Transcript 56611_CH05_Tyson

Quality
Management
and Performance
Improvement
©2010 Jones and Bartlett Publishers
Definitions
• Adverse Event
– The result of medical intervention in which the
outcome was unforeseen and unexpected
• Benchmarking
– Performance comparison of one organization with
that of a similar organization in that area
• Error
– An unintended act, either of omission or commission,
or an act that does not achieve its intended outcome
©2010 Jones and Bartlett Publishers
Definitions (cont.)
• Compliance
– Process of meeting a prescribed set of standards or regulations to
maintain active accreditation, licensure or certification status
• Accreditation
– The act of granting approval to a healthcare organization
• Licensure
– The act of granting a healthcare organization or an individual
healthcare practitioner permission to provide services of a defined
scope in a limited geographical area
• Certification
– Grants approval for a healthcare organization to provide services to a
specific group of beneficiaries
©2010 Jones and Bartlett Publishers
Definitions (cont.)
• Quality
– Degree of excellence, superior in kind
• Quality Improvements
– Methods or activities designated for the purpose of increasing
the quality of a service product
• Quality Assessment
– Process of measuring and evaluating service activities to
determine the current level of quality
• Quality Management
– The process of coordinating all quality activities as necessary
towards the accomplishment of desirable performance
outcomes
©2010 Jones and Bartlett Publishers
Definitions (cont.)
• Quality Control
– A group of activities designed to detect and recognize positive
and negative variances with the existing performance and to
ensure a predicted outcome
• Total Quality Management
– A mentality or philosophy based upon continuous quality
improvement in the complete process of providing care
• Performance Improvement
– Production of the company’s product in the most efficient and
effective means possible
– In the health care industry, it is the key to helping people with
challenged health return to healthier more productive lives by
providing high quality health care
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Definitions (cont.)
• Quality Indicators
– A quantifiable measurement or standard to
identify the point of acceptable from nonacceptable performance.
– Performance measure that enables healthcare
organizations to monitor a process to determine
whether it is meeting process requirements
– May be established and implemented internally,
externally or generically
– May be written as ratio such as
– Number of admissions meeting criteria x 100 /
number of admissions
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Definitions (cont.)
• Sentinel Event
– An unexpected occurrence involving death or serious physical or
psychological injury to a patient
• Root Cause Analysis
– A process for identifying the basic or causative factor that
underlines variation in performance
• Safety
– All health care facilities are required to report all suspected and
identified patient safety occurrences related to care or lack of
care, which resulted, or could have resulted to a patient.
©2010 Jones and Bartlett Publishers
Quality Management
©2010 Jones and Bartlett Publishers
The Joint Commission (TJC)
10-step process
• Assign responsibility
• Delineate scope of care
• Identify important aspects of care
• Identify indicators
• Establish thresholds
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The Joint Commission (TJC)
10-step process (cont.)
• Collect and organize data
• Initiate evaluation
• Take actions to improve care and services
• Assess the effectiveness of actions and maintain the
gain
• Communicate results to affected individuals and
groups
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Avedis Donabedian Model for Assessing
Healthcare Quality
• Structure
– Measures the ability of the organization to coordinate all its
resources such as physical, manpower, facility, technology,
policies and procedures, financial and other characteristics as
needed to successfully support the delivery of health care
services
• Process
– Measures the ability of the organization to foster and focus on
positive interactions between the receiver of health care service
and the provider of service through out the course of the care
• Outcome
– Measures and focus on the end result of the care provided and
the overall satisfaction level of the patient with the care
received
©2010 Jones and Bartlett Publishers
Historical Perspectives
• Mid-1700s, Pennsylvania Hospital becomes
the model for the organization and
development of hospitals
•
• 1760, New York State begins the practice of
medical licensure
• 1771, New Jersey begins the practice of
medical licensure
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Historical Perspectives (cont.)
• 1851, Massachusetts General Hospital establishes the
first disease/procedure index by classifying patient
disposition
• 1854, Florence Nightingale introduced the following
new protocols for nurses during the Crimean War:
Nurses / patient care relationship, sanitations and
ventilation systems
• 1874, American Medical Association encourages the
creation of independent state licensing boards
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Historical Perspectives (cont.)
