The Joint Commission Medical Staff Standards and FPPE/OPPE Compliance

1
The Joint Commission Medical Staff Standards and
FPPE/OPPE Compliance

• Stephen M. Dorman, M.D.
• www.redandgold.com

2
2013 Scoring andAccreditation Decision Model
3
Standard

• 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.

4
Element 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
  organizations overall compliance with a
  standard.

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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

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2013 Scoring/Accreditation Decision Model
-Summary

• 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.

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2013 Scoring/Accreditation Decision Model
-Summary

• SITUATION DECISION (2) PDA
• DIRECT impact (3) 45 days for ESC
• INDIRECT impact (4) 60 days for ESC

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2013 Scoring/Accreditation Decision Model
-Summary

• If partial compliance or insufficient compliance
  is not resolved, a progressively more adverse
  accreditation decision may result
• Provisional, Contingent, Preliminary Denial of
  Accreditation.

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2013 Scoring/Accreditation Decision Model

• Accreditation Follow Up Survey
• If any element of performance is cited twice in
  subsequent surveys, a 45 day follow up survey
  will occur AFS 02
• Affects both direct and indirect findings

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2013 Scoring/Accreditation Decision Model
-Summary

• Critical Levels
• Immediate threat to life no a single standard,
  but condition (APR)
• Falsification (APR)
• Situational Decision Rule immediate
  recommendation of Denial of Accreditation or
  Contingent accreditation alone.

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2013 Scoring/Accreditation Decision Model
-Summary

• DIRECT impact standard Sedation
• INDIRECT impact standard Policies
• Labels on standards
• (D) Documentation required
• (2) Situational Decision Rule
• (3) Direct Impact Requirements
• (4) Indirect Impact Requirements

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MS 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)

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MS Chapter Outline

• 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)

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MS Chapter Outline

• 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)

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MS Chapter Outline

• 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)

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MS Chapter Outline

• 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)

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MS Chapter Outline

• 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).

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MS Chapter Outline

• 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)

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MS Chapter Outline

• 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)

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MS Chapter Outline

• 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)

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LEADERSHIP

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

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LD.01.02.01

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

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LD.01.05.01 (A/4)

• 1 NO EP
• 2 Self-governing
• 3 Conforms to guiding principles
• 4 Governing body approves structure
• 5 Medical staff oversees quality care provided
  by individuals with clinical privileges
• 6 Accountable to governing body

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LD.01.05.01

• 7 MD/DO/Dentist/Podiatrist responsible for the
  organization and conduct of the medical staff.
• 8 There is a SINGLE organized medical staff.

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LD.01.07.01

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

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LD.01.07.01

• 2 leaders of the organized medical staff are
  oriented to
• Mission/Values
• Safety and Quality goals
• Structure and decision making process
• Budget
• Population served
• Responsibility
• Law and Regulation

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LD.02.02.01

• 1. Define conflict of interest.
• 2. Policy on management of conflict of interest.
• 3. Obtain disclosures of conflicts of interest.
• This standard applies to LEADERSHIP

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LD.02.04.01

• 1 Ongoing process for conflict management.

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LD.04.01.05

• CMS REQUIRED PHYSICIAN DEPARTMENT DIRECTORS
• Anesthesia
• Emergency Medicine Services
• Respiratory Care Service
• Radiology
• Nuclear Medicine

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LD.04.01.05

• 6 Emergency services are directed and
  supervised by a qualified member of the medical
  staff.
• 7 Physicians direct anesthesia, nuclear
  medicine, respiratory care.
• 9 Anesthesia responsible for ALL anesthesia
  services (ref. deep sedation)

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LD.04.02.01

• 1. Define conflict of interest
• 2. Policy on conflict of interest
• 3. Disclosures of conflicts of interest.

