reflecting clearly recognized roles, responsibilities, and accountabilities, to enhance the quality and safety of care, treatment, and services provided to patients.

3636

This collaborative relationship is critical to providing safe, high quality care in the hospital. While the governing body is ultimately responsible for the quality and safety of care at the hospital, the governing body, medical staff, and administration collaborate to provide safe, quality care.

3737

To support its work, and its relationship with and accountability to the governing body, the organized medical staff creates a written set of documents that describes its organizational structure and the rules for its self-governance.

3838

These documents are called medical staff bylaws, rules and regulations, and policies. These documents create a system of rights, responsibilities, and accountabilities between the organized medical staff and the governing body, and between the organized medical staff and its members.

3939

Because of the significance of these documents, the medical staff leaders should strive to ensure that the medical staff members understand the content and purpose of the medical staff bylaws and relevant rules and regulations and policies, and their adoption and amendment processes.

4040

Of the members of the organized medical staff, only those who are identified in the bylaws as having voting rights can vote to adopt and amend the medical staff bylaws.

4141

The voting members of the organized medical staff may include within the scope of responsibilities delegated to the medical executive committee the authority to adopt, on the behalf of the voting members of the organized medical staff, any details associated with Elements of Performance 12 through 36 that are placed in rules and regulations, or policies.

4242

MS.01.01.01MS.01.01.01

Medical staff bylaws address self-Medical staff bylaws address self-governance and accountability to governance and accountability to

the governing body the governing body

Approved. Effective date: 3/31/2011

4343

1: The organized medical staff develops medical staff bylaws, rules and regulations, and policies.

4444

2: The organized medical staff adopts and amends medical staff bylaws. Adoption or amendment of medical staff bylaws cannot be delegated. After adoption or amendment by the organized medical staff, the proposed bylaws are submitted to the governing body for action. Bylaws become effective only upon governing body approval.

4545

3: Every requirement set forth in Elements of Performance 12 through 36 is in the medical staff bylaws. These requirements may have associated details, some of which may be extensive; such details may reside in the medical staff bylaws, rules and regulations, or policies. The organized medical staff adopts what constitutes the associated details, where they reside, and whether their adoption can be delegated. Adoption of associated details that reside in medical staff bylaws cannot be delegated.

4646

3: (cont): For those Elements of Performance 12 through 36 that require a process, the medical staff bylaws include at a minimum the basic steps, as determined by the organized medical staff and approved by the governing body, required for implementation of the requirement. The organized medical staff submits its proposals to the governing body for action. Proposals become effective only upon governing body approval.

4747

4: The medical staff bylaws, rules and regulations, and policies, the governing body bylaws, and the hospital policies are compatible with each other and are compliant with law and regulation.

4848

5: The medical staff complies with the medical staff bylaws, rules and regulations, and policies.

4949

6: The organized medical staff enforces the medical staff bylaws, rules and regulations, and policies by recommending action to the governing body in certain circumstances, and taking action in others.

5050

7: The governing body upholds the medical staff bylaws, rules and regulations, and policies that have been approved by the governing body.

5151

8: The organized medical staff has the ability to adopt medical staff bylaws, rules and regulations, and policies, and amendments thereto, and to propose them directly to the governing body.

5252

9: If the voting members of the organized medical staff propose to adopt a rule, regulation, or policy, or an amendment thereto, they first communicate the proposal to the medical executive committee. If the medical executive committee proposes to adopt a rule or regulation, or an amendment thereto, it first communicates the proposal to the medical staff; when it adopts a policy or an amendment thereto, it communicates this to the medical staff. This Element of Performance applies only when the organized medical staff, with the approval of the governing body, has delegated authority over such rules, regulations, or policies to the medical executive committee.

5353

10: The organized medical staff has a process which is implemented to manage conflict between the medical staff and the medical executive committee on issues including, but not limited to, proposals to adopt a rule, regulation, or policy or an amendment thereto. Nothing in the foregoing is intended to prevent medical staff members from communicating with the governing body on a rule, regulation, or policy adopted by the organized medical staff or the medical executive committee. The governing body determines the method of communication.

5454

11: In cases of a documented need for an urgent amendment to rules and regulations necessary to comply with law or regulation, there is a process by which the medical executive committee, if delegated to do so by the voting members of the organized medical staff, may provisionally adopt and the governing body may provisionally approve an urgent amendment without prior notification of the medical staff. In such cases, the medical staff will be immediately notified by the medical executive committee. The medical staff has the opportunity for retrospective review of and comment on the provisional amendment.

5555

11: (cont): If there is no conflict between the organized medical staff and the medical executive committee, the provisional amendment stands. If there is conflict over the provisional amendment, the process for resolving conflict between the organized medical staff and the medical executive committee is implemented. If necessary, a revised amendment is then submitted to the governing body for action.

5656

12: The structure of the medical staff. (CMS CoP requirement)

13: Qualifications for appointment to the medical staff. (CMS CoP requirement)

14: The process for privileging and re-privileging licensed independent practitioners, which may include the process for privileging and re-privileging other practitioners. (CMS CoP requirement)

5757

15: A statement of the duties and privileges related to each category of the medical staff (for example, active, courtesy). (CMS CoP requirement)

Note: The word “privileges” can be interpreted in several ways. The Joint Commission interprets it, solely for the purposes of this element of performance, to mean the duties and prerogatives of each category, and not the clinical privileges to provide patient care, treatment, and services related to each category. The Joint Commission is in discussion with CMS to clarify this term’s meaning.

5858

16: The requirements for completing and documenting medical histories and physical examinations. The medical history and physical examination are completed and documented by a physician, an oral maxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy. (CMS CoP requirement)

5959

17: A description of those members of the medical staff who are eligible to vote.

18: The process, as determined by the organized medical staff and approved by the governing body, by which the organized medical staff selects and/or elects and removes the medical staff officers.

19: A list of all the officer positions for the medical staff.

6060

20: The medical executive committee’s function, size, and composition, as determined by the organized medical staff and approved by the governing body; the authority delegated to the medical executive committee by the organized medical staff to act on the medical staff’s behalf; and how such authority is delegated or removed.

6161

21: The process, as determined by the organized medical staff and approved by the governing body, for selecting and/or electing and removing the medical executive committee members.

22: That the medical executive committee includes physicians and may include other practitioners and any other individuals as determined by the organized medical staff.

6262

23: That the medical executive committee acts on the behalf of the medical staff between meetings of the organized medical staff, within the scope of its responsibilities as defined by the organized medical staff.

24: The process for adopting and amending the medical staff bylaws.

25: The process for adopting and amending the medical staff rules and regulations, and policies.

6363

26: The process for credentialing and re-credentialing licensed independent practitioners, which may include the process for credentialing and re-credentialing other practitioners.

27: The process for appointment and re-appointment to membership on the medical staff.

28: Indications for automatic suspension of a practitioner’s medical staff membership or clinical privileges.

6464

29: Indications for summary suspension of a practitioner’s medical staff membership or clinical privileges.

30: Indications for recommending termination or suspension of medical staff membership, and/or termination, suspension, or reduction of clinical privileges.