• 1910, Flexner Report indicates unacceptable variation in
medical school curricula
• 1917, American College of Surgeons (ACS) establishes the
Hospital Standardization Program (minimum standard of care)
• 1920, Most medical colleges meet rigorous academic
standards and are approved by the American Association of
Medical Colleges
• 1946, Hill-Burton Act establishes funding to build new
hospitals.
• 1952, The Joint Commission on Accreditation of Hospitals
(JCAH) was formed now referred to as The Joint Commission
(TJC)
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Historical Perspectives (cont.)
• 1953, The Joint Commission on Accreditation of Hospitals
(JCAH) published its first set of standards for hospitals
• 1965, The Congress passed the Social Security
Amendment which establishes Medicare and Medicaid
coverage for citizens 65 years of age or older (PL 89-97)
• 1972, Professional Standard Review Organizations (PSROs)
are formed (PL 92-603) now referred to as Quality
Improvement Organizations (QIOs)
• 1976, Condition of Participation was developed
• 1980, The JCAH introduced accreditation standards
©2010 Jones and Bartlett Publishers
Historical Perspectives (cont.)
• 1982, Tax Equity and Fiscal Responsibility Act (TEFRA).
Reimbursement structure changed from retrospective
determined cost-based payment to prospectively established
fixed price determined by patients’ final principal diagnosis
thus creating the Prospective Payment System (PPS)
• 1982, Prospective payment system is created (TEFRA)
• 1982, Peer Review Organizations (PRO) were created now
referred to as Quality Improvement Organizations (QIOs)
• 1982, State and regional peer review organizations contract
with HCFA (Centers for Medicare and Medicaid – CMS)
• 1983, Prospective Payment for Medicare was established (PL
98-21)
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Historical Perspectives (cont.)
• 1986, Health Care Quality Improvement Act (HCQIA)
Public Law 99-660. Established the National Practitioner
Data Bank (NPDB) a clearinghouse to collect and release
information to eligible parties for the purpose of
identifying problematic incompetent health care
practitioners
• 1985, JCAH developed a ten-step model for monitoring
and evaluating effectiveness of a QA efforts
• 1986, JCAH developed the project called “Agenda for
Change”
• 1989, Agency for Health Care Policy & Research was
created (PL 101-239)
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Historical Perspectives (cont.)
• 1996, Health Insurance Portability and Accountability Act
(HIPAA) was launched (PL 104-191)
• 1997, The ORYX initiative program began, to incorporate
outcome measures and monitoring into healthcare
accreditation processes
•
• 1990, Deming’s total quality management philosophy begins
to spread in U.S. healthcare
• 1990, TJC integrates quality improvement into the
accreditation process
• Health Care Quality Improvement Program (1993) redirected
PROs focus toward improving quality
©2010 Jones and Bartlett Publishers
Historical Perspectives (cont.)
• 2001, Ambulatory payment classification system
is initiated
• 2002, HCFA becomes the Centers for Medicare
and Medicaid Services (CMS)
• 2002, Peer Review Organizations (PROs) were
renamed Quality Improvement Organizations
(QIOs)
©2010 Jones and Bartlett Publishers
Historical Perspectives (cont.)
