Credentialing Resource Center Journal

Transcription

1 Credentialing Resource Center Journal P4 P7 P9 P11 Book excerpt What makes a complete medical record? Todd Sagin, MD, JD, offers sample language for an effective medical staff policy and procedure for medical staff records completion. Privileges for Ps in the ER Hospitals must ensure that physician assistants privileges match those of the supervising physician, and pay close attention to state regulations. The lowdown on locums Without full credentials verification, MSPs could clinically and legally endanger patients and organizations, explains Sally Pelletier, CPMSM, CPCS. The MSP s voice Kathy Matzka, CPMSM, CPCS, makes the case for sharing practitioner data and suggests ways to do so without compromising privacy or policies. Volume 24 Issue No. 3 MRCH 2015 Credentialing Forum brings wide range of stakeholders to the same table With myriad stakeholders and requirements that can seem contradictory, MSPs may wonder what would happen if all sides gathered in one place to work through the processes and challenges of credentialing. They might be surprised to learn that such an event happens annually. For more than 25 years, the National Credentialing Forum (NCF) has convened for two days each February. The meeting atmosphere is informal, the agenda is fluid, long-winded presentations are discouraged, and there is ample time to discuss hot topics as well as traditional concerns. Insights from the annual meeting might lead to new or updated accreditation standards, improvements in credentialing software, or new agenda items at other conferences. But the meeting is limited to 50 attendees, and don t expect a press release, says nnette Van Veen Gippe, NCF organizer and executive director of the merican Osteopathic ssociation of Medical Informatics in Chicago. Both the NCF and the meeting have evolved with the credentialing process. The NCF was established in the 1980s as a special interest group for the merican ssociation of Medical Society Executives, an organization of executive directors of state, county, and specialty societies in the M House of Delegates. t the time, most physician credentialing was handled through creden- CLINICL PRIVILEGE WHITE PPERS We are constantly updating our library of Clinical Privilege White Papers. Here are a few of the most recently updated papers: Physician assistants in the emergency department Practice area 409 Endovascular surgical neuroradiology Practice area 104 Physical therapist Practice area 173 Hospital pharmacist Practice area 183 llergy and immunology Practice area 124 Download the latest papers from

2 Credentialing Resource Center Journal March 2015 tials verification organizations (CVO) for counties or states, which were created by state medical societies. They were doing this locally. They wanted to talk to each other about best practices, she says. They weren t in hospitals, or groups, they were medical society people," says Van Veen Gippe. They would do verification for all the hospitals in a town, or in the state. Eventually, medical societies got out of the credentials verification business. The process moved to hospitals and other organizations, and the NCF meeting roster grew to accommodate the changes. Today the NCF meeting includes stakeholders from across the credentialing spectrum. Invitations go out to the major accrediting organizations, CMS, medical societies, the Federation of State Medical Boards, the Education Commission of Foreign Medical Graduates, and software vendors, among others. The National ssociation Medical Staff Services (NMSS) sends two representatives. lthough the forum is limited to 50 participants, Van Veen Gippe sees the attendee list and the forum getting larger in the future. We try to get representatives from all accrediting bodies: TJC, HFP, DNV, and we re trying to get HC [the ccreditation ssociation for mbulatory Health Care] and other organizations, she says. The forum offers an opportunity for accreditors to discuss potential new requirements or revisions, expectations regarding physician quality, and so on. Nurse practitioners and physician assistants have been represented at the forum in the past two years. We need to get more into team health: How does that work, what issues are they facing? There are many different organizations involved in team health, and they don t all come, but maybe someday they will, says Van Veen Gippe. Sales pitches stay home The informal atmosphere spurs discussions among groups that might not otherwise talk as openly about the issues, she says. Everyone gets a chance to talk. Everybody has an equal voice. The NCF s agenda gives everyone a chance to talk about what they re doing, from NMSS to the Educational Commission for Foreign Medical Graduates, the Federation of State Medical Boards, the O, the M, and more. Everybody sits collaboratively in a room and talks about this is what we re doing, this is what works, this is what doesn t, and this is what the accreditors want us to do. ccreditors get to sit at the table, as do the folks This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission. EDITORIL DVISORY BORD Product Manager, Digital Solutions drienne Trivers Follow Us Follow and chat with us about all things healthcare compliance, management, and Managing Editor Mary Stevens mstevens@hcpro.com Carol S. Cairns, CPMSM, CPCS Senior Consultant The Greeley Company Danvers, Massachusetts President PRO-CON Plainfield, Illinois Becky Cochran, CPMSM, CPCS Director of Medical Staff Services San Juan Regional Medical Center Farmington, New Mexico Christina W. Giles, CPMSM, MS Independent Consultant, Medical Staff dministration Nashua, New Hampshire Kathy Matzka, CPMSM, CPCS Medical Staff Consultant Lebanon, Illinois Robert W. McCann, Esq. Partner Drinker Biddle & Reath, LLP Washington, D.C. Maggie Palmer, MS, CPMSM, CPCS, FCHE National Director of Credentialing Tenet Healthcare Dallas, Texas Sheri Patterson, CPCS President MSO Staffing Telecommuting Solutions Newport, Oregon Sally J. Pelletier, CPMSM, CPCS dvisory Consultant, Chief Credentialing Officer The Greeley Company Danvers, Massachusetts nne Roberts, CPMSM, CPCS Senior Director, Medical ffairs Children s Medical Center Dallas, Texas Elizabeth Libby Snelson, JD Legal Counsel to the Medical Staff St. Paul, Minnesota Fatema Zanzi, Esq. ssociate Drinker Biddle & Reath, LLP Chicago, Illinois Credentialing Resource Center Journal (ISSN: [print]; [online]), the newsletter of the Credentialing Resource Center (CRC), is published monthly by HCPro, a division of BLR. Enrollment fee in the CRC is $499/year or $899/two years. Credentialing Resource Center Journal, 100 Winners Circle, Suite 300, Brentwood, TN Copyright 2015 HCPro, a division of BLR. ll rights reserved. Printed in the US. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center at Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call or fax For renewal or subscription information, call customer service at , fax , or customerservice@hcpro.com. Visit our website at Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of CRCJ. Mention of products and services does not constitute endorsement. dvice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. 2 HCPRO.COM 2015 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