31: The process for automatic suspension of a practitioner’s medical staff membership or clinical privileges.

6565

32: The process for summary suspension of a practitioner’s medical staff membership or clinical privileges.

33: The process for recommending termination or suspension of medical staff membership and/or termination, suspension, or reduction of clinical privileges.

6666

34: The fair hearing and appeal process regarding the fair hearing and appeal process), which at a minimum shall include:

The process for scheduling hearings and appealsThe process for conducting hearings and appeals

35: The composition of the fair hearing committee.

6767

36: If departments of the medical staff exist, the qualifications and roles and responsibilities of the department chair, which are defined by the organized medical staff and include the following:

Qualifications:

Certification by an appropriate specialty board or comparable competence affirmatively established through the credentialing process.

6868

Roles and responsibilities:

Clinically related activities of the department.

Administratively related activities of the department, unless otherwise provided by the hospital.

Continuing surveillance of the professional performance of all individuals in the department who have delineated clinical privileges.

Recommending to the medical staff the criteria for clinical privileges that are relevant to the care provided in the department.

6969

Recommending clinical privileges for each member of the department.

Assessing and recommending to the relevant hospital authority off-site sources for needed patient care, treatment, and services not provided by the department or the organization.

Integration of the department or service into the primary functions of the organization.

Coordination and integration of interdepartmental and intradepartmental services.

7070

Development and implementation of policies and procedures that guide and support the provision of care, treatment, and services.

Recommendations for a sufficient number of qualified and competent persons to provide care, treatment, and services.

Determination of the qualifications and competence of department or service personnel who are not licensed independent practitioners and who provide patient care, treatment, and services.

7171

Continuous assessment and improvement of the quality of care, treatment, and services.

Maintenance of quality control programs, as appropriate.

Orientation and continuing education of all persons in the department or service.

Recommending space and other resources needed by the department or service.

7272

Thou Shalt MeasureThou Shalt MeasureThou Shalt AnalyzeThou Shalt Analyze

Thou Shalt Take ActionThou Shalt Take Action

The Joint Commissions New The Joint Commissions New Approach to Assessing Approach to Assessing Physician PerformancePhysician Performance

7373

Why?Why?

Lack of previous success of physicians Lack of previous success of physicians rigorously dealing with issues related to rigorously dealing with issues related to colleague performance.colleague performance.

Lack of valid data when difficult decisions Lack of valid data when difficult decisions needed to be made related to physician needed to be made related to physician performance.performance.

Threat of litigation real in light of lack of Threat of litigation real in light of lack of substantial performance documentation.substantial performance documentation.

7474

Why?Why?

Peer recommendations were essentially Peer recommendations were essentially useless.useless.

Physicians would never provide objective Physicians would never provide objective references if they knew that substandard references if they knew that substandard performance would be reported.performance would be reported.

““CredentialingCredentialing”” always focused on always focused on documents.documents.

NPDB only listed most serious issues.NPDB only listed most serious issues.

7575

Why?Why?

Databank reports were not timely.Databank reports were not timely.

Physicians were allowed to resign when Physicians were allowed to resign when under the threat of or under actual under the threat of or under actual investigation.investigation.

Interruption of referral patterns.Interruption of referral patterns.

Interference with friendships.Interference with friendships.

Accusations of financial motivations for Accusations of financial motivations for competition.competition.

7676

Measurement Part IMeasurement Part I

In the early 90s with the advent of In the early 90s with the advent of performance improvement, a physician performance improvement, a physician ““profileprofile”” was to be maintained and used at was to be maintained and used at reappointment every two years.reappointment every two years.

Areas for measurement have not actually Areas for measurement have not actually changed much since then.changed much since then.

Compliance was spotty, but not often Compliance was spotty, but not often scored.scored.

7777

Measurement Part IMeasurement Part I

Subject to surveyor variability.Subject to surveyor variability.

Many physician surveyors were not Many physician surveyors were not comfortable with the measurement comfortable with the measurement standards and did not understand them.standards and did not understand them.

Most of the data collection at that time was Most of the data collection at that time was manual.manual.

Profiles frequently indicated Profiles frequently indicated ““00”” for lack of for lack of quality issues despite poor performance.quality issues despite poor performance.

7878

Measurement Part IIMeasurement Part II

With a change in Joint Commission With a change in Joint Commission leadership, it because apparent that these leadership, it because apparent that these standards were never scored and were standards were never scored and were essentially meaningless.essentially meaningless.

Physician Physician ““thinkersthinkers”” at the Joint at the Joint Commission became instrumental in Commission became instrumental in changing the approach (and some changing the approach (and some prodding by CMS).prodding by CMS).

7979


First things first: render the current First things first: render the current standards meaningfulstandards meaningful

Implement physician performance Implement physician performance measures that were rate based so that measures that were rate based so that they could be compared with peer they could be compared with peer performance (early 2000).performance (early 2000).

Comparisons were to be meaningful Comparisons were to be meaningful (meaning statistically analyzed)(meaning statistically analyzed)

8080


Profiles slowly became more meaningfulProfiles slowly became more meaningful

Hospitals elected to participate in national Hospitals elected to participate in national measurement venues (Care Science, measurement venues (Care Science, Premier Data, STS, ACC databases etc)Premier Data, STS, ACC databases etc)

Though data became available, still no Though data became available, still no action was taken on bad performance.action was taken on bad performance.

8181


There was a paralysis because of lack of There was a paralysis because of lack of benchmark databenchmark data

Hospitals did not understand that it was Hospitals did not understand that it was acceptable to compare performance to acceptable to compare performance to ““peer grouppeer group””

External data was not available because External data was not available because of peer review protectionof peer review protection

Low volume providers were not measuredLow volume providers were not measured

8282

Measurement Part IIIMeasurement Part III

It became apparent that even though It became apparent that even though suboptimal performance could be detected suboptimal performance could be detected at the two year reappointment period, what at the two year reappointment period, what was being done in advance of that date.was being done in advance of that date.

It became It became ““too latetoo late”” to take action or the to take action or the reappointment was due and had to be reappointment was due and had to be done with less than desirable performance done with less than desirable performance data.data.