• April 14, 2001, The Standard for Privacy of
Individually Identified Health Information (the
Privacy rule) took effect
• April 14, 2003, covered entity must comply
• January 2004, TJC begins unannounced tracer
methodology for healthcare accreditation review
process
• 2000s TJC places emphasis on patient safety
©2010 Jones and Bartlett Publishers
Healthcare Accrediting and Licensing Agencies
ABBREVIATION
AAAHC
AGENCY
AREAS OF RESPONSIBILITY
Accreditation Association for
Specialized in assisting ambulatory healthcare
Ambulatory Health Care
organizations to improve quality of their services
ACS
American College of Surgeons
Initiated standard review in health care practice
CARF
Commission on Accreditation of
Responsible for evaluating quality of care in organizations
Rehabilitation Facilities
providing rehabilitative treatment
Health Plan Employer Data &
Responsible for collecting data on managed care plans
HEDIS
Information Set
TJC (formerly
The Joint Commission
Refined ACS standards and assumed responsibility
National Committee for Quality
Certifying qualified healthcare professional in quality
Assurance
assurance
National Association of Healthcare
Certifying qualified healthcare professional in promoting
Quality
continuous QI efforts
JCAHO)
NCQA
NAHQ
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Walter Shewhart Model made popular
by Edwards Deming
Plan
Act
Do
Check
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Accomplishments of QI Pioneers
CROSBY
DEMING
JOINER
JURAN
Quality means
Developed 14
Developed the JOINER
Developed
complete
principles and
Triangle
Trilogy
conformance
7 deadly
to standards
diseases
process
Quality
Scientific
Approach
All One
Team
©2010 Jones and Bartlett Publishers
Deming’s 14 principles
1. Create constant consistency towards purpose of the
product or service
2. Adopt new philosophy
3. Focus on quality process flow of the product rather
than mass inspection
4. Price tag does not always indicate quality, end
practice of rewarding bases on price tag, embrace
long term relationship, trust, loyalty and honesty
©2010 Jones and Bartlett Publishers
Deming’s 14 principles (cont.)
5. Constantly assess and improve all processes
6. Institute on the job training, job orientation, continued
education, equipment training etc
7. Institute leadership, remove workmanship barriers, be
realistic, understand all staff can not be above average
8. Drive out fear (no one perform its best under fear)
9. Breakdown barriers within the organization by improving
communication
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Deming’s 14 principles (cont.)
10. Eliminate numerical quotas, quota causes loss, chaos,
dissatisfaction, burnout, boredom, turnover, etc
11. Eliminate quick fix solution
12. Eliminate inconsistent slogans and exhortation
13. Create an open atmosphere of creativity, identify and
uplift talented staff
14. Involve everybody within the organization to work
towards the transformation or improvement of the
organization
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Deming’s 7 Deadly Diseases
1. Lack of vision, mission, plan, and purpose of the product or
service
2. Laying emphasis on short-time profits
3. Inconsistent, unfair and un-measurable evaluation, and merit
rating
4. Employee job dissatisfaction
5. Customer, vendor and community dissatisfaction
6. Excessive medical cost
7. Excessive cost of liability
©2010 Jones and Bartlett Publishers
Court Decisions on Quality of Healthcare
Year
Case
Decision
1965
Darling Vs. Charleston
Court ruled that the hospital must assume certain responsibilities
Community Hospital
for care of the patient. The courts ruled that a hospital was
negligent for permitting a general practitioner to perform
orthopedic surgery. The court ruled that the hospital had a duty to
apply reasonable standards to the practice of its physicians, since it
was responsible for the privileging of physicians on its staff.
1973
1981
Gonzales Vs. Nork &
The court found the hospital negligent if it knew or had reason to
Mercy Hospital
know or should have known of the surgeon’s incompetence.
John Vs. Misericordia
The court found that the hospital owes a duty to its patients in
Hospital
selecting medical staff members and granting privileged.
