Transcript Document

The Joint Commission
Medical Staff Standards
and FPPE/OPPE
Compliance
Stephen M. Dorman, M.D.
www.redandgold.com
1
2013 Scoring and
Accreditation Decision Model
2
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.
3
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 organization’s overall compliance with
a standard.
4
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
5
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.
6
2013 Scoring/Accreditation Decision Model Summary
SITUATION DECISION (2): PDA
DIRECT impact: (3): 45 days for ESC
INDIRECT impact: (4): 60 days for ESC
7
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.
8
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
9
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.
10
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
11
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)
12
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)
13
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)
14
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)
15
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)
16
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).
17
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)
18
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)
19
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)
20
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.
21
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)
22
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
23
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.
24
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.
25
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
26
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
27
LD.02.04.01
1: Ongoing process for conflict
management.
28
LD.04.01.05
CMS REQUIRED PHYSICIAN
DEPARTMENT DIRECTORS:
– Anesthesia
– Emergency Medicine Services
– Respiratory Care Service
– Radiology
– Nuclear Medicine
29
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)
30
LD.04.02.01
1. Define conflict of interest
2. Policy on conflict of interest
3. Disclosures of conflicts of interest.
31
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.
32
MS.01.01.01
What is required in the bylaws
and new Medical staff
communication processes
33
The doctors of medicine and
osteopathy and, in accordance with
medical staff bylaws, other
practitioners are organized into a selfgoverning medical staff that oversees
the quality of care provided by all
physicians and by other practitioners
who are privileged through a medical
staff process.
34
The organized medical staff and the
governing body collaborate in a wellfunctioning relationship, reflecting
clearly recognized roles,
responsibilities, and accountabilities, to
enhance the quality and safety of care,
treatment, and services provided to
patients.
35
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.
36
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.
37
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.
38
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.
39
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.
40
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.
41
MS.01.01.01
Medical staff bylaws address selfgovernance and accountability to
the governing body
Approved. Effective date: 3/31/2011
42
1: The organized medical staff develops
medical staff bylaws, rules and
regulations, and policies.
43
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.
44
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.
45
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.
46
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.
47
5: The medical staff complies with the
medical staff bylaws, rules and
regulations, and policies.
48
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.
49
7: The governing body upholds the
medical staff bylaws, rules and
regulations, and policies that have
been approved by the governing body.
50
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.
51
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.
52
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.
53
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.
54
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.
55
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 reprivileging licensed independent
practitioners, which may include the
process for privileging and re-privileging
other practitioners. (CMS CoP
requirement)
56
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.
57
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)
58
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.
59
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.
60
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.
61
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.
62
26: The process for credentialing and recredentialing licensed independent
practitioners, which may include the
process for credentialing and recredentialing other practitioners.
27: The process for appointment and reappointment to membership on the medical
staff.
28: Indications for automatic suspension of a
practitioner’s medical staff membership or
clinical privileges.
63
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.
64
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.
65
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.
66
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.
67
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.
68
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.
69
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.
70
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.
71
Thou Shalt Measure
Thou Shalt Analyze
Thou Shalt Take Action
The Joint Commissions New
Approach to Assessing
Physician Performance
72
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.
73
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.
74
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.
75
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.
76
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.
77
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).
78
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)
79
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.
80
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
81
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.
82
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
83
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
84
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)
85
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
86
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.
87
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)
88
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)
89
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.
90
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
91
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
92
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
93
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)
94
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
95
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)
96
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.
97
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.
98
The Standard: MS.05.01.03:
CITIZENSHIP
1: The organized medical staff participates
in the following activities: Education of
patients and families.
99
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.
100
The Standard: MS.05.01.03:
CITIZENSHIP
3: The organized medical staff participates
in the following activities: Accurate,
timely, and legible completion of
patient’s medical records.
101
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 individual’s
performance. The organized medical
staff is responsible for determining the
use of this information in the ongoing
evaluations of a practitioner’s
competence.
102
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.
103
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.
104
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 practitioner’s
professional practice. (D means there
must be a policy)
105
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).
106
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).
107
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.
108
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.
109
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.
110
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.
111
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.
112
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.
113
The Standard: MS.08.01.01
The organized medical staff defines the
circumstances requiring monitoring and
evaluation of a practitioner’s professional
performance.