8383

Measurement Part IVMeasurement Part IV

ONGOING REVIEWONGOING REVIEWThe time frame for the review of physician The time frame for the review of physician performance data was discussed at TJCperformance data was discussed at TJCTo be To be ““ongoingongoing””, it was determined that , it was determined that every 2 years was insufficient, and in fact, every 2 years was insufficient, and in fact, that every year was insufficientthat every year was insufficientTJC stated that ongoing review should be TJC stated that ongoing review should be conducted every 6-9 months unless conducted every 6-9 months unless ““triggertrigger”” events had occurred events had occurred

8484


Ongoing review dependent on those Ongoing review dependent on those performance measures that primarily performance measures that primarily depend on the performance of an depend on the performance of an individual providerindividual provider

These concepts apply not only to These concepts apply not only to physicians, but also others who are physicians, but also others who are credentialed and privilegedcredentialed and privileged

8585


It also became apparent that privileges It also became apparent that privileges that were granted were not based on that were granted were not based on evidenced-based criteria or any other evidenced-based criteria or any other criteria for that mattercriteria for that matter

Now the tie is between measured Now the tie is between measured performance and privileges is clearperformance and privileges is clear

No data – no privilegesNo data – no privileges

No use of external data (see letter)No use of external data (see letter)

8686


CMS requires that each privilege granted be CMS requires that each privilege granted be based on the assessment of the competence of based on the assessment of the competence of the physician to exercise that privilege.the physician to exercise that privilege.There is a move to Core Privileges (assuming There is a move to Core Privileges (assuming that competence is common to the group as that competence is common to the group as defined)defined)Special request privileges must be individually Special request privileges must be individually evaluatedevaluated““Laundry listsLaundry lists”” are still highly problematic for all are still highly problematic for all the reasons statedthe reasons stated

8787

The Standard: MS.05.01.01: The Standard: MS.05.01.01: CLINICALCLINICAL

The organized medical staff has a leadership The organized medical staff has a leadership role in organization performance improvement role in organization performance improvement activities to improve quality of care, treatment, activities to improve quality of care, treatment, and services and [patient] safety.and services and [patient] safety.

Relevant information developed from the Relevant information developed from the following processes is integrated into following processes is integrated into performance improvement initiatives and performance improvement initiatives and consistent with [organization] preservation of consistent with [organization] preservation of confidentiality and privilege of information.confidentiality and privilege of information.

8888

The Standard: MS.05.01.01The Standard: MS.05.01.01

1: The organized medical staff provides 1: The organized medical staff provides leadership for measuring, assessing, and leadership for measuring, assessing, and improving processes that improving processes that primarily primarily depend on the activities of one or more depend on the activities of one or more licensed independent practitionerslicensed independent practitioners, and , and other practitioners credentialed and other practitioners credentialed and privileged through the medical staff privileged through the medical staff process. (See also PI.03.01.01, EPs 1-4)process. (See also PI.03.01.01, EPs 1-4)

8989


2: The medical staff is 2: The medical staff is actively involvedactively involved in the measurement, assessment, and in the measurement, assessment, and improvement of the following: improvement of the following: Medical Medical assessment and treatment of patientsassessment and treatment of patients. . (See also PI.03.01.01, EPs 1-4)(See also PI.03.01.01, EPs 1-4)

9090


3: The medical staff is actively involved in 3: The medical staff is actively involved in the measurement, assessment, and the measurement, assessment, and improvement of the following: Use of improvement of the following: Use of information about adverse privileging information about adverse privileging decisionsdecisions for any practitioner privileged for any practitioner privileged through the medical staff process.through the medical staff process.

9191


4: The medical staff is actively involved in 4: The medical staff is actively involved in the measurement, assessment, and the measurement, assessment, and improvement of the following: improvement of the following: Use of Use of medicationsmedications

9292


5: The medical staff is actively involved in 5: The medical staff is actively involved in the measurement, assessment, and the measurement, assessment, and improvement of the following: improvement of the following: Use of Use of blood and blood componentsblood and blood components

9393


6: The medical staff is actively involved in 6: The medical staff is actively involved in the measurement, assessment, and the measurement, assessment, and improvement of the following: improvement of the following: Operative Operative and other procedure(s)and other procedure(s)– Judgment (decision making)Judgment (decision making)– Clinical and Technical SkillsClinical and Technical Skills

9494


7: The medical staff is actively involved in 7: The medical staff is actively involved in the measurement, assessment, and the measurement, assessment, and improvement of the following: improvement of the following: Appropriateness of clinical practice Appropriateness of clinical practice patterns.patterns.– Utilization Review (LOS, Avoidable days, Utilization Review (LOS, Avoidable days,

denials)denials)

9595


8: The medical staff is actively involved in 8: The medical staff is actively involved in the measurement, assessment, and the measurement, assessment, and improvement of the following: improvement of the following: Significant Significant departures from established patterns of departures from established patterns of clinical practice.clinical practice.– All other departments: Pathology, All other departments: Pathology,

radiology, anesthesiology, ERradiology, anesthesiology, ER

9696


9: The medical staff is actively involved in 9: The medical staff is actively involved in the measurement, assessment, and the measurement, assessment, and improvement of the following: improvement of the following: The use of The use of developed criteria for autopsiesdeveloped criteria for autopsies. (CMS . (CMS REQUIREMENT)REQUIREMENT)

9797


10: Information used as part of the 10: Information used as part of the performance improvement mechanisms, performance improvement mechanisms, measurement, or assessment includes the measurement, or assessment includes the following: following: Sentinel event dataSentinel event data. .

9898


11: Information used as part of the 11: Information used as part of the performance improvement mechanisms, performance improvement mechanisms, measurement, or assessment includes the measurement, or assessment includes the following: following: Patient safety dataPatient safety data. .

9999

The Standard: MS.05.01.03: The Standard: MS.05.01.03: CITIZENSHIPCITIZENSHIP

1: The organized medical staff participates 1: The organized medical staff participates in the following activities: in the following activities: Education of Education of patients and families.patients and families.

100100


2: The organized medical staff participates 2: The organized medical staff participates in the following activities: in the following activities: Coordination of Coordination of care, treatment, and services with other care, treatment, and services with other practitioners and hospital personnel, as practitioners and hospital personnel, as relevant to the care, treatment, and relevant to the care, treatment, and services of an individual patient.services of an individual patient.

101101


3: The organized medical staff participates 3: The organized medical staff participates in the following activities: in the following activities: Accurate, Accurate, timely, and legible completion of timely, and legible completion of patientpatient’’s medical records.s medical records.

102102


4: The organized medical staff participates 4: The organized medical staff participates in the following activities: in the following activities: Review of Review of findings of the assessment process findings of the assessment process that are relevant to an individualthat are relevant to an individual’’s s performance. The organized medical performance. The organized medical staff is responsible for determining the staff is responsible for determining the use of this information in the ongoing use of this information in the ongoing evaluations of a practitionerevaluations of a practitioner’’s s competence.competence.

103103


5: The organized medical staff participates 5: The organized medical staff participates in the following activities: Communication in the following activities: Communication of findings, conclusions, of findings, conclusions, recommendations, and actions to improve recommendations, and actions to improve performance to appropriate staff members performance to appropriate staff members and the and the governing bodygoverning body..

104104


Ongoing professional practice evaluation Ongoing professional practice evaluation information is factored into the decision to information is factored into the decision to maintain existing privilege(s), to revise maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege(s), or to revoke an existing privilege prior to or at the time of existing privilege prior to or at the time of renewal.renewal.

105105


1: The process for the ongoing 1: The process for the ongoing professional practice evaluation includes professional practice evaluation includes the following: the following: There is a clearly defined There is a clearly defined processprocess in place that facilitates the in place that facilitates the evaluation of each practitionerevaluation of each practitioner’’s s professional practice. (D means there professional practice. (D means there must be a policy)must be a policy)

106106


2: The process for the ongoing 2: The process for the ongoing professional practice evaluation includes professional practice evaluation includes the following: The the following: The type of datatype of data to be to be collected is determined by individual collected is determined by individual departments and approved by the departments and approved by the organized medical stafforganized medical staff. (Performance . (Performance measures must be defined for CMS in a measures must be defined for CMS in a Medical Staff Plan).Medical Staff Plan).