32
LD.04.03.09

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

33
MS.01.01.01

• What is required in the bylaws and new Medical
  staff communication processes

34
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.
35
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.
36
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.
37
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.
38
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.
39
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.
40
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.
41
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.
42
MS.01.01.01Medical staff bylaws address
self-governance and accountability to the
governing body
Approved. Effective date 3/31/2011
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1 The organized medical staff develops medical
staff bylaws, rules and regulations, and policies.
44
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.
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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.
46
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.
47
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.
48
5 The medical staff complies with the medical
staff bylaws, rules and regulations, and
policies.
49
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.
50
7 The governing body upholds the medical staff
bylaws, rules and regulations, and policies that
have been approved by the governing body.
51
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.
52
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.
53
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.
54
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.
55
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.
56
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)
57
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 terms meaning.
58
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)
59
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.
60
20 The medical executive committees 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 staffs
behalf and how such authority is delegated or
removed.
61
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.
62
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.
63
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 practitioners medical staff membership or
clinical privileges.
64
29 Indications for summary suspension of a
practitioners 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
practitioners medical staff membership or
clinical privileges.
65
32 The process for summary suspension of a
practitioners 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.
66
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 appeals The process for
conducting hearings and appeals 35 The
composition of the fair hearing committee.
67
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.
68
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.
69
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.
70
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.
71
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.
72
Thou Shalt MeasureThou Shalt AnalyzeThou Shalt
Take Action

• The Joint Commissions New Approach to Assessing
  Physician Performance

73
Why?

• Lack of previous success of physicians rigorously
  dealing with issues related to colleague
  performance.
• Lack of valid data when difficult decisions
  needed to be made related to physician
  performance.
• Threat of litigation real in light of lack of
  substantial performance documentation.

74
Why?

• Peer recommendations were essentially useless.
• Physicians would never provide objective
  references if they knew that substandard
  performance would be reported.
• Credentialing always focused on documents.
• NPDB only listed most serious issues.

75
Why?

• Databank reports were not timely.
• Physicians were allowed to resign when under the
  threat of or under actual investigation.
• Interruption of referral patterns.
• Interference with friendships.
• Accusations of financial motivations for
  competition.

76
Measurement Part I

• In the early 90s with the advent of performance
  improvement, a physician profile was to be
  maintained and used at reappointment every two
  years.
• Areas for measurement have not actually changed
  much since then.
• Compliance was spotty, but not often scored.

77
Measurement Part I

• Subject to surveyor variability.
• Many physician surveyors were not comfortable
  with the measurement standards and did not
  understand them.
• Most of the data collection at that time was
  manual.
• Profiles frequently indicated 0 for lack of
  quality issues despite poor performance.

78
Measurement Part II

• With a change in Joint Commission leadership, it
  because apparent that these standards were never
  scored and were essentially meaningless.
• Physician thinkers at the Joint Commission
  became instrumental in changing the approach (and
  some prodding by CMS).

79
Measurement Part II

• First things first render the current standards
  meaningful
• Implement physician performance measures that
  were rate based so that they could be compared
  with peer performance (early 2000).
• Comparisons were to be meaningful (meaning
  statistically analyzed)

80
Measurement Part II

• Profiles slowly became more meaningful
• Hospitals elected to participate in national
  measurement venues (Care Science, Premier Data,
  STS, ACC databases etc)
• Though data became available, still no action was
  taken on bad performance.

81
Measurement Part II

• There was a paralysis because of lack of
  benchmark data
• Hospitals did not understand that it was
  acceptable to compare performance to peer group
• External data was not available because of peer
  review protection
• Low volume providers were not measured

82
Measurement Part III

• It became apparent that even though suboptimal
  performance could be detected at the two year
  reappointment period, what was being done in
  advance of that date.
• It became too late to take action or the
  reappointment was due and had to be done with
  less than desirable performance data.