©2010 Jones and Bartlett Publishers
10 core elements of a
Performance Improvement Plan
1. Statement of mission
6. Organizational Structure
2. Statement of vision
7. Performance Measure
Objectives
3. Objectives
8. Methodology for
improvement
4. Organizational Values &
Culture
9. Annual Review Plan
5. Leadership
10. Communication models
©2010 Jones and Bartlett Publishers
Continuous Quality Improvement (CQI)
• A never-ending cycle
• Concept that came out of business industry
• Rather than creating a culture of blame if things do
not go well, the focus is on a team approach to
improvement that rewards the group when things
get better
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Benefits of CQI
• A continuously learning organization
• Strategically aligned improvement projects knowledge of key
customers and suppliers at every level of the hospital
• An integrated, customer-focused business plan for all organization
functions
• Improved satisfaction among patients, physician, employees and
payers
• Reduced expenses as a result of removing waste, needless
complexity and rework
• Assistance with meeting accreditation standards
©2010 Jones and Bartlett Publishers
FOCUS
• Find a process to improve
• Organize to improve a process
• Clarify what is known
• Understand variation
• Select a process improvement
©2010 Jones and Bartlett Publishers
Methods to Improve Quality
• Department of Health and Human Services (HHS)
– Quality Initiative
– Hospital Compare
• Clinical Practice Guidelines
– Systematically developed statements used to assist provider and
patient decisions about appropriate health care for specific clinical
circumstances
– Developed with the goal of standardizing clinical decision-making
– Meant to be flexible and do not necessarily apply in every case
• Clinical Protocols
– Treatment recommendations often based on guidelines
– The step-by-step description of an accepted procedure recommended
by an authoritative body
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Tools for Implementing
Clinical Guidelines and Protocols
• Critical paths
– Display goals for patients and provide the
corresponding ideal sequence and timing of staff
actions to achieve those goals with optimal efficiency
• Clinical pathways
– Structured plans of care
• Care maps
– Multidisciplinary standards that outline the processes
of care and expected outcomes within predetermined
timeframes
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Project Management
• Rooted in engineering, oriented toward quantitative
application methods
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Project Management (cont.)
• Initiation
– Determine gap between organization performance an expected outcomes
– Project Teams
•
•
•
•
•
•
Identify improvement opportunity
Research and define performance expectations
Implement process education
Measure performance
Document and communicate findings
Analyze and compare internal and external data
• Planning
– Expected impact on organization
– Design
• Development of alternative solutions
• Gantt charts
– Project management tool used to schedule important activities
– Charts divide a horizontal scale into days, weeks or months an vertical scale into project
activities or tasks
• PERT Charts
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Project Management (cont.)
• Execution
– Once plan is completed, execution begins
– Installation of equipment or construction begins
– Training
– Measure performance
• Closure
– Evaluation and control
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Role of HIM staff in QI
• HIM management must establish a service
delivery and expectation standard for each
services and products provided
• It is important that the HIM staff knows the
timeliness of specific service or product its
department has to offer
©2010 Jones and Bartlett Publishers
Role of HIM staff in QI (cont.)
• Participate in QI planning
• Interpret data
• Identify deviations from norm
• Display data
• Identify areas needing
improvement
• Present data
• Provide chart / information
• Collect data
• Analyze data
• Benchmark collected data
• Implement required changes
• Monitor and evaluate changes
• Communicate
• Update / revise / or create
supportive policy
©2010 Jones and Bartlett Publishers
Services & Products offered by HIM
•
Chart retrieval
•
Filing
•
Coding
•
Chart maintenance
•
Abstracting
•
Record Imaging & Indexing
•
Chart analysis
•
Transcription
•
Release of information
•
Hard copy & electronic storage
•
Disclosure tracking
•
Research processing
•
Record processing
•
Loose sheet processing
•
Chart tracking
©2010 Jones and Bartlett Publishers
Some Internal Customers of HIM
•
Other HIM staff within HIM department
•
Social workers and social service staff
•
Receptionists
•
Patient advocates, volunteers
•
Physicians
•
Eligibility counselor
•
Laboratory technicians
•
Risk management staff
•
Nurses and other medical assistants
•
Utilization review staff
•
Business services
•
Quality assurance staff
•
Radiology technician
•
Business associates