3 March 2015 Credentialing Resource Center Journal from the National Practitioner Data Bank and others, says Van Veen Gippe. Medical staff consultants have a seat at the table as well. They know what the problems are because they re [working with medical staff services departments and hospitals] and finding out what s working and what s not working, she says. Primary sources find out from other attendees how to fix or expand the services they re offering or the kinds of data they re collecting. Likewise, software vendors who attend the event will gather information for improving their products and services. However, no participants are allowed to sell at the show, notes Van Veen Gippe: We re here to learn what s needed to streamline the process and let everybody have better outcomes. flexible agenda The basic NCF agenda doesn t change much from year to year, "but what people put on the table is different, she says. Therefore, the agenda will accommodate changes depending on developments in the field. Van Veen Gippe drafts the agenda and invites participants to make suggestions. Then I hear from them: We need to address this, We need to talk about this. We can move things around if a topic needs to be addressed, she says. We change the agenda in the middle of the meeting if necessary. It s not a formal thing, so we can spend more time on things people really are concerned about. Emerging topics such as telemedicine credentialing or retail clinics come up for discussion, and NCF attendees might ask who s accrediting practitioners and how the process works. For example, there s new focus on credentials verification in ambulatory surgical centers, and an organization such as the HC might provide some answers. Employed physicians and their impact on the credentialing process was a scheduled topic for uestions from the field include: Is it still done the same way? If you ve bought a practice, how do you [credential] if the practitioner isn t in the hospital? says Van Veen Gippe. The forum discussion is continually rejuvenated because people including accreditors get answers, take what they learn, and make changes, she says. In addition, the informal atmosphere means people can be more open than they would if they had to stick to an official company-approved PowerPoint presentation, she adds. People don t need the stump speech. This group wants to know what s coming, what s new, what [accreditors] are looking for, and innovative things they ve seen from people they accredit. That s the kind of stuff they want to know, and we have time to talk about it. The take-home insights have spurred numerous results, she believes. For example, NCF members reported having issues with staff privileges and verifying information medical societies have standard lists of elements to verify, and that list has evolved. NMSS picked up on that and developed its list of items to check, Van Veen Gippe says. Likewise, when The Joint Commission introduced FPPE and OPPE, NCF participants had questions that showed more information was necessary in order to effectively measure quality in short, to explain how OPPE and FPPE really work and what [The Joint Commission surveyors were] looking for