107107


3: The process for the ongoing 3: The process for the ongoing professional practice evaluation includes professional practice evaluation includes the following: Information resulting from the following: Information resulting from the ongoing professional practice the ongoing professional practice evaluation is evaluation is used to determine whether used to determine whether to continue, limit, or revoke any to continue, limit, or revoke any existing privilege(s).existing privilege(s).

108108

FOCUSED REVIEWFOCUSED REVIEW

While it was a good thing to evaluate While it was a good thing to evaluate providers after they had already been providers after they had already been working 6 months, it was apparent that working 6 months, it was apparent that there was real risk in the there was real risk in the ““unknownunknown””..

Peer Recommendations could not be Peer Recommendations could not be trusted.trusted.

Harm could come to patients soon after Harm could come to patients soon after practice began.practice began.

109109


There were analogous standards in the There were analogous standards in the Human Resources chapter for an Human Resources chapter for an ““initial initial assessment of competencyassessment of competency”” before before hospital staff could carry out job hospital staff could carry out job responsibilities independently.responsibilities independently.

110110


It was clear that something was needed on It was clear that something was needed on the the ““front end.front end.””

Next it was determined that in classic Next it was determined that in classic ““peer reviewpeer review””, cases simply fell off and , cases simply fell off and issues were never closed or casually issues were never closed or casually investigated. There was no accountability investigated. There was no accountability for closure of many significant issues.for closure of many significant issues.

111111


The purpose:The purpose:– Initial assessment of competence of all new Initial assessment of competence of all new

physicians or new privileges regardless of physicians or new privileges regardless of experience.experience.

– Conduct intensive, planned and Conduct intensive, planned and ““focusedfocused”” investigations when adverse events occurred investigations when adverse events occurred (trigger events).(trigger events).

– Conduct intensive, planned and Conduct intensive, planned and ““focusedfocused”” investigations when ongoing performance investigations when ongoing performance measurement indicated undesirable measurement indicated undesirable performance.performance.

112112

Focused Review: New PrivilegesFocused Review: New Privileges

Goal: To be conducted as rapidly as Goal: To be conducted as rapidly as possible.possible.

““VolumeVolume”” of review defined by the medical of review defined by the medical staff and departments.staff and departments.

Individual plans should be developed to allow Individual plans should be developed to allow the medical staff to know when review has the medical staff to know when review has concluded.concluded.

Each provider may warrant a tailored plan.Each provider may warrant a tailored plan.

Some departments are completely uniform.Some departments are completely uniform.

113113

Focused Review: New PrivilegesFocused Review: New Privileges

Should be conducted in a time frame that Should be conducted in a time frame that is too short for rate based performance is too short for rate based performance measurement: data collection would not measurement: data collection would not be statistically significant for short term.be statistically significant for short term.

Evaluation of privilege must be realistic: Evaluation of privilege must be realistic: chart review versus direct observation.chart review versus direct observation.

All requirements defined in a plan.All requirements defined in a plan.

TOP Medical Staff Standard RFI in 2009.TOP Medical Staff Standard RFI in 2009.

114114


The organized medical staff defines the The organized medical staff defines the circumstances requiring monitoring and circumstances requiring monitoring and evaluation of a practitionerevaluation of a practitioner’’s professional s professional performance.performance.

- Initial Appointment (new privileges)- Initial Appointment (new privileges)- New mid-cycle privilege- New mid-cycle privilege- Trigger events- Trigger events- Variant data - Variant data

115115


The focused evaluation process is defined by The focused evaluation process is defined by the organized medical staff. The time period of the organized medical staff. The time period of the evaluation can be extended, and/or a the evaluation can be extended, and/or a different type of evaluation process assigned. different type of evaluation process assigned. Information for focused professional practice Information for focused professional practice evaluation may include chart review, monitoring evaluation may include chart review, monitoring clinical practice patterns, simulation, proctoring, clinical practice patterns, simulation, proctoring, external peer review, and discussion with other external peer review, and discussion with other individuals involved in the care of each patient individuals involved in the care of each patient (e.g., consulting physicians, assistants at (e.g., consulting physicians, assistants at surgery, nursing or administrative personnel).surgery, nursing or administrative personnel).

116116


Relevant information resulting from the Relevant information resulting from the focused evaluation process is integrated focused evaluation process is integrated into performance improvement activities, into performance improvement activities, consistent with the organizationconsistent with the organization’’ss policies policies and procedures that are intended to and procedures that are intended to preserve confidentiality and privilege of preserve confidentiality and privilege of information.information.

117117


1: A period of focused professional 1: A period of focused professional practice evaluation is implemented for all practice evaluation is implemented for all initially requested privileges.initially requested privileges.

118118


2: The organized medical staff develops 2: The organized medical staff develops criteria to be used for evaluating the criteria to be used for evaluating the performance of practitioners when issues performance of practitioners when issues affecting the provision of safe, high quality affecting the provision of safe, high quality patient care are identified. (D means patient care are identified. (D means Plan)Plan)

119119


3: The performance monitoring process is clearly 3: The performance monitoring process is clearly defined and includes each of the following defined and includes each of the following elements: elements: - Criteria for conducting performance monitoring- Criteria for conducting performance monitoring- Method for establishing a monitoring - Method for establishing a monitoring planplan specific to the requested privilegespecific to the requested privilege- Method for determining the duration of - Method for determining the duration of performance monitoringperformance monitoring- Circumstances under which monitoring by an - Circumstances under which monitoring by an external source is requiredexternal source is required

120120


4: Focused professional practice 4: Focused professional practice evaluation is evaluation is consistently implementedconsistently implemented in accordance with the criteria and in accordance with the criteria and requirements defined by the organized requirements defined by the organized medical staff.medical staff.

121121


5: The 5: The triggerstriggers that indicate the need for that indicate the need for performance monitoring are clearly performance monitoring are clearly defined. defined.

Note: Triggers can be single incidents or Note: Triggers can be single incidents or evidence of a clinical practice trend.evidence of a clinical practice trend.

122122


6: The decision to assign a period of 6: The decision to assign a period of performance monitoring to performance monitoring to further assessfurther assess current competence is based on the evaluation current competence is based on the evaluation of a practitionerof a practitioner’’s current clinical competence, s current clinical competence, practice behavior, and ability to perform the practice behavior, and ability to perform the requested privilege.requested privilege.

Note: Other existing privileges in good standing Note: Other existing privileges in good standing should not be affected by this decision.should not be affected by this decision.

123123


7: Criteria are developed that determine 7: Criteria are developed that determine the type of monitoring to be conducted. (D the type of monitoring to be conducted. (D means this has to be in the plan).means this has to be in the plan).

124124


8: The measures employed to resolve 8: The measures employed to resolve performance issues are clearly defined. (D performance issues are clearly defined. (D means it must be in the plan).means it must be in the plan).

125125


9: The measures employed to resolve 9: The measures employed to resolve performance issues are consistently performance issues are consistently implemented.implemented.