•
Pharmacists and Pharmacy staff
•
Students and researchers
•
Janitorial staff
•
Office of patient financial service
•
Physical therapist, respiratory therapist
•
Billing office
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Some External Customers of HIM
• Patient
• Vendor
• Physician
• Licensing agencies
• Accreditation agencies
• Law enforcement agencies
with needs to know
• Medical Examiners
• Patient advocates
• Patient’s identified personal
representatives
• Local, state and federal
agencies with needs to know
©2010 Jones and Bartlett Publishers
Data Collection
• Primary source of clinical data
• Medical record
• Secondary sources of clinical data
•
•
•
•
•
Insurance data
Registry data
Reimbursement data
Census data
Other data
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Data Collection Methodologies
• Questionnaire
• Mail
• Survey
• Phone
• Face to face interview
• Primary clinical data
• Secondary clinical data
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Tools for Displaying Data
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Bar Graphs
• Can be used to
measure different
types of data that
can not be broken
to sub-categories
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Pie Chart
• Illustrates
how an
individual
component of
chart relates
in part or
compared to
the whole
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Pareto Chart
16
• Type of bar
graph which
displays
categories of
data in
descending
order of
frequency or
significance
120.00%
14
100.00%
12
80.00%
10
8
60.00%
Frequency
Cumulative
6
40.00%
4
20.00%
2
0
0.00%
Dislike
Neutral
Very Good
Excellent
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Scatter Diagram
• Indicates a
relationship
between
two
variables
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Idea Generating Techniques
• Brainstorming
– Used to generate ideas to encourage creativity and a
free flow of ideas. Example of a brainstorming topic
can be customer satisfaction form design
• Nominal group technique
– Comparable to brainstorming, the group members
generate the ideas, however, after ideas are generated
they are objectively ranked or rated in the order of
priority
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Data Organization
• Cause and effect diagrams
– Also called “fishbone diagram”
– Utilized to separate root causes for an effect or problem
• Check sheet
– Indicates how often an event occurs. Check sheets Contribute
to data for the creation of histograms, Run charts, etc…
• Decision matrix
– Grid design to rank ideas and proposals. It also allows for
scoring of each alternative. It helps to prioritize objectives
• Flow chart
– Pictorial illustration of sequenced steps to complete a process
©2010 Jones and Bartlett Publishers
Utilization Management
©2010 Jones and Bartlett Publishers
Utilization Management
• Method of controlling health care costs and quality of
care by reviewing the appropriateness and necessity of
care provided to patients
• Embodied in a hospital quality program
• Goal is to review the facility’s efficiency in the provision
of services and resources in the most cost effective
manner
• Under-utilization and over-utilization of services,
resources, and facilities are outcomes are prevented
©2010 Jones and Bartlett Publishers
Utilization Management (cont.)
• Public Law 92-603 of 1972, established Professional
Standards Review Organizations (PSROs)
– Comprised of licensed physicians whose goal is to
determine if services provided were medically necessary
and cost effective
• TEFRA(1982) replaced PSROs with PROs
– Now known as Quality Improvement Organizations (QIOs),
are responsible for each state, territory and District of
Columbia
– Non-governmental agencies empowered to evaluate
performance relative to quality and appropriateness of
service and can recommend punitive action to CMS
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Centers for Medicare / Medicaid Services (CMS)
• Formerly Health Care Financing Agency
• Oversee Quality Improvement Organizations
(QIOs)
• Scope of Work
– Clinical quality outcomes
– Payment error prevention
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Some Medical Services Requiring
Utilization Monitoring
• Inpatient confinement
•
•
•
•
•
Surgical and non-surgical confinements
Skilled nursing facility
Rehabilitation facility
Inpatient hospice
Maternity confinements
• Reconstructive procedures and procedures that may be considered
cosmetic
• Selected durable medical equipment
• Medical injectables
• Surgical procedures
©2010 Jones and Bartlett Publishers
Some Medical Services Requiring
Utilization Monitoring (cont.)
• Elective (non-emergent) transportation by ambulance
or medical van and all transfers via air ambulance
• All home health care services
• Requests for in-network level of benefits for
nonparticipating physicians and providers for nonemergent services
• Dental implants and oral appliances
©2010 Jones and Bartlett Publishers
Some Medical Services Requiring
Utilization Monitoring (cont.)
