Transcript Slide 1

2015 HFAP Standards
CMS Final Rule –
Burden Reduction II
May 2014
Karen Beem, MS, RN
HFAP Standards Interpretation
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01.00.33 Governing Body Periodically
Consults with Medical Staff (NEW)
The governing body must consult directly with the individual
assigned the responsibility for the organization and conduct of
the hospital’s medical staff, or designee.
1. To discuss matters related to the quality of medical care
provided to patients of the hospital
2. Twice per year with minutes to memorialize discussions
3. Face-to-face or via telecommunications
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01.00.33 Governing Body Periodically Consults with
the Medical Staff
• Does not preclude having a physician as member of the governing
body
• However; physician membership on the governing body is not
sufficient to satisfy the requirement for periodic consultation.
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03.00.01 Eligibility and Process
for Appointment to Medical Staff
1.
All practitioners who require privileges to furnish care to hospital
patients must be evaluated under the hospital’s medical staff
privileging system before the hospital’s governing body may grant
them privileges.
2.
All practitioners granted hospital privileges must function under the
bylaws, regulations and rules of the hospital’s medical staff.
3. The privileges granted to an individual practitioner must be
consistent with State scope-of-practice laws.
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03.00.01 Eligibility and Process for Appointment to
the Medical Staff
Non-physician Practitioners:
• Physician assistant
• Nurse practitioner
• Clinical nurse specialist
• Certified registered nurse anesthetist
• Certified nurse-midwife
• Clinical social worker
• Clinical psychologist
• Anesthesia Assistant
• Registered dietician or nutrition professional
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03.00.01 Eligibility and Process for Appointment to
the Medical Staff
Other types of licensed healthcare professionals with a more
limited scope of practice and USUALLY not eligible for privileges
unless permitted by State Scope of Practice:
• Physical Therapist
• Occupational Therapist
• Speech Language Therapist
• Some States:
 Licensed pharmacists are permitted to provide ordering medications
and laboratory tests
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03.00.06 Recommendation for Appointment to
Governance
Standard: Enforcement
• The medical staff must enforce its medical staff requirements
and take appropriate actions when individual members or
other practitioners with privileges do not adhere to the
medical staff’s bylaws, regulations, or rules.
Standard: Protection and Due Process Rights
• It must likewise afford all members/ practitioners who hold
privileges the protections and due process rights provided for
in the bylaws, rules and regulations.
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Multiple-Hospital Systems
Multiple-Hospital Systems:
• Each hospital has a separate CMS Agreement and CCN
• Hospitals have the option of a unified integrated medical staff.
The following apply to hospitals with a unified medical staff:
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03.00.11
03.00.12
03.00.13
03.00.14
03.00.15
Unified and Integrated Medical Staff
Voting Requirements
Bylaws of the Unified Medical Staff
Unique Circumstances of the hospitals
Policies of the Unified Medical Staff
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03.00.11 Multiple-Hospital Systems:
Unified and Integrated Medical Staff (NEW)
When granting practitioners privileges the governing body must:
1. Specify the hospital(s) in the system where the privileges
apply
2. Consider the services provided at each hospital when
granting privileges.
– Would be inappropriate to grant neurosurgical privileges if a hospital
has no neurosurgical services
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03.00.12 Multiple-Hospital Systems:
Voting Requirements for Separately Certified Hospitals
Standard:
The medical staff members of each separately certified hospital
in the system have voted by majority, in accordance with medical
staff bylaws, either:
a) To accept a unified and integrated medical staff structure,
or
a) To opt out of such a structure and to maintain a separate and
distinct medical staff for their respective hospital;
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03.00.12 Multiple-Hospital Systems:
Voting Requirements for Separately Certified Hospitals
If a unified medical staff, the Medical Staff Bylaws address:
1. Processes for voting to accept /opt out of a unified medical staff
2. Whether the decision for acceptance or to opt-out is determined
by “majority” vs “supermajority”
3. How a vote can be requested
4. Whether all categories of members holding privileges to practice
on-site at the hospital are afforded voting rights
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03.00.12 Multiple-Hospital Systems:
Voting Requirements for Separately Certified Hospitals
The Bylaws address (continued):
5. Whether voting will be in writing and open or by secret ballot
6. Minimum interval between votes to accept or opt-out, e.g., once
every two years
7. If a majority of a hospital’s medical staff voted to use a unified
medical staff in the past, the members of the unified medical staff
with voting rights and holding privileges to practice onsite at that
hospital still retain the right to hold a vote to opt-out at a future
date.