126126

NEW CMS REQUIREMENTSNEW CMS REQUIREMENTS

RADIOLOGYRADIOLOGY

ANESTHESIAANESTHESIA

127127

RADIOLOGYRADIOLOGY

New CMS requirements for oversight of New CMS requirements for oversight of radiology.radiology.

Policies and procedures must comply with Policies and procedures must comply with nationally recognized standards: ACRnationally recognized standards: ACR

Physician supervision of all contrast Physician supervision of all contrast administration (CT and MRI). ACR administration (CT and MRI). ACR requires a radiologist.requires a radiologist.

128128

RADIOLOGYRADIOLOGY

Training of all providers who operate Training of all providers who operate radiology equipment: physicians using C-radiology equipment: physicians using C-Arm, Fluoroscopy.Arm, Fluoroscopy.

Supervision of all ionizing radiology Supervision of all ionizing radiology services by director. Best done through services by director. Best done through radiation safety committee.radiation safety committee.

129129


1: Director of Anesthesia Services1: Director of Anesthesia Services

2: 2: ““Deep SedationDeep Sedation”” now considered now considered anesthesia and is referred to a Monitored anesthesia and is referred to a Monitored Anesthesia Care.Anesthesia Care.

3: MAC may only be administered only 3: MAC may only be administered only by an appropriate practitioner privileged by an appropriate practitioner privileged by director of anesthesia servicesby director of anesthesia services

130130


4: Director of anesthesia responsible for 4: Director of anesthesia responsible for all anesthetics (general to local).all anesthetics (general to local).

5: Director of anesthesia services sets 5: Director of anesthesia services sets policies for all anesthetic use.policies for all anesthetic use.

6: Director of anesthesia services 6: Director of anesthesia services decides on how to privilege for moderate decides on how to privilege for moderate sedation.sedation.

131131


7: Epidurals administered by CRNAs do 7: Epidurals administered by CRNAs do not require direct supervision unless they not require direct supervision unless they become an anesthetic.become an anesthetic.

8: Post-anesthesia note may be written 8: Post-anesthesia note may be written from the time a patient can participate from the time a patient can participate until discharge or 48 hours whichever until discharge or 48 hours whichever comes sooner.comes sooner.

132132


Practical effects:Practical effects:– Nursing staff will not longer be able to Nursing staff will not longer be able to

administer anesthesia agents: Etomidate, administer anesthesia agents: Etomidate, Ketamine, Pentothal, or Propofol because this Ketamine, Pentothal, or Propofol because this is MAC.is MAC.

– Anesthesia will have to privilege for MAC Anesthesia will have to privilege for MAC (deep sedation), and recommend privileging (deep sedation), and recommend privileging process for moderate sedationprocess for moderate sedation

133133

ScoringScoring

All of the medical staff standards on these All of the medical staff standards on these issues are issues are ““AA”” meaning 100% compliance meaning 100% compliance is required.is required.

Focused Review: 16% of hospitals cited.Focused Review: 16% of hospitals cited.

Ongoing Review: 15% of hospitals cited.Ongoing Review: 15% of hospitals cited.

Problems with no or low volume providersProblems with no or low volume providers

Changes to privileges based to dataChanges to privileges based to data

MEC FUNCTIONMEC FUNCTION

134134

135135

MS.02.01.01MS.02.01.01

7: Requests evaluation of practitioner 7: Requests evaluation of practitioner when doubt about applicantwhen doubt about applicant’’s ability to s ability to perform privileges (focused review)perform privileges (focused review)

136136

MS.02.01.01MS.02.01.01

11: Recommends to governing body: 11: Recommends to governing body: delineation of privileges (no delegation)delineation of privileges (no delegation)

12: Receives/acts on reports by 12: Receives/acts on reports by committees, departments, groups.committees, departments, groups.

137137

MS.03.01.01MS.03.01.01

Medical staff oversees quality of care, Medical staff oversees quality of care, treatments, or services provided by treatments, or services provided by practitioners privileged through the practitioners privileged through the medical staff processmedical staff process

2: Practitioners practices within scope of 2: Practitioners practices within scope of privileges (DIRECT IMPACT) (100%)privileges (DIRECT IMPACT) (100%)

138138

MS.03.01.01MS.03.01.01

4: Leadership in patient safety4: Leadership in patient safety

5: Oversight of process of analyzing and 5: Oversight of process of analyzing and improving patient satisfactionimproving patient satisfaction

6: Minimal content of H&Ps defined6: Minimal content of H&Ps defined

7: MS monitors quality of H&Ps7: MS monitors quality of H&Ps

8: Privileged provider performs H&Ps8: Privileged provider performs H&Ps

9: Others as allowed by laws may perform 9: Others as allowed by laws may perform H&Ps, under a specified physicianH&Ps, under a specified physician

139139

MS.03.01.01MS.03.01.01

10: Define when H&P must be validated or 10: Define when H&P must be validated or countersignedcountersigned

11: Defines scope of H&P when required 11: Defines scope of H&P when required for non-inpatient servicesfor non-inpatient services

140140

MS.03.01.03MS.03.01.03

The management and coordination of The management and coordination of each patienteach patient’’s care, treatment, or services s care, treatment, or services is the responsibility of a practitioner with is the responsibility of a practitioner with appropriate privilegesappropriate privileges1: LIP with privileges manage and 1: LIP with privileges manage and coordinate patientcoordinate patient’’s care, treatment and s care, treatment and services.services.2: Hospital educates all LIPs on assessing 2: Hospital educates all LIPs on assessing and managing pain.and managing pain.

141141

MS.03.01.03MS.03.01.03

3: Patient3: Patient’’s general medical condition s general medical condition managed by a doctor of medicine or managed by a doctor of medicine or osteopathy.osteopathy.

4: Circumstances warranting consultation4: Circumstances warranting consultation

5: Consultations obtained when warranted5: Consultations obtained when warranted

6: Coordination of care among 6: Coordination of care among practitionerspractitioners

CMS COP ChangeCMS COP Change

Non-privileged providers as allowed by law Non-privileged providers as allowed by law may order outpatient care. may order outpatient care.

Verification of their authority to order the Verification of their authority to order the care or treatment.care or treatment.

Policy on which orders will be accepted and Policy on which orders will be accepted and under what circumstances.under what circumstances.

Still requires for patient to be under the Still requires for patient to be under the general medical care of a privileged provider.general medical care of a privileged provider.

142142

143143

MS.04.01.01MS.04.01.01

Graduate Medical EducationGraduate Medical Education1: Defined process for supervision1: Defined process for supervision2: Written description of roles and 2: Written description of roles and responsibilities and patient care activities responsibilities and patient care activities are provided to medical and hospital staffare provided to medical and hospital staff3: Mechanisms about decisions about 3: Mechanisms about decisions about progressive involvementprogressive involvement4: Define who may write orders and 4: Define who may write orders and requirements for countersignaturerequirements for countersignature

144144

MS.04.01.01MS.04.01.01

5: Communication between committee 5: Communication between committee overseeing GME and hospital medical overseeing GME and hospital medical staff and governing bodystaff and governing body

6: GME communicates about safety and 6: GME communicates about safety and quality of care, supervisory need to MEC quality of care, supervisory need to MEC and governing bodyand governing body

7: Communicate from local hospital to 7: Communicate from local hospital to GMECGMEC

145145

MS.04.01.01MS.04.01.01

8: Quality of care, treatment, services 8: Quality of care, treatment, services educational need to governing body of educational need to governing body of sponsoring hospitalsponsoring hospital

9: Compliance with residency review 9: Compliance with residency review committee citations.committee citations.