• Services that may be considered investigational or
experimental special programs
– Mental health, substance abuse or behavioral health
services
– Maternity management programs, including genetic
testing, antenatal testing, prenatal consultations and
counseling
– Infertility Program
– Pharmacy pre-certification for certain pharmaceuticals
– Major organ transplant evaluations and transplants
including but not limited to kidney, liver, heart, lung, and
pancreas and bone marrow replacement or stem cell
transfer after high-dose chemotherapy
– Outpatient imaging pre-certification for CTs, MRI/MRA,
nuclear cardiology, PET scans
©2010 Jones and Bartlett Publishers
Case Management
• Coordination, development and provision of
patient care plans for the patients with
complicated cases. The goal is to provide
patient care plan in a cost effective manner to
patients with complicated cases
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Peer review
• Crucial component of Medicare
reimbursement process
• Individual hospitals submit claims for payment
of covered services to fiscal intermediary by
way of a standardized billing form
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Peer review (cont.)
• For Medicare claims, fiscal intermediary transmits duplicate
of all claims for a review period to PRO to determine
– Whether services are reasonable and medically necessary
– Whether services could effectively be furnished on an
outpatient basis as opposed to inpatient admission
– Medical necessity, reasonableness and appropriate inpatient
services
– Inappropriate medical or other practices resulting in
inappropriate admission or fraudulent billing for reimbursement
– Validity of diagnostic and procedural information submitted to
request reimbursement
– Completeness and adequacy of care provided
– Whether the quality of services meets professionally recognized
standards of care
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Goal of the Peer Review
• For the PRO physician reviewer to identify
three primary issues
– Utilization concerns
– Quality concerns
– Diagnostic related group concerns
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Utilization Review Process
• Preadmission review (Prospective review)
– Review prior to admission that determines if the procedure and
reason for potential admission is appropriate and necessary
– Consist of comparing patient’s medical condition with standard
criteria that specify clinical indications for admission.
• Criteria are Intensity of Service / Severity of Illness criteria (IS/ SI)
• Admission review
– Review at time of admission to determine medical necessity and
appropriateness
• Concurrent review
– Review of medical necessity for tests and procedures ordered
during an inpatient hospitalization
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Utilization Review Process (cont.)
• Discharge review
– Review at time of discharge that determines if the
patients meet specific discharge screen criteria. It
may involves arranging appropriate home health care
services for the discharged patient
• Retrospective review
– Review conducted by the PRO for evaluation of quality
issues, cost and outliers issues, and issues of
utilization management and appropriateness of care.
©2010 Jones and Bartlett Publishers
Risk Management
©2010 Jones and Bartlett Publishers
Risk Management
• The management of any event or situation that could
potentially result in an injury to an individual or
financial loss to the health care institution
• Consists of policies, procedures and practices that
reduce risk and liabilities for injuries that may occur
©2010 Jones and Bartlett Publishers
Risk Management Objectives
• To create and maintain a safe, healthy environment
and enhance quality care
• To minimize risk of medical or accidental injuries and
losses
• Provide cost-effective techniques to insure against
financial loss
©2010 Jones and Bartlett Publishers
Risk Management Program
• Elements
– Risk identification
• Identifying areas of existing or potential loss. The
incident report is the essential tool that is used in
identifying risk.
– Risk control
• Prevention and control of risks and minimizing of
occurrences for which the facility may be held liable
– Risk Financing
• Plan to financially cover losses. Types of funds to be
considered include self insurance, insurance pools, and
commercial insurance
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Risk Management Program (cont.)
• Components
– Loss prevention and reduction
– Claims management
– Safety and security
– Employee programs
– Patient relations
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Risk Management Program (cont.)
• Methodology
– Occurrence screening
• Adverse patient occurrences
• Potential compensable events
– Incident report
• Reportable incidents are written and investigated
• Root cause analysis is done to determine underlying
factors of a sentinel event
– Patient advocacy
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Risk Management Program (cont.)
• Use of Risk Management information
– Improve system processes
– Increase patient and employee satisfaction
– Improve clinical outcomes
– Decrease risk factors
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Reportable Adverse Events
• Unauthorized
Medication
• Omission
• I.V. Infiltration
• Wrong dose
• Wrong Patient
• Wrong Medication
• Wrong Site
• Wrong Route
• Wrong dosage
• Wrong Time
• Wrong Technique
• Wrong Drug
Preparation
• Wrong Rate
• Drug Interaction
• Drug allergy
• Food & Drug Interaction
• Deteriorated Drug
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Other Types of Reportable Events
•
•
•
•
Patient abuse
Patient neglect
Medically unstable at discharge
Returning to intensive care unit within 24
hours of being transferred out
• Unplanned return to surgery for same
condition
• Patient Fall
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Other Types of Reportable Events (cont.)
