2007 Joint Commission Standards and Core Privileging in MIDAS+ Seeker. Jana Darnell, CPMSM, CPCS Product Manager, Seeker ACS MIDAS+

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1 2007 Joint Commission Standards and Core Privileging in MIDAS+ Seeker Jana Darnell, CPMSM, CPCS Product Manager, Seeker ACS MIDAS+

2 "Cynthia, yesterday I asked you to consider creating and implementing a core privileging system establishing criteria and qualifications specific to each specialty area of practice and for each clinical setting. Have you made a decision?"

3 Centers for Medicare/Medicaid Services Conditions of Participation (a)(6): The governing body must ensure (that) the criteria for selection (to the medical staff) are individual and based on character, competence, training, experience, and judgment (c)(6): Patient care is provided by a practitioner who meets the medical staff criteria and procedures for the privileges granted. Privileges are granted by the governing body based upon the medical staff s review of that individual practitioner s qualifications and the medical staff s recommendations.

4 2007 Joint Commission Standards What s New Peer Recommendations include regarding the practitioner s General Competencies Patient Care: Practitioners are expected to provide patient care that is compassionate, appropriate, and effective for the promotion of health, prevention of illness, treatment of disease, and care at the end of life. Medical/Clinical Knowledge: Practitioners are expected to demonstrate knowledge of established and evolving biomedical, clinical, and social sciences, and the application of their knowledge to patient care and the education of others. Practice-Based Learning and Improvement: Practitioners are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care.

5 2007 Joint Commission Standards What s New (cont.) General Competencies (continued) Interpersonal and Communication Skills: Practitioners are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of health care teams. Professionalism: Practitioners are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity, and a responsible attitude toward their patients, the profession, and society. Systems-Based Practice: Practitioners are expected to demonstrate both an understanding of the contexts and systems to which health care is provided, and the stability to apply this knowledge to improve and optimize healthcare.

6 2007 Joint Commission Standards MS 2.10: The organized medical staff oversees the quality of patient care, treatment, and services provided by practitioners privileged through the medical staff process. MS 4.00: Prior to granting a privilege, the resources necessary to support the requested privilege are determined to be currently available, or available within a specified time frame. MS 4.15: The decision to grant or deny a privilege(s) and/or to renew an existing privilege(s), is an objective evidence-based process.

7 2007 Joint Commission Standards (cont.) MS 4.30: The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner s professional performance (focused professional practice review proctoring, precepting) MS 4.40: 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. (Peer Review) PA s and APRN s must be privileged in the same manner as members of the medical staff.

8 How do we achieve effective ongoing professional practice evaluations and focused professional practice evaluations and relate it to the privileges granted to the provider to insure current competence?

9 Customers Patient Provider Hospitals Nurse on the floor Accreditation agencies State and local regulators

10 Privileging Basics Physician friendly Specific as to scope of the privilege Specific criteria required Provide user friendly, easily accessible, and understandable presentation to the nurses on the floor to eliminate gray areas.

11 Privileging Options Laundry list Lack consistency in terminology Do not correspond to specific procedures Difficult to know what is included and granted, i.e. hernia repair, pancreatic surgery Does not allow annual appraisal of procedures performed that were not privileged Does not allow long term evaluation of privileges not exercised

12 Privileging Options (cont.) General core: Privileges granted in the practice of general surgery based on completion of an ACGME accredited residency program in general surgery Too generic Does not allow a lookup of any individual procedure to see if privileges have been granted Does not allow annual appraisal of procedures performed that were not privileged Does not allow long term evaluation of privileges not exercised

13 Privileging Options (cont.) Core grouping: Admit, evaluate, perform H&P examinations, diagnose, treat, and provide consultation to patients, except as specifically excluded from practice, with all types of cancer, and other benign and malignant tumors. Privileges include but are not limited to: Administration of chemotherapeutic agents and biological response modifiers through all therapeutic routes Bone marrow aspiration and biopsy Diagnostic lumbar puncture Does not allow a lookup of any individual procedure to see if privileges have been granted Does not allow annual appraisal of procedures performed that were not privileged Does not allow long term evaluation of privileges not exercised

14 Privileging Options (cont.) CPT4 codes Codes physicians use to bill Outpatient codes-doesn t correspond to procedures performed within the hospital 7510 Procedures Major Diagnostic Categories (MDCs) - The Major Diagnostic Categories (MDC) are formed by dividing all possible principal diagnoses (from ICD-9) into 25 mutually exclusive diagnosis areas. The diagnoses in each MDC correspond to a single organ system or etiology and in general are associated with a particular medical specialty 1 Nervous System, 2 Eye, 3 Ear, Nose, Mouth And Throat, 4 Respiratory System, etc. Too Generic no drill down to individual procedures