146146

MS.06.01.03MS.06.01.03

The [organization] collects information regarding each practitioner’s current license status, training, experience, competence, and ability to perform the requested privilege.

147147

MS.06.01.03MS.06.01.03

1: Clearly defined process1: Clearly defined process

2: Process based on recommendations by 2: Process based on recommendations by medical staffmedical staff

3: Process approved by governing body3: Process approved by governing body

4: Outlined in bylaws4: Outlined in bylaws

5: Verify that the REQUESTING individual 5: Verify that the REQUESTING individual be identified by VIEWING official ID. be identified by VIEWING official ID.

148148

MS.06.01.03MS.06.01.03

6: Primary Source verification of:6: Primary Source verification of:– The applicant’s current licensure at time of

initial granting, renewal, and revision of privileges, and at the time of license expiration.

– The applicant’s relevant training.– The applicant’s current competence.

149149

MS.06.01.05MS.06.01.05

The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidenced-based process.

150150

MS.06.01.05MS.06.01.05

1: 1: All licensed independent practitioners that provide care possess a current license, certification, or registration, as required by law and regulation. (SITUATIONAL DECISION)

151151

MS.06.01.05MS.06.01.05

2: Criteria based privileges include:2: Criteria based privileges include:– Current licensure and/or certification, as appropriate,

verified with the primary source.– The applicant’s specific relevant training, verified with

the primary source.– Evidence of physical ability to perform the requested

privilege.– Data from professional practice review by an

organization(s) that currently privileges the applicant (if available).

– Peer and/or faculty recommendation.– When renewing privileges, review of the practitioner’s

performance within the hospital.

152152

MS.06.01.05MS.06.01.05

3: 3: All of the criteria used are consistently evaluated for all practitioners holding that privilege

4: Process defined for granting, renewing, 4: Process defined for granting, renewing, revising privilegesrevising privileges

5: Process is approved by medical staff5: Process is approved by medical staff

153153

MS.06.01.05MS.06.01.05

6: Applicant submits health statement.6: Applicant submits health statement.

7: Hospital queries NPDB at initial 7: Hospital queries NPDB at initial privileges, renewal of privileges, and when privileges, renewal of privileges, and when new privileges requested.new privileges requested.

154154

MS.06.01.05MS.06.01.05

8: Peer Recommendation includes:8: Peer Recommendation includes:– Medical/Clinical knowledge.– Technical and clinical skills.– Clinical judgment.– Interpersonal skills.– Communication skills.– Professionalism.

155155

MS.06.01.05MS.06.01.05

9: 9: Before recommending privileges, the organized medical staff also evaluates the following:

– Challenges to any licensure or registration.– Voluntary and involuntary relinquishment of any license or

registration.– Voluntary and involuntary termination of medical staff membership.– Voluntary and involuntary limitation, reduction, or loss of clinical

privileges.– Any evidence of an unusual pattern or an excessive number of

professional liability actions resulting 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.

156156

MS.06.01.05MS.06.01.05

10: 10: The hospital has a process to determine whether there is sufficient clinical performance information to make a decision to grant, limit, or deny the requested privilege. (CMS)

11: Completed applications for privileges are acted on within the time period specified in the medical staff bylaws.

157157

MS.06.01.05MS.06.01.05

12: 12: Information regarding each practitioner’s scope of privileges is updated as changes in clinical privileges for each practitioner are made.

158158

MS.06.01.07MS.06.01.07

The organized medical staff reviews and analyzes all relevant information regarding each requesting practitioner’s current licensure status, training, experience, current competence, and ability to perform the requested privilege.

159159

MS.06.01.07MS.06.01.07

1: 1: The information review and analysis process is clearly defined.

2: 2: The hospital, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a requested privilege.

160160

MS.06.01.07MS.06.01.07

NEW EP: July 2010NEW EP: July 2010

3: Gender, race, and national origin are 3: Gender, race, and national origin are not used in making decisions regarding not used in making decisions regarding the granting or denying of clinical the granting or denying of clinical privileges.privileges.

161161

MS.06.01.07MS.06.01.07

4: 4: The hospital completes the credentialing and privileging decision process in a timely manner.

5: 5: The hospital’s privilege granting /denial criteria are consistently applied for each requesting practitioner.

6: 6: Decisions on membership and granting of privileges include criteria that are directly related to the quality of health care, treatment, and services.

162162

MS.06.01.07MS.06.01.07

7: 7: 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.

163163

MS.06.01.07MS.06.01.07

8: 8: The governing body or delegated governing body committee has final authority for granting, renewing, or denying privileges.

9: 9: Privileges are granted for a period not to exceed two years.

164164

MS.06.01.09MS.06.01.09

The decision to grant, limit, or deny an initially requested privilege or an existing privilege petitioned for renewal is communicated to the requesting practitioner within the time frame specified in the medical staff bylaws.

165165

MS.06.01.09MS.06.01.09

1: 1: Requesting practitioners are notified regarding the granting decision.

2: 2: In the case of privilege denial, the applicant is informed of the reason for denial.

3: 3: The decision to grant, deny, revise, or revoke privilege(s) is disseminated and made available to all appropriate internal and external persons or entities, as defined by the hospital and applicable law.

166166

MS.06.01.09MS.06.01.09

4: 4: The process to disseminate all granting, modification, or restriction decisions is approved by the organized medical staff.

5: 5: The hospital makes the practitioner aware of available due process or, when applicable, the option to implement the Fair Hearing and Appeal Process for Adverse Privileging Decisions.

167167

MS.06.01.11MS.06.01.11

An expedited governing body approval process may be used for initial appointment and reappointment to the medical staff and for granting privileges when criteria for that process are met.

168168

MS.06.01.11MS.06.01.11

1: 1: The organized medical staff develops criteria for an expedited process for granting privileges. (two voting members)2: The criteria provide that an applicant for privileges is ineligible for the expedited process if any of the following has occurred:- The applicant submits an incomplete application.- The medical staff executive committee makes a final recommendation that is adverse or has limitations.

169169

MS.06.01.11MS.06.01.11

Ineligible if:Ineligible if:

3: 3: There is a current challenge or a previously successful challenge to licensure or registration.

4: The following situations are evaluated on a case-by-case basis and usually result in ineligibility for the expedited process: The applicant has received an involuntary termination of medical staff membership at another hospital.

170170

MS.06.01.11MS.06.01.11

Ineligible if:Ineligible if:5: 5: The applicant has received involuntary limitation, reduction, denial, or loss of clinical privileges.6: The hospital determines that there has been either an unusual pattern of, or an excessive number of, professional liability actions resulting in a final judgment against the applicant.