•
•
•
•
•
•
•
•
Missed diagnosis
Delayed diagnosis
Blood transfusion error
Complication with anesthesia
Unanticipated death
Suicide / Unsuccessful Suicide Attempt
Prenatal death
Inappropriate use of restraints
©2010 Jones and Bartlett Publishers
Other Types of Reportable Events (cont.)
• Operative injury or complications
• Unexpected admission, readmission, or return
to Emergency Center following inpatient or
outpatient care for same condition
• Equipment failure
• Infant abduction
• Blood Transfusion reaction
• Unauthorized inpatient departure
• Patient injury while in restraints
©2010 Jones and Bartlett Publishers
Sentinel Events
• Surgery on wrong patient
• Infant discharged to wrong family
• Rape
• Blood transfusion related to blood group
incompatibilities
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Sentinel Events
• Surgery on wrong body part
• Unanticipated death
• Infant abduction
• Suicide
• Permanent loss of major function associated with
medication or surgical error
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Credentialing
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Credentialing
• The reviewing, verifying, validating, and evaluating of
key factors that determines an individual
practitioner’s ability to carry out certain patient care
activities and granting of professional privileges
• TJC states, “authorization granted by the governing
board to a practitioner to provide specific patient
care services in the hospital within defined limits,
based on an individual practitioner’s license,
education, training, experience, competence, health
status, and judgment”
©2010 Jones and Bartlett Publishers
Credentialing
• Crucial role in maintaining high quality
professional care to the patients
• Hospital has obligation to carefully select its
staff and to grant them privileges as
appropriate to ensure the staff highly
educated, trained, experienced, qualified and
competent to deliver needed services
©2010 Jones and Bartlett Publishers
Purpose of Credentialing
• Ensure medical staff members only perform
procedures and services they are qualified and
competent to perform through training and
experience
• Key aspects
•
•
•
•
Initial appointments to the medical staff
Initial delineation and granting of clinical privileges
Periodic reappointment to the medical staff
Periodic renewal or revision of clinical privileges
©2010 Jones and Bartlett Publishers
Medical Staff Functions
• Adopts medical staff by-laws
• Provides patient care and carry out other
professional responsibilities
• Actively participate and exercise professional
leadership in measuring, assessing, and improving
the performance of the organizations within which
they practice
©2010 Jones and Bartlett Publishers
Medical Staff Functions (cont.)
• Continually improve the quality of healthcare services
delivered
• Provides patient care within their professional competence
• Provides patient care as reflected in the scope of their clinical
privileges
• Participating in ongoing measurement, assessment, and
improvement of both clinical and non-clinical processes
©2010 Jones and Bartlett Publishers
Characteristics of Medical Staff
• Clinical privileges subject to medical staff and
departmental bylaws, rules and regulations, and
policies and subject to review as part of the
organization's performance improvement activities
• Fully licensed staff
• Staff permitted by law and by the hospital to provide
patient care services independently in the hospital
©2010 Jones and Bartlett Publishers
Characteristics of Medical Staff (cont.)
• Delineated clinical privileges that define the scope of patient
care services they may provide independently in the hospital
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Medical Staff Record Maintenance
• A separate record is maintained for each individual
requesting medical staff membership or clinical privileges
• Complete applications are acted on within a reasonable
period of time, as specified in the medical staff bylaws
• Each file is consistent with applicant’s consents for
inspection of records and documents pertinent to his or
her licensure, specific training, experience, current
competence, and ability to perform the privileges
requested, and, if requested, appears for an interview
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Medical Staff Record Maintenance (cont.)
• Each file is consistent with applicant’s consents for
inspection of records and documents pertinent to his
or her licensure, specific training, experience, current
competence, and ability to perform the privileges
requested, and, if requested, appears for an
interview
• Applicant pledges to provide for continuous care for
his or her patients
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Medical Staff Record Maintenance (cont.)