- Initial Appointment (new privileges)
- New mid-cycle privilege
- Trigger events
- Variant data
114
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).
115
The Standard: MS.08.01.01
Relevant information resulting from the
focused evaluation process is integrated
into performance improvement activities,
consistent with the organization’s policies
and procedures that are intended to
preserve confidentiality and privilege of
information.
116
The Standard: MS.08.01.01
1: A period of focused professional
practice evaluation is implemented for all
initially requested privileges.
117
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)
118
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
119
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.
120
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.
121
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 practitioner’s 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.
122
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).
123
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).
124
The Standard: MS.08.01.01
9: The measures employed to resolve
performance issues are consistently
implemented.
125
NEW CMS REQUIREMENTS
RADIOLOGY
ANESTHESIA
126
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.
127
RADIOLOGY
Training of all providers who operate
radiology equipment: physicians using CArm, Fluoroscopy.
Supervision of all ionizing radiology
services by director. Best done through
radiation safety committee.
128
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
129
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.
130
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.
131
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
132
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
133
MEC FUNCTION
134
MS.02.01.01
7: Requests evaluation of practitioner
when doubt about applicant’s ability to
perform privileges (focused review)
135
MS.02.01.01
11: Recommends to governing body:
delineation of privileges (no delegation)
12: Receives/acts on reports by
committees, departments, groups.
136
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%)
137
MS.03.01.01
4: Leadership in patient safety
5: Oversight of process of analyzing and
improving patient satisfaction
6: Minimal content of H&Ps defined
7: MS monitors quality of H&Ps
8: Privileged provider performs H&Ps
9: Others as allowed by laws may perform
H&Ps, under a specified physician
138
MS.03.01.01
10: Define when H&P must be validated or
countersigned
11: Defines scope of H&P when required
for non-inpatient services
139
MS.03.01.03
The management and coordination of
each patient’s care, treatment, or services
is the responsibility of a practitioner with
appropriate privileges
1: LIP with privileges manage and
coordinate patient’s care, treatment and
services.
2: Hospital educates all LIPs on assessing
and managing pain.
140
MS.03.01.03
3: Patient’s 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
141
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.
142
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
143
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
144
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.
145
MS.06.01.03
The [organization] collects information
regarding each practitioner’s current
license status, training, experience,
competence, and ability to perform the
requested privilege.
146
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.
147
MS.06.01.03
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.
148
MS.06.01.05
The decision to grant or deny a
privilege(s), and/or to renew an existing
privilege(s), is an objective, evidencedbased process.
149
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)
150
MS.06.01.05
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.
151
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
152
MS.06.01.05
6: Applicant submits health statement.
7: Hospital queries NPDB at initial
privileges, renewal of privileges, and when
new privileges requested.
153
MS.06.01.05
8: Peer Recommendation includes:
– Medical/Clinical knowledge.
– Technical and clinical skills.
– Clinical judgment.
– Interpersonal skills.
– Communication skills.
– Professionalism.
154
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 applicant’s health status.
– Relevant practitioner-specific data as compared to aggregate
data, when available.
– Morbidity and mortality data, when available.
155
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.
156
MS.06.01.05
12: Information regarding each
practitioner’s scope of privileges is
updated as changes in clinical privileges
for each practitioner are made.
157
MS.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.
158
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.
159
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.
160
MS.06.01.07
4: The hospital completes the credentialing and
privileging decision process in a timely manner.
5: The hospital’s 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.
161
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.
162
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.
163
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.
164
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.
165
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.
166
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.
167
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.
168
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.
169
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.
170
MS.06.01.11
7: The organized medical staff uses the
criteria developed for the expedited
process when recommending privileges.
171
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.
172
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.
173
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.
174
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.
175
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.
176
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.
177
Telemedicine
CMS REQUIREMENTS
178
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
179
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.
180
Governing Body
Distant site provides these services in a
manner that allows the hospital to be
compliant.
181
Medical Staff
Medical staff may rely on credentialing and
privileging decision of distant site (proxy).
1). Distant site must be medicareparticipating hospital.
2). Privileged at distant site, and list
provided to hospital.
3). Individual holds license in state where
patients are located.
182
Medical Staff
4). Hospital performs internal review of
performance and sends to “distant site.”