171171

MS.06.01.11MS.06.01.11

7: 7: The organized medical staff uses the criteria developed for the expedited process when recommending privileges.

172172

MS.06.01.13MS.06.01.13

Under certain circumstances, temporary clinical privileges may be granted for a limited period of time.

1: 1: Temporary privileges are granted to meet an important patient care need for the time period defined in the medical staff bylaws.

173173

MS.06.01.13MS.06.01.13

2: 2: When temporary privileges are granted to meet an important care need, the organized medical staff verifies current licensure and current competence.

174174

MS.06.01.13MS.06.01.13

3: 3: Temporary privileges for new applicants may be granted while awaiting review and approval by the organized medical staff upon verification of the following:– Current licensure.– Relevant training or experience.– Current competence.

175175

MS.06.01.13MS.06.01.13

Verification (cont):Verification (cont):– Ability to perform the privileges requested.– Other criteria required by the organized medical staff

bylaws.– A query and evaluation of the National Practitioner

Data Bank (NPDB) information.– A complete application.– No current or previously successful challenge to

licensure or registration.– No subjection to involuntary termination of medical

staff membership at another organization.– No subjection to involuntary limitation, reduction,

denial, or loss of clinical privileges.

176176

MS.06.01.13MS.06.01.13

4: 4: All temporary privileges are granted by the chief executive officer or authorized designee.

5: 5: All temporary privileges are granted on the recommendation of the medical staff president or authorized designee.

6: 6: Temporary privileges for new applicants are granted for no more than 120 days.

MS.07.01.01MS.07.01.01

1. Criteria for 1. Criteria for membershipmembership

2. Criteria reflect quality of care.2. Criteria reflect quality of care.

3. Appointment and reappointment do not 3. Appointment and reappointment do not exceed two years (730 days) (100%)exceed two years (730 days) (100%)

4. Non-discrimination4. Non-discrimination

5. Membership recommended by medical 5. Membership recommended by medical staff and approved by governing body.staff and approved by governing body.

177177

178178

TelemedicineTelemedicine

CMS REQUIREMENTSCMS REQUIREMENTS

DefinitionsDefinitions

Hospital: location where patient receives Hospital: location where patient receives telemedicine servicestelemedicine services

Distant Site: where the physician is Distant Site: where the physician is remotely who is providing servicesremotely who is providing services

Entity: a non-hospital providing locationEntity: a non-hospital providing location

179179

Governing BodyGoverning Body

(Hospital) Agreement to provide services (Hospital) Agreement to provide services with “distant site.”with “distant site.”

Governing body of “distant site” Governing body of “distant site” responsible for compliance in writing.responsible for compliance in writing.

(Hospital) May locally privilege using (Hospital) May locally privilege using documents provided by distant site.documents provided by distant site.

Distant site is a “contractor” for services.Distant site is a “contractor” for services.

180180

Governing BodyGoverning Body

Distant site provides these services in a Distant site provides these services in a manner that allows the hospital to be manner that allows the hospital to be compliant.compliant.

181181

Medical StaffMedical Staff

Medical staff may rely on credentialing and Medical staff may rely on credentialing and privileging decision of distant site (proxy).privileging decision of distant site (proxy).

1). Distant site must be medicare-1). Distant site must be medicare-participating hospital.participating hospital.

2). Privileged at distant site, and list 2). Privileged at distant site, and list provided to hospital.provided to hospital.

3). Individual holds license in state where 3). Individual holds license in state where patients are located.patients are located.

182182


4). Hospital performs internal review of 4). Hospital performs internal review of performance and sends to “distant site.”performance and sends to “distant site.”

5). Includes all adverse events and 5). Includes all adverse events and complaints.complaints.

183183


Requirements if the “distant site” is not a Requirements if the “distant site” is not a medicare participating hospital but is a non-medicare participating hospital but is a non-medicare participating “entity”.medicare participating “entity”.

•1. Agreement requires that the services be 1. Agreement requires that the services be furnished in a manner that permits the furnished in a manner that permits the hospital to be in compliance with CMS hospital to be in compliance with CMS requirements.requirements.

184184

Medical Staff: ENTITYMedical Staff: ENTITY

2). Distant entity credentialing and 2). Distant entity credentialing and privileging process meets CMS standards.privileging process meets CMS standards.

3). Distant entity providers privilege 3). Distant entity providers privilege list/delineations.list/delineations.

4). Holds license in state where patient 4). Holds license in state where patient located.located.

5). Hospital sends performance review to 5). Hospital sends performance review to distant entity.distant entity.

185185

Medical Staff: ENTITYMedical Staff: ENTITY

6). Criteria for privileging established.6). Criteria for privileging established.

186186

Critical Access HospitalsCritical Access Hospitals

Requires distant site to have:Requires distant site to have:

1). Medical staff structure that complies 1). Medical staff structure that complies with CMS medical staff requirements.with CMS medical staff requirements.

All other structures are same as for All other structures are same as for hospitals.hospitals.

187187

Critical Access HospitalsCritical Access Hospitals

1). Quality and appropriateness of the 1). Quality and appropriateness of the diagnosis and treatment reviewed by:diagnosis and treatment reviewed by:– One hospital in the networkOne hospital in the network– One QIOOne QIO– One qualified entity defined by state rural One qualified entity defined by state rural

health planhealth plan– Written agreement with hospitalWritten agreement with hospital

188188

189189

Disaster PrivilegesDisaster Privileges

Moved to the new Emergency Moved to the new Emergency Management chapter. Process consistent Management chapter. Process consistent for all volunteer providers: LIPs, and NON-for all volunteer providers: LIPs, and NON-LIPsLIPs

190190

QUESTIONSQUESTIONS

Q&AQ&A

191191

REFERENCE DOCUMENTSREFERENCE DOCUMENTS

192192

Ongoing Physician Ongoing Physician Performance Performance

Components of a compliant Components of a compliant processprocess

193193

CMSCMS

CMS requires that physician CMS requires that physician performance plans be defined in performance plans be defined in writing. This is scored as part of writing. This is scored as part of quality and not credentialing or quality and not credentialing or privileging.privileging.

194194

BasicsBasics

Indicators must be established Indicators must be established that are appropriate to each that are appropriate to each physician. Generally this is physician. Generally this is specialty based.specialty based.