• Bylaws, rules and regulations, and policies of the
medical staff indicate applicant for reappointment or
renewal of clinical privileges is required to submit
any reasonable evidence of current ability to perform
privileges that may be requested
• Signed acknowledgement for release and immunity
from civil liability
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Types of Membership Privileges
• Active
• Consulting
• Honorary
• Disaster
• Courtesy
• House Staff
• Faculty
• Temporary
• Associate or Provisional
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Purpose of Clinical Privileges
• Delineates the types of procedures that can
be performed by each provider of care
• Delineates the types of care and treatment
that can be carried out by each provider of
care
• Delineates the types of patients the health
care provider will be allowed to have access to
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Credentialing Application Process
• The medical staff bylaws and the medical staff rules and
regulations delineate what needs to be collected and
reviewed during the credentialing phase. It also delineates
the processes and responsibilities for approval and denial of
medical staff clinical privileges and membership
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Categories of Applicants
• Type One
– Physicians
– Dentist
– Podiatrist
• Type Two
– Physician Assistant
– Advanced Nurse Practitioner
– Allied health providers
– All other licensed and certified staff
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Application Information
• Applicant’s demographic
and identifying information
• Education
• State Licensure Number
• State Licensure Expiration
Date
• Previous Employer
• Prior Malpractice Claims
• Denial of Medical Privileges
with other institutions
• Narcotics number
• Third Party Payment Program
Involvements
• Name of References / letter
• Acknowledgement of Medicare
/ Medicaid fraud
• Revocation of Medical
Privileges with other Institution
• Suspension of Medical
Privileges with other Institution
• Voluntary relinquishment of
licensure
• Involuntary relinquishment of
licensure
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Credential Verification
• Education
• Liability insurance coverage
• Current licensure
• Clinical competence
• Satisfactory health status
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Privilege Delineation
• Process to determine specific procedures and
services a practitioner is permitted to perform
under jurisdiction of institution
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Credentialing Department Chair
• Responsible for coordinating, reviewing, evaluating, and
validating timeliness and appropriateness of submitted
application
• With satisfactory application, the Departmental Chair request
for privilege verification
• Maintains documentation
• Forwards the application and the request for clinical privileges
to Credentialing Committee for further review
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Credentialing Committee
• Functions in advisory capacity and is not empowered
to make appointment
• Peer review of applicant is conducted
• Makes recommendation for appointment and
privileges to executive committee
– Executive committee makes recommendation to governing
board
– Governing board approves or denies membership
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Re-appointment
• Practitioner profile
– Mechanism to integrate information compiled
from quality management activities into
credentialing process to determine reappointment
– Re-appointment criteria may be different from
initial appoint criteria
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Continued Education
• All individuals with clinical privileges participate in an ongoing
continuing education activities related to their granted privilege
• Continued education must be documented and must be made
available and become a part of indicator for qualifying for
reappointment or renewal or revision of individual clinical privileges
• The educational activities must be related to the type of care
performed by the particular medical staff and in part, care offered
by the hospital
• Continued education must be considered in re-appointment,
revision or renewal of medical staff clinical privileges
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Example Data Collection Tool For
Credentialing Application
ITEMS
YES NO
COMMENT
Application is completed
Requested privileges specified
Attestation to correctness and completeness of
information submitted
Authorization to request, disclose and or share
information is signed
Special consent was signed as needed
Names of three professional recommendations was
submitted
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Example Status Check Sheet Credentialing
ITEMS
RECEIVED PENDING SENT
CONTACT
DATE
PERSON
DATE
Proof of professional liability verification
Three professional recommendations
Verification of past and or pending professional disciplinary
actions
Verification of voluntary and involuntary limitations, loss of
clinical privileges, or reduction of privileges
Confirmation from National Practitioner Data Bank (NPDB)
Confirmation from American Medical Association (AMA)
Confirmation from Drug Enforcement Agency (DEA)
Verification of educational background
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