83
Measurement Part IV

• ONGOING REVIEW
• The time frame for the review of physician
  performance data was discussed at TJC
• To be ongoing, it was determined that every 2
  years was insufficient, and in fact, that every
  year was insufficient
• TJC stated that ongoing review should be
  conducted every 6-9 months unless trigger
  events had occurred

84
Measurement Part IV

• Ongoing review dependent on those performance
  measures that primarily depend on the performance
  of an individual provider
• These concepts apply not only to physicians, but
  also others who are credentialed and privileged

85
Measurement Part IV

• It also became apparent that privileges that were
  granted were not based on evidenced-based
  criteria or any other criteria for that matter
• Now the tie is between measured performance and
  privileges is clear
• No data no privileges
• No use of external data (see letter)

86
Measurement Part IV

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

87
The Standard MS.05.01.01 CLINICAL

• The organized medical staff has a leadership role
  in organization performance improvement
  activities to improve quality of care, treatment,
  and services and patient safety.
• Relevant information developed from the following
  processes is integrated into performance
  improvement initiatives and consistent with
  organization preservation of confidentiality
  and privilege of information.

88
The Standard MS.05.01.01

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

89
The Standard MS.05.01.01

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

90
The Standard MS.05.01.01

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

91
The Standard MS.05.01.01

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

92
The Standard MS.05.01.01

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

93
The Standard MS.05.01.01

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

94
The Standard MS.05.01.01

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

95
The Standard MS.05.01.01

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

96
The Standard MS.05.01.01

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

97
The Standard MS.05.01.01

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

98
The Standard MS.05.01.01

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

99
The Standard MS.05.01.03 CITIZENSHIP

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

100
The Standard MS.05.01.03 CITIZENSHIP

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

101
The Standard MS.05.01.03 CITIZENSHIP

• 3 The organized medical staff participates in
  the following activities Accurate, timely, and
  legible completion of patients medical records.

102
The Standard MS.05.01.03 CITIZENSHIP

• 4 The organized medical staff participates in
  the following activities Review of findings of
  the assessment process that are relevant to an
  individuals performance. The organized medical
  staff is responsible for determining the use of
  this information in the ongoing evaluations of a
  practitioners competence.

103
The Standard MS.05.01.03 CITIZENSHIP

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

104
The Standard MS.08.01.03

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

105
The Standard MS.08.01.03

• 1 The process for the ongoing professional
  practice evaluation includes the following There
  is a clearly defined process in place that
  facilitates the evaluation of each practitioners
  professional practice. (D means there must be a
  policy)

106
The Standard MS.08.01.03

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

107
The Standard MS.08.01.03

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

108
FOCUSED REVIEW

• While it was a good thing to evaluate providers
  after they had already been working 6 months, it
  was apparent that there was real risk in the
  unknown.
• Peer Recommendations could not be trusted.
• Harm could come to patients soon after practice
  began.

109
FOCUSED REVIEW

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

110
FOCUSED REVIEW

• It was clear that something was needed on the
  front end.
• Next it was determined that in classic peer
  review, cases simply fell off and issues were
  never closed or casually investigated. There was
  no accountability for closure of many significant
  issues.

111
FOCUSED REVIEW

• The purpose
• Initial assessment of competence of all new
  physicians or new privileges regardless of
  experience.
• Conduct intensive, planned and focused
  investigations when adverse events occurred
  (trigger events).
• Conduct intensive, planned and focused
  investigations when ongoing performance
  measurement indicated undesirable performance.

112
Focused Review New Privileges

• Goal To be conducted as rapidly as possible.
• Volume of review defined by the medical staff
  and departments.
• Individual plans should be developed to allow the
  medical staff to know when review has concluded.
• Each provider may warrant a tailored plan.
• Some departments are completely uniform.

113
Focused Review New Privileges

• Should be conducted in a time frame that is too
  short for rate based performance measurement
  data collection would not be statistically
  significant for short term.
• Evaluation of privilege must be realistic chart
  review versus direct observation.
• All requirements defined in a plan.
• TOP Medical Staff Standard RFI in 2009.

114
The Standard MS.08.01.01

• The organized medical staff defines the
  circumstances requiring monitoring and evaluation
  of a practitioners professional performance.
• - Initial Appointment (new privileges)
• - New mid-cycle privilege
• - Trigger events
• - Variant data

115
The Standard MS.08.01.01

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

116
The Standard MS.08.01.01

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

117
The Standard MS.08.01.01

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

118
The Standard MS.08.01.01

• 2 The 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. (D means Plan)

119
The Standard MS.08.01.01

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

120
The Standard MS.08.01.01

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

121
The Standard MS.08.01.01

• 5 The triggers that indicate the need for
  performance monitoring are clearly defined.
• Note Triggers can be single incidents or
  evidence of a clinical practice trend.