Components to be included are Components to be included are delineated in MS.05.01.01 and delineated in MS.05.01.01 and MS.05.03.01MS.05.03.01

195195

Indicator DevelopmentIndicator Development

Must originate at the department levelMust originate at the department level

Must be approved by department Must be approved by department chairmanchairman

Must be approved by MECMust be approved by MEC

Must be approved by Governing bodyMust be approved by Governing body

196196


Many of appropriate indicators are Many of appropriate indicators are already being measured within the already being measured within the hospital:hospital:– Core measures (internal medicine)Core measures (internal medicine)

– SCIP measures (procedural specialties)SCIP measures (procedural specialties)

– Traditional review (LOS, denials)Traditional review (LOS, denials)

– Medical recordsMedical records

197197


Some measures have been part of Some measures have been part of generic screens:generic screens:– Returns to the operating roomReturns to the operating room

– Returns to the emergency roomReturns to the emergency room

– Surgical site wound infectionsSurgical site wound infections

– Critical eventsCritical events

198198


Some indicators are antiquated:Some indicators are antiquated:

– C-Section rateC-Section rate

– Appropriateness of AppendectomiesAppropriateness of Appendectomies

199199


Commonly used indicators:Commonly used indicators:–ASA Indicator set:ASA Indicator set:

Prolonged recovery for anesthesiaProlonged recovery for anesthesia

Failed regional anesthesiaFailed regional anesthesia

HypotensionHypotension

HypoxiaHypoxia

Difficult intubationDifficult intubation

200200


Obstetrics:Obstetrics:– Fetal age at C-Section deliveryFetal age at C-Section delivery

– 33rdrd and 4 and 4thth degree lacerations for degree lacerations for delivery (morbidity)delivery (morbidity)

– Appropriate management of labor (as Appropriate management of labor (as defined)defined)

– Use of analgesiaUse of analgesia

201201


Radiology:Radiology:– ““Over-readsOver-reads”” for diagnostic imaging for diagnostic imaging

– Appropriateness and outcomes from Appropriateness and outcomes from invasive radiology proceduresinvasive radiology procedures

202202


Surgical Specialties:Surgical Specialties:– Appropriateness of selected procedures Appropriateness of selected procedures

(high risk, problem-prone)(high risk, problem-prone)

– Outcomes:Outcomes:Surgical site wound infectionSurgical site wound infection

Other post-operative morbidityOther post-operative morbidity

MortalityMortality

203203


Psychiatry:Psychiatry:– Multi-drug therapyMulti-drug therapy

– Restraint needRestraint need

– Recidivism rateRecidivism rate

– Appropriateness of evaluationsAppropriateness of evaluations

204204

Data UseData Use

The periodicity of data collection must The periodicity of data collection must be defined, and the method of be defined, and the method of collecting data defined:collecting data defined:– Retrospective reviewRetrospective review

– Concurrent reviewConcurrent review

205205

Data UseData Use

Once the indicators are established Once the indicators are established and methodology developed for and methodology developed for collection of the data then the task of collection of the data then the task of analysis must occur.analysis must occur.

Data analysis: Conversion of all raw Data analysis: Conversion of all raw numbers to rate based performance.numbers to rate based performance.

Incumbent on having good Incumbent on having good denominator data.denominator data.

206206

Data UseData Use

Some data may be available on an Some data may be available on an aggregate basis, but not at a aggregate basis, but not at a practitioner specific level:practitioner specific level:– Core Measure dataCore Measure data

– SCIP dataSCIP data

– Other PI dataOther PI data

207207

Data UseData Use

Once the rate based data is collected on Once the rate based data is collected on an individual basis, it must be compared to an individual basis, it must be compared to ““peerpeer”” or departmental performance. or departmental performance.

The comparison must be analytical, and The comparison must be analytical, and indicate if sub-par performance is a simple indicate if sub-par performance is a simple data variant, or truly statistically significant.data variant, or truly statistically significant.

Tools will be required for this analysis.Tools will be required for this analysis.

208208

Data UseData Use

Once the organization has the ability Once the organization has the ability to define, collect, and analyze the to define, collect, and analyze the data, then the periodicity of review data, then the periodicity of review must be determined.must be determined.

Ongoing performance monitoring has Ongoing performance monitoring has been stated by TJC to be at an been stated by TJC to be at an interval not greater than every 6-9 interval not greater than every 6-9 months.months.

209209

Data UseData Use

Now that data collection and analysis Now that data collection and analysis is ongoing, it should be easy to is ongoing, it should be easy to establish a comprehensive physician establish a comprehensive physician based reappointment profile for based reappointment profile for reappointment.reappointment.

Performance data must then go to the Performance data must then go to the board for their consideration when board for their consideration when reappointments are being granted.reappointments are being granted.

210210

Data UseData Use

What will go to board?What will go to board?–Normal data?Normal data?

–Variant data?Variant data?

–Who will present this to board with Who will present this to board with credentials file?credentials file?

211211

20102010

What determines What determines ““passpass”” or or ““failfail””??

How will further evaluation be How will further evaluation be conducted?conducted?

What will happen if the physician What will happen if the physician performance in a sub-optimal?performance in a sub-optimal?

How long will you wait to take action.How long will you wait to take action.

212212

IndicatorsIndicators

Some events should not be Some events should not be ““rated rated basedbased”” such as sentinel or critical such as sentinel or critical events. Even one is too many, such events. Even one is too many, such as as ““intra-operative anesthesia death.intra-operative anesthesia death.””

These types of cases should be These types of cases should be defined as requiring immediate defined as requiring immediate ““focused review.focused review.””

213213

PlanPlan

Define indicatorsDefine indicators

Obtain department and leadership Obtain department and leadership approvalapproval

Formulate a Formulate a ““data inventorydata inventory”” and specify and specify methodology for data collectionmethodology for data collection

Establish reporting chain of commandEstablish reporting chain of command

Write the planWrite the plan

Define focused reviewDefine focused review

214214

PlanPlan

Define ongoing reviewDefine ongoing review

Establish a methodology to write Establish a methodology to write focused review plans for all new focused review plans for all new appointments to the medical staff. appointments to the medical staff.

Establish methodology for statistical Establish methodology for statistical analysis.analysis.

215215

ChallengesChallenges

Most data collection is manual. Extra staff Most data collection is manual. Extra staff will probably be required.will probably be required.

Data collection and analysis is not a job Data collection and analysis is not a job that is normally undertaken by the medical that is normally undertaken by the medical staff office, but usually originates from the staff office, but usually originates from the performance measurement department performance measurement department (quality).(quality).

Expertise must be acquired for analysis.Expertise must be acquired for analysis.

216216

FAIR HEARINGFAIR HEARING

Unchanged for 2010-2013Unchanged for 2010-2013

217217

MEDICAL STAFF MEDICAL STAFF STANDARDSSTANDARDS

DUPLICATIVE AFTER DUPLICATIVE AFTER MS.01.01.01 BECOMES MS.01.01.01 BECOMES

EFFECTIVEEFFECTIVE

218218

MS.09.01.01MS.09.01.01

The organized medical staff, pursuant to the medical staff bylaws, evaluates and acts upon reported concerns regarding a privileged practitioner’s clinical practice and/or competence.

STANDARD WILL BE RENDERED MOOT AFTER MS.01.01.01 BECOME EFFECTIVE

219219

MS.09.01.01MS.09.01.01

1: 1: The hospital, based on recommendations by the organized medical staff and approval by the governing body, has a clearly defined process for collecting, investigating, and addressing clinical practice concerns.

220220

MS.09.01.01MS.09.01.01

2: 2: Reported concerns regarding a privileged practitioner’s professional practice are uniformly investigated and addressed, as defined by the hospital and applicable law.

the joint commission medical staff standards and fppe/oppe compliance

Documents

adverse accreditation

medical staff role

coordination of care

performance ep

quality of care

situational decision

medical staff bylaws

pdadirect impact