15 Privileging Options (cont.) ICD9 codes Hospital inpatient procedure/diagnoses billing codes Correspond to actual procedures being performed 3476 Procedures Provides lookup of any individual procedure to see if privileges have been granted Provides basis for annual appraisal of procedures performed that were not privileged Provides long term evaluation of privileges not exercised

16 Defined Criteria Privileges in General Surgery Qualifications: To be eligible for core privileges in general surgery, the applicant must meet the following qualifications: * Adequate documentation of current competency in general surgery's CORE procedures with the performance of at least 100 general surgical procedures during the past two years or demonstrated successful completion of a hospital-affliated formalized residency or clinical fellowship in the past two years and *Current certification or active participation in the examination process leading to certification in general surgery by the American Board of Surgery, or the American Osteopathic Board of Surgery or Successful completion of a postgraduate residency in general surgery accredited by the ACGME, AOA, or equivalent.

17 Meeting JC Standards through ICD9 Core Privileges Define Procedural Specialties Define Procedural ICD9s by System Assign Categories to each ICD9 Determine what is included in core, what are exceptions to the core or require special documentation, and what would not be in the core Determine which procedures will cross specialties Define the major/core privileges within Seeker Assign major/core and special procedures to providers Privilege Inquiry with or without login launch point defined on intranet Establish ongoing and focused professional practice review based on actual procedures performed

18 Define Procedural Specialties General Surgery Neurosurgery Thoracic Surgery Vascular Surgery Urologic Surgery Gynecologic Surgery Orthopedic Surgery Opthalamic Surgery Otolaryngologic Surgery Oral Surgery Cardiac Surgery Transplant Surgery Obstetrics Plastic Surgery Hand Surgery Core Skills Adv Core Skills Cardiology Gastroenterology Pulmonology

19 Examine Procedural ICD9s by System Cardiac System 145 Dental System 37 Digestive System 519 Ear,Nose,& Throat 252 Endocrine System 81 Eye System 336 Female Genital System 225 Hemic & Lymphatic System 58 Integumentary System 110 Male Genital System 311 Musculoskeletal System 697 Nervous System 159 Obstetrical Procedures 76 Respiratory System 134 Vascular System 123 (blank) 22 Skills 38 Grand Total 3323

20 Assign Categories to each ICD9

21 Determine Core

22 Core Privilege Categories General Surgery

23 Determine which Procedures Cross Specialties

24 Major Privilege Definition

25 Privilege Entry

26 Privilege Entry (cont.)

27 Privilege Entry (cont.)

28 Privilege Inquiry

29 Privilege Inquiry (cont.)

30 Privilege Inquiry (cont.)

31 Privilege Inquiry (cont.)

32 Privilege Inquiry (cont.)

33 Privilege Inquiry (cont.)

34 Privilege Inquiry (cont.)

35 Privileges by Individual Privilege Standard Report

36 Privileges by Provider Standard Report

37 Privileges by Provider Standard Report (cont.)

38 Global Procedure Profile Profile: Principal Discharge Procedures MD 1234 Facility: Midas General Service: SURGERY Specialty: GENERAL SURGERY Indicator 2002 Total Service Nervous System Operations ( ) Endocrine System Operations ( ) Eye Operations ( ) Ear Operations ( ) Nasopharynx Operations ( ) Respiratory System Operations ( ) Cardiovascular System Operations ( ) Hemic/Lymph System Operations ( ) Digestive System Operations ( ) Urinary System Operations ( ) Male Genital Operations ( ) Female Genital Operations ( ) Obstetrics Operations ( ) Musculoskeletal System Operations ( ) Integumentary System Operations ( ) Misc Diagnostic & Therapeutic Procedures ( ) Total Inpatient & Observation Discharges w/ Prin Px

39 QM ICD9 Procedure Summary Standard Report

40 Dr Year Procedure Report Profile: A-General Surgery Privilege Performance Provider: Facility: Midas General HOSPITAL Service: SURGERY Specialty: GENERAL SURGERY Indicator Total Specialty Service Nervous System Operations ( ) Endocrine System Operations ( ) Eye Operations ( ) Ear Operations ( ) Nasopharynx Operations ( ) Respiratory System Operations ( ) Cardiovascular System Operations ( ) Hemic/Lymph System Operations ( ) Digestive System Operations ( ) Urinary System Operations ( ) Male Genital Operations ( ) Female Genital Operations ( ) Obstetrics Operations ( ) Musculoskeletal System Operations ( ) Integumentary System Operations ( ) Misc Diagnostic & Therapeutic Procedures ( ) Total Inpatient & Observation Discharges w/ Prin Px Gastric Resection Colon Resection Appendectomy Cholecystectomy Mastectomy Partial Mastectomy Endocrine Surgery Hernia Surgery Pancreatic Resection Esophageal Resection

41 QUESTIONS?