122
The Standard MS.08.01.01

• 6 The decision to assign a period of performance
  monitoring to further assess current competence
  is based on the evaluation of a practitioners
  current clinical competence, practice behavior,
  and ability to perform the requested privilege.
• Note Other existing privileges in good standing
  should not be affected by this decision.

123
The Standard MS.08.01.01

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

124
The Standard MS.08.01.01

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

125
The Standard MS.08.01.01

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

126
NEW CMS REQUIREMENTS

• RADIOLOGY
• ANESTHESIA

127
RADIOLOGY

• New CMS requirements for oversight of radiology.
• Policies and procedures must comply with
  nationally recognized standards ACR
• Physician supervision of all contrast
  administration (CT and MRI). ACR requires a
  radiologist.

128
RADIOLOGY

• Training of all providers who operate radiology
  equipment physicians using C-Arm, Fluoroscopy.
• Supervision of all ionizing radiology services by
  director. Best done through radiation safety
  committee.

129
ANESTHESIA

• 1 Director of Anesthesia Services
• 2 Deep Sedation now considered anesthesia and
  is referred to a Monitored Anesthesia Care.
• 3 MAC may only be administered only by an
  appropriate practitioner privileged by director
  of anesthesia services

130
ANESTHESIA

• 4 Director of anesthesia responsible for all
  anesthetics (general to local).
• 5 Director of anesthesia services sets policies
  for all anesthetic use.
• 6 Director of anesthesia services decides on how
  to privilege for moderate sedation.

131
ANESTHESIA

• 7 Epidurals administered by CRNAs do not require
  direct supervision unless they become an
  anesthetic.
• 8 Post-anesthesia note may be written from the
  time a patient can participate until discharge or
  48 hours whichever comes sooner.

132
ANESTHESIA

• Practical effects
• Nursing staff will not longer be able to
  administer anesthesia agents Etomidate,
  Ketamine, Pentothal, or Propofol because this is
  MAC.
• Anesthesia will have to privilege for MAC (deep
  sedation), and recommend privileging process for
  moderate sedation

133
Scoring

• All of the medical staff standards on these
  issues are A meaning 100 compliance is
  required.
• Focused Review 16 of hospitals cited.
• Ongoing Review 15 of hospitals cited.
• Problems with no or low volume providers
• Changes to privileges based to data

134
MEC FUNCTION
135
MS.02.01.01

• 7 Requests evaluation of practitioner when doubt
  about applicants ability to perform privileges
  (focused review)

136
MS.02.01.01

• 11 Recommends to governing body delineation of
  privileges (no delegation)
• 12 Receives/acts on reports by committees,
  departments, groups.

137
MS.03.01.01

• Medical staff oversees quality of care,
  treatments, or services provided by practitioners
  privileged through the medical staff process
• 2 Practitioners practices within scope of
  privileges (DIRECT IMPACT) (100)

138
MS.03.01.01

• 4 Leadership in patient safety
• 5 Oversight of process of analyzing and
  improving patient satisfaction
• 6 Minimal content of HPs defined
• 7 MS monitors quality of HPs
• 8 Privileged provider performs HPs
• 9 Others as allowed by laws may perform HPs,
  under a specified physician

139
MS.03.01.01

• 10 Define when HP must be validated or
  countersigned
• 11 Defines scope of HP when required for
  non-inpatient services

140
MS.03.01.03

• The management and coordination of each patients
  care, treatment, or services is the
  responsibility of a practitioner with appropriate
  privileges
• 1 LIP with privileges manage and coordinate
  patients care, treatment and services.
• 2 Hospital educates all LIPs on assessing and
  managing pain.

141
MS.03.01.03

• 3 Patients general medical condition managed by
  a doctor of medicine or osteopathy.
• 4 Circumstances warranting consultation
• 5 Consultations obtained when warranted
• 6 Coordination of care among practitioners

142
CMS COP Change

• Non-privileged providers as allowed by law may
  order outpatient care.
• Verification of their authority to order the care
  or treatment.
• Policy on which orders will be accepted and under
  what circumstances.
• Still requires for patient to be under the
  general medical care of a privileged provider.