5). Includes all adverse events and
complaints.
183
Medical Staff
Requirements if the “distant site” is not a
medicare participating hospital but is a nonmedicare participating “entity”.
•1. Agreement requires that the services be
furnished in a manner that permits the
hospital to be in compliance with CMS
requirements.
184
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.
185
Medical Staff: ENTITY
6). Criteria for privileging established.
186
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.
187
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
188
Disaster Privileges
Moved to the new Emergency
Management chapter. Process consistent
for all volunteer providers: LIPs, and NONLIPs
189
QUESTIONS
Q&A
190
REFERENCE DOCUMENTS
191
Ongoing Physician
Performance
Components of a compliant
process
192
CMS
CMS requires that physician
performance plans be defined in
writing. This is scored as part of
quality and not credentialing or
privileging.
193
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
194
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
195
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
196
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
197
Indicator Development
Some indicators are antiquated:
– C-Section rate
– Appropriateness of Appendectomies
198
Indicator Development
Commonly used indicators:
–ASA Indicator set:
Prolonged recovery for anesthesia
Failed regional anesthesia
Hypotension
Hypoxia
Difficult intubation
199
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
200
Indicator Development
Radiology:
– “Over-reads” for diagnostic imaging
– Appropriateness and outcomes from
invasive radiology procedures
201
Indicator Development
Surgical Specialties:
– Appropriateness of selected procedures
(high risk, problem-prone)
– Outcomes:
Surgical site wound infection
Other post-operative morbidity
Mortality
202
Indicator Development
Psychiatry:
– Multi-drug therapy
– Restraint need
– Recidivism rate
– Appropriateness of evaluations
203
Data Use
The periodicity of data collection must
be defined, and the method of
collecting data defined:
– Retrospective review
– Concurrent review
204
Data Use
Once the indicators are established
and methodology developed for
collection of the data then the task of
analysis must occur.
Data analysis: Conversion of all raw
numbers to rate based performance.
Incumbent on having good
denominator data.
205
Data Use
Some data may be available on an
aggregate basis, but not at a
practitioner specific level:
– Core Measure data
– SCIP data
– Other PI data
206
Data Use
Once the rate based data is collected on
an individual basis, it must be compared to
“peer” or departmental performance.
The comparison must be analytical, and
indicate if sub-par performance is a simple
data variant, or truly statistically significant.
Tools will be required for this analysis.
207
Data Use
Once the organization has the ability
to define, collect, and analyze the
data, then the periodicity of review
must be determined.
Ongoing performance monitoring has
been stated by TJC to be at an
interval not greater than every 6-9
months.
208
Data Use
Now that data collection and analysis
is ongoing, it should be easy to
establish a comprehensive physician
based reappointment profile for
reappointment.
Performance data must then go to the
board for their consideration when
reappointments are being granted.
209
Data Use
What will go to board?
–Normal data?
–Variant data?
–Who will present this to board with
credentials file?
210
2010
What determines “pass” or “fail”?
How will further evaluation be
conducted?
What will happen if the physician
performance in a sub-optimal?
How long will you wait to take action.
211
Indicators
Some events should not be “rated
based” such as sentinel or critical
events. Even one is too many, such
as “intra-operative anesthesia
death.”
These types of cases should be
defined as requiring immediate
“focused review.”
212
Plan
Define indicators
Obtain department and leadership
approval
Formulate a “data inventory” and specify
methodology for data collection
Establish reporting chain of command
Write the plan
Define focused review
213
Plan
Define ongoing review
Establish a methodology to write
focused review plans for all new
appointments to the medical staff.
Establish methodology for statistical
analysis.
214
Challenges
Most data collection is manual. Extra staff
will probably be required.
Data collection and analysis is not a job
that is normally undertaken by the medical
staff office, but usually originates from the
performance measurement department
(quality).
Expertise must be acquired for analysis.
215
FAIR HEARING
Unchanged for 2010-2013
216
MEDICAL STAFF
STANDARDS
DUPLICATIVE AFTER
MS.01.01.01 BECOMES
EFFECTIVE
217
MS.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
218
MS.09.01.01
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.
219
MS.09.01.01
2: Reported concerns regarding a
privileged practitioner’s professional
practice are uniformly investigated and
addressed, as defined by the hospital and
applicable law.
220