Transcript Comparison of The Joint Commission and DNVHC NIAHO

Comparison of The Joint
Commission and DNV- GL HC’s
National Integrated Accreditation
for Healthcare Organizations
(NIAHO℠) MS Standards
Kathy Matzka, CPMSM, CPCS
1
History
TJC
• 1952 began
• Unique statutory hospital deeming
authority 1965 Medicare statute
• July 15, 2008, the Medicare
Improvements for Patients and
Providers Act of 2008 became law
• 11/09 – CMS approval
• 4,546 Hospital and CAH in 2011
• 4,429 Hospital and CAH in 2013
(90% of accredited hospitals)
• 4,032 Hospital and CAH in 2016
(88% of accredited hospitals)
NIAHO
• 12/19/07 Application to
CMS
• 09/08 CMS approval
• 94 Hospital and CAH
on 7/14/10
• 393 Hospital and CAH
on 4/17/2016
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Process
TJC
NIAHO
• Three year survey
• Annual Survey
• Standards directly
• Most MS standards
related to the CMS as
directly related to the
well as self-defined
CMS
• ISO 9001 quality
management
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Scoring Process
TJC
NIAHO
• Three-point scale:
– 0 = insufficient compliance
– 1 = partial compliance
– 2 = satisfactory compliance
• Icons
– Documentation required
– Situational decision rules
apply
– Direct impact requirements
apply
– Category A requirement
– Category C requirement
(based on # of times does not
meet standard)
– Measurement of Success
needed
• Standards Scored as
– Meets requirements
– Nonconformity Category I
Conditional level – Egregious
non-compliance
– Nonconformity Category I Noncompliant
– Nonconformity Category II –
Occasional or isolated lapse in
compliance
– Immediate Jeopardy Immediate threat to patient
safety
• No aggregate scoring
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Appointment Timeframe
TJC
• Two years
NIAHO
• Three years if
state law does
not address
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Continuing Medical Education
TJC
NIAHO
• LIPs and other practitioners
• All with privileges participate in
privileged through the medical
CE that is at least in part
staff process must participate
related to their clinical
in CE
privileges
• Participation must be
• CME considered in decisions
documented and considered in
about reappointment or
decisions about
renewal or revision of clinical
reappointment, renewal, or
privileges
revision of individual clinical
• Action on an individual’s
privileges
application for appointment
/reappointment or initial or
subsequent clinical privileges
is withheld until the information
is available and verified
6
Current Competence
TJC
• The hospital verifies in writing
and from the primary source,
whenever feasible, or from a
CVO, information concerning
the current competence
• Evaluate data from other
organizations where the
applicant currently has
privileges, if available
NIAHO
• Initial - MS qualifications
include verification of current
competence
• Reap - Review of individual
performance data for variation
from benchmark Variations to
peer review for determination
of validity, written explanation
of findings and, if appropriate,
an action plan to include
improvement strategies
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Malpractice History
TJC
• MS evaluates
involvement in a
professional liability
action, including final
judgments and
settlements involving a
practitioner
• Must evaluate any
evidence of an unusual
pattern or an excessive
number of professional
liability actions resulting
in a final judgment
against the applicant
NIAHO
• Review of involvement in
any professional liability
action at initial and
reappointment
8
Peer Recommendations
TJC
NIAHO
• Required at initial, reap, consideration of
termination, or revision/revocation of
clinical privileges
• Address the relevant training and
experience, current competence, and
any effects of health status on privileges
being requested
• Include evaluation of the applicant’s
medical knowledge, technical and clinical
skills, clinical judgment, communication
skills, interpersonal skills, and
professionalism
• Obtained from a practitioner in the same
professional discipline as the applicant
with personal knowledge of the
applicant’s ability to practice
• List of appropriate sources
• Two peer
recommendations required
at initial
appointment
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Clinical Privileges
TJC
NIAHO
• PSV for current licensure or
• All permitted by the
certification
organization and by law to
• PSV of relevant training
provide patient care services
• Evidence of physical ability to
independently have delineated
perform the requested privilege
clinical privileges
• If available, data from
• If available and/or required by
professional practice review
the MS, a review of individual
from other organization where
performance data variation
the applicant currently has
from criteria determined by the
privileges
medical staff to identify need
• Recommendations from
for training or proctoring that
peers/faculty
may be required
• On renewal, review of the
applicant’s performance within
the hospital
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•
Telemedicine
TJC
NIAHO
3 choices
– The originating site can fully
privilege and credential the
practitioner according to MS
standards or
– Use credentialing information
from the distant site if the
distant site is a Joint
Commission-accredited
organization or
– Use credentialing and
privileging decision from the
Joint Commission-accredited
distant site
• Medical staff at both sites
make recommendation for
services to be provided via
telemedicine
• For non-deeming, can be via
contract only if TJC accredited
entity
• 2 choices
– The originating site can fully
privilege and credential the
practitioner according to MS
standards or
– Use credentialing and
privileging decision from
telemedicine entity or distant
site Medicare participating
hospital
• When services provided by a
contracted entity, GB must
identify criteria for selection
and procurement of services
and how to evaluate the entity
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Temporary Privileges
TJC
NIAHO
• 120 days for new applicant
with complete file awaiting