143
MS.04.01.01

• Graduate Medical Education
• 1 Defined process for supervision
• 2 Written description of roles and
  responsibilities and patient care activities are
  provided to medical and hospital staff
• 3 Mechanisms about decisions about progressive
  involvement
• 4 Define who may write orders and requirements
  for countersignature

144
MS.04.01.01

• 5 Communication between committee overseeing GME
  and hospital medical staff and governing body
• 6 GME communicates about safety and quality of
  care, supervisory need to MEC and governing body
• 7 Communicate from local hospital to GMEC

145
MS.04.01.01

• 8 Quality of care, treatment, services
  educational need to governing body of sponsoring
  hospital
• 9 Compliance with residency review committee
  citations.

146
MS.06.01.03

• The organization collects information regarding
  each practitioners current license status,
  training, experience, competence, and ability to
  perform the requested privilege.

147
MS.06.01.03

• 1 Clearly defined process
• 2 Process based on recommendations by medical
  staff
• 3 Process approved by governing body
• 4 Outlined in bylaws
• 5 Verify that the REQUESTING individual be
  identified by VIEWING official ID.

148
MS.06.01.03

• 6 Primary Source verification of
• The applicants current licensure at time of
  initial granting, renewal, and revision of
  privileges, and at the time of license
  expiration.
• The applicants relevant training.
• The applicants current competence.

149
MS.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.

150
MS.06.01.05

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

151
MS.06.01.05

• 2 Criteria based privileges include
• Current licensure and/or certification, as
  appropriate, verified with the primary source.
• The applicants 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
  practitioners performance within the hospital.

152
MS.06.01.05

• 3 All of the criteria used are consistently
  evaluated for all practitioners holding that
  privilege
• 4 Process defined for granting, renewing,
  revising privileges
• 5 Process is approved by medical staff

153
MS.06.01.05

• 6 Applicant submits health statement.
• 7 Hospital queries NPDB at initial privileges,
  renewal of privileges, and when new privileges
  requested.

154
MS.06.01.05

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

155
MS.06.01.05

• 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 applicants health
  status.
• Relevant practitioner-specific data as compared
  to aggregate data, when available.
• Morbidity and mortality data, when available.

156
MS.06.01.05

• 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.

157
MS.06.01.05

• 12 Information regarding each practitioners
  scope of privileges is updated as changes in
  clinical privileges for each practitioner are
  made.

158
MS.06.01.07

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

159
MS.06.01.07

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

160
MS.06.01.07

• NEW EP July 2010
• 3 Gender, race, and national origin are not used
  in making decisions regarding the granting or
  denying of clinical privileges.

161
MS.06.01.07

• 4 The hospital completes the credentialing and
  privileging decision process in a timely manner.
• 5 The hospitals privilege granting /denial
  criteria are consistently applied for each
  requesting practitioner.
• 6 Decisions on membership and granting of
  privileges include criteria that are directly
  related to the quality of health care, treatment,
  and services.

162
MS.06.01.07

• 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.

163
MS.06.01.07

• 8 The governing body or delegated governing body
  committee has final authority for granting,
  renewing, or denying privileges.
• 9 Privileges are granted for a period not to
  exceed two years.

164
MS.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.

165
MS.06.01.09

• 1 Requesting practitioners are notified
  regarding the granting decision.
• 2 In the case of privilege denial, the applicant
  is informed of the reason for denial.
• 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.

166
MS.06.01.09

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

167
MS.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.

168
MS.06.01.11

• 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.

169
MS.06.01.11

• Ineligible if
• 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.

170
MS.06.01.11

• Ineligible if
• 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.

171
MS.06.01.11

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

172
MS.06.01.13

• Under certain circumstances, temporary clinical
  privileges may be granted for a limited period of
  time.
• 1 Temporary privileges are granted to meet an
  important patient care need for the time period
  defined in the medical staff bylaws.