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03.00.12 Multiple-Hospital Systems:
Voting Requirements for Separately Certified Hospitals
A hospital may NOT:
1. Set up bylaws that unduly restrict the rights of medical staff
members when voting on the issue of accepting or opting
out of a unified medical staff structure
2. Establish different criteria as to which categories of medical
staff members have voting rights with respect to a vote to
accept or opt out of a unified medical staff than are used for
other amendments to the medical staff’s bylaws
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03.00.13 Multiple-Hospital Systems: Bylaws of
the Unified Medical Staff (NEW)
Standard: If a unified medical staff,
The unified and integrated medical staff has bylaws, rules, and requirements
that describe its processes for:
• Self-governance
• Appointment
• Credentialing and privileging
• Oversight
• Peer review policies and due process rights guarantees, and include a
process for the members of the medical staff of each separately certified
hospital to be advised of their rights to opt out of the unified and
integrated medical staff structure
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03.00.14 Multiple-Hospital Systems:
Unique Circumstances (NEW)
Standard: If a unified medical staff,
• The unified and integrated medical staff is established in a
manner that takes into account each member hospital’s
unique circumstances and any significant differences in
patient populations and service.
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03.00.14 Multiple-Hospital Systems:
Unique Circumstances
The separately certified hospitals belonging to a multi-hospital
system and using a single unified medical staff may:
1. Be very different from each other, presenting different needs
and challenges for the medical staff.
2. Consist of hospitals that differ in size or provide specialized
services.
3. Such differences could have implications for various medical
staff requirements, such as on-call requirements.
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03.00.14 Multiple-Hospital Systems:
Unique Circumstances
Example:
A multi-hospital system may consist of a mixture of hospitals, such as:
• short-term acute care hospitals
• psychiatric hospitals
• rehabilitation hospitals
• children’s hospitals
• long-term care hospitals
For this reason, the medical staff must assure that standard orders, policies,
and procedures:
1) Address the unique hospital circumstances
2) Are approved by the nursing and pharmacy leadership at each separately
certified hospital
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03.00.15 Multiple-Hospital Systems:
Policies of the Unified Medical Staff
Standard: If a unified medical staff,
• The hospital’s unified medical staff must have written policies
and procedures that address how it considers and addresses
needs and concerns expressed by members who practice at the
hospital.
Example:
• Physicians practicing in a children’s hospital may have
concerns about protocols for medication administration that
reflect specific pediatric patient concerns.
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31.00.11 Orders for Outpatient Services
Standard:
Outpatient services must be ordered by a practitioner who:
1.
2.
3.
4.
Is responsible for the care of the patient.
Is licensed in the State where he/she provides care to the patient.
Is acting within his or her scope of practice under State law.
Is authorized in accordance with State law and policies adopted by the
medical staff, and approved by the governing body, to order the applicable
outpatient services.
• Benefit: Hospitals have the flexibility to determine whether or not
they will allow a practitioner who is not a member of the medical
staff to order outpatient services.
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31.00.11 Orders for Outpatient Services
Through the Bylaws, the Medical Staff establishes whether to allow a
practitioner who is not a member of the medical staff to order outpatient
services consistent with State law and regulations:
1. Non-physician practitioners, such as
• Physical Therapists,
• Occupational Therapists,
• Speech Language Pathologists,
• Qualified dietitians and qualified nutrition professionals
2. Practitioners with a professional license from another State
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Medical Staff Approved Policies
A. The procedure to implement when a patient presents with a
referral or order for outpatient services
B. Before start of test/procedure, verify the practitioner is:
1) Licensed in the State where he/she provides care to patient
2) Acting within scope of practice per State law
3) Authorized by the medical staff and governing body to order the
applicable outpatient services.
C. Documentation expectations
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24.00.07 Diet Orders
Standard:
• All patient diets, including therapeutic diets, must be ordered
by a practitioner responsible for the care of the patient, or by
a qualified dietitian or qualified nutrition professional as
authorized by the medical staff and in accordance with State
law governing dietitians and nutrition professionals.
Includes:
• Orders for Therapeutic Diets
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24.00.07 Diet Orders
Hospitals have the flexibility to determine whether or not they:
1. Will allow a practitioner who is not a member of the medical staff
to order outpatient services
2. The ability to establish through medical staff bylaws and hospital
policy other parameters for who will and who will not be
authorized to order outpatient services.
• In accordance with respective State laws, regulations, and other
appropriate professional standards.
• This does not require the granting of privileges, but allows the
flexibility to do so if they so choose.
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QUESTIONS?
Please submit questions to:
[email protected]
312-202-8069
or
[email protected]
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