MEC approval
• Time as specified in bylaws for
patient care need
• On recommendation of MS
President or designee
• No successful challenges to
licensure or registration;
involuntary termination of MS
appointment; involuntary
limitation, reduction, denial, or
loss of clinical privileges
• Not exceed 120 days
• Locum tenens not to exceed 6
months
• On recommendation of a MEC
member, MS president or
medical director (as defined by
MS
• Urgent patient care need
• Complete application w/o
negative or adverse
information before action by
the medical staff or governing
body
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Temporary Privileges
TJC
NIAHO
• Patient care need verify
– Current licensure
– Current competence
•
New Applicant verify
•
•
•
•
•
•
Current licensure
Relevant training or
experience
Current competence
Ability to perform the
privileges requested
Other criteria required by
medical staff bylaws
NPDB
• In all cases verify
– education (AMA/AOA Profile
OK
– current competence
– primary verification of State
professional licenses
– professional references
(including current
competence)
– Database profiles from AMA,
AOA, NPDB, and OIG
Medicare/Medicaid
Exclusions
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Allied Health Professionals
TJC
NIAHO
• LIPs through MS
process
• Non-LIP APRNs and
PAs HR or MS if not
providing a medical
level of care
If State law allows, MS
may include DPM, OD,
DC, PA, CRNA, NM,
APRN, DMD, PHD or
other designated
professionals approved
by MS and Board and
eligible for appointment
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Executive Committee
TJC
NIAHO
• 10 EPs outlining
responsibilities,
structure, function
• If MS has an executive
committee, a majority of
the members of the
committee shall be
doctors of medicine or
osteopathy
• CEO and the nurse
executive of the
organization or designee
shall attend each meeting
on an ex-officio basis,
with or without vote
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TJC
Notifications
NIAHO
• The decision to grant, • A current roster listing
deny, revise, or
each practitioner’s
revoke privilege(s) is
specific surgical
disseminated and
privileges must be
made available to all
available in the
appropriate internal
surgical suite and
and external persons
scheduling area
or entities, as defined • Include surgeons with
by the hospital and
suspended surgical
applicable law
privileges or whose
surgical privileges
have been restricted
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Surgical Privileges
TJC
NIAHO
• Included in
general
category
for
privileges
• All practitioners performing surgery
have surgical privileges established
by the department of surgery and
medical staff and approved by the
governing body
• Privileges for general surgery and
surgical subspecialties defined with
established criteria approved by MS
• Privileges correspond with
established competencies of each
practitioner
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Automatic Suspension
TJC
NIAHO
• The medical staff bylaws
include
•
– description of indications
for automatic suspension
or summary suspension of
a practitioner’s medical
staff membership or clinical
privileges
– description of when
•
automatic suspension or
summary suspension
procedures are
implemented
The medical staff will define the criteria
and have a mechanism for
consideration of automatic suspension
of clinical privileges of a practitioner at
a minimum when:
–
–
–
–
revocation/restriction of professional
license
DEA certificate has been revoked,
suspended or on probation
Failure to maintain the minimum
specified amount of professional
liability insurance
non-compliance with written medical
record delinquency or deficiency
requirements
Mechanism for immediate and
automatic suspension of clinical
privileges due to the termination or
revocation of the practitioner’s
Medicare or Medicaid status
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QA/PI Data
TJC
• FPPE
• OPPE
• Medical Assessment
– Blood
– Medication
– Operative and other
procedure(s)
– Appropriateness of clinical
practice patterns
– Significant departures from
established patterns of clinical
practice
– Use of criteria for autopsies
– Sentinel event data
– Patient safety data
NIAHO
•
Practitioner specific performance
data is required and must be ratebased with comparative peer or
national data available for
comparison.
–
–
–
–
–
–
–
Blood use
Prescribing of medications
Surgical Case Review
Specific departmental indicators
Moderate Sedation Outcomes
Anesthesia events
Appropriateness of care for noninvasive procedures/interventions
– Utilization data
– Significant deviations from
established standards of practice
– Timely and legible completion of
patients’ medical records
•
Variants analyzed for statistical
significance
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Addressed by TJC, Not NIAHO
• Verification of applicant identity
• Use of CVO (DNV does allow – is addressed
under telemedicine)
• Health status (DNV only under surgical
privileges)
• Applicant required to provide info re: previously
successful or currently pending challenges to
licensure or voluntary relinquishment, felony
convictions
• Leadership standards place additional
responsibilities on MS
• Residency program requirements
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Addressed by NIAHO, not TJC
• Receipt of database profile from OIG Medicare/Medicaid Exclusions
initial/reappointment/temporary privileges
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Resources
• Standards: NIAHO® Standards, Interpretive
Guidelines, or Accreditation Process
www.dnvaccreditation.com
• Jointcomission.org
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Questions to Consider…
• Will our reputation in the community suffer
if we change? (Are minimal standards
sufficient in today’s healthcare climate?)
• Contracts with insurers may require
certain accreditation and may need
renegotiation
• Will there be a saving in direct and indirect
accreditation costs?
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Questions
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