173
MS.06.01.13

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

174
MS.06.01.13

• 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.

175
MS.06.01.13

• 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.

176
MS.06.01.13

• 4 All temporary privileges are granted by the
  chief executive officer or authorized designee.
• 5 All temporary privileges are granted on the
  recommendation of the medical staff president or
  authorized designee.
• 6 Temporary privileges for new applicants are
  granted for no more than 120 days.

177
MS.07.01.01

• 1. Criteria for membership
• 2. Criteria reflect quality of care.
• 3. Appointment and reappointment do not exceed
  two years (730 days) (100)
• 4. Non-discrimination
• 5. Membership recommended by medical staff and
  approved by governing body.

178
Telemedicine

• CMS REQUIREMENTS

179
Definitions

• Hospital location where patient receives
  telemedicine services
• Distant Site where the physician is remotely
  who is providing services
• Entity a non-hospital providing location

180
Governing Body

• (Hospital) Agreement to provide services with
  distant site.
• Governing body of distant site responsible for
  compliance in writing.
• (Hospital) May locally privilege using documents
  provided by distant site.
• Distant site is a contractor for services.

181
Governing Body

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

182
Medical Staff

• Medical staff may rely on credentialing and
  privileging decision of distant site (proxy).
• 1). Distant site must be medicare-participating
  hospital.
• 2). Privileged at distant site, and list
  provided to hospital.
• 3). Individual holds license in state where
  patients are located.

183
Medical Staff

• 4). Hospital performs internal review of
  performance and sends to distant site.
• 5). Includes all adverse events and complaints.

184
Medical Staff

• Requirements if the distant site is not a
  medicare participating hospital but is a
  non-medicare participating entity.
• 1. Agreement requires that the services be
  furnished in a manner that permits the hospital
  to be in compliance with CMS requirements.

185
Medical Staff ENTITY

• 2). Distant entity credentialing and privileging
  process meets CMS standards.
• 3). Distant entity providers privilege
  list/delineations.
• 4). Holds license in state where patient located.
• 5). Hospital sends performance review to distant
  entity.

186
Medical Staff ENTITY

• 6). Criteria for privileging established.

187
Critical Access Hospitals

• Requires distant site to have
• 1). Medical staff structure that complies with
  CMS medical staff requirements.
• All other structures are same as for hospitals.

188
Critical Access Hospitals

• 1). Quality and appropriateness of the diagnosis
  and treatment reviewed by
• One hospital in the network
• One QIO
• One qualified entity defined by state rural
  health plan
• Written agreement with hospital

189
Disaster Privileges

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

190
QUESTIONS

• QA

191
REFERENCE DOCUMENTS
192
Ongoing Physician Performance

• Components of a compliant process

193
CMS

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

194
Basics

• Indicators must be established that are
  appropriate to each physician. Generally this is
  specialty based.
• Components to be included are delineated in
  MS.05.01.01 and MS.05.03.01

195
Indicator Development

• Must originate at the department level
• Must be approved by department chairman
• Must be approved by MEC
• Must be approved by Governing body

196
Indicator Development

• Many of appropriate indicators are already being
  measured within the hospital
• Core measures (internal medicine)
• SCIP measures (procedural specialties)
• Traditional review (LOS, denials)
• Medical records

197
Indicator Development

• Some measures have been part of generic screens
• Returns to the operating room
• Returns to the emergency room
• Surgical site wound infections
• Critical events

198
Indicator Development

• Some indicators are antiquated
• C-Section rate
• Appropriateness of Appendectomies

199
Indicator Development

• Commonly used indicators
• ASA Indicator set
• Prolonged recovery for anesthesia
• Failed regional anesthesia
• Hypotension
• Hypoxia
• Difficult intubation

200
Indicator Development

• Obstetrics
• Fetal age at C-Section delivery
• 3rd and 4th degree lacerations for delivery
  (morbidity)
• Appropriate management of labor (as defined)
• Use of analgesia

201
Indicator Development

• Radiology
• Over-reads for diagnostic imaging
• Appropriateness and outcomes from invasive
  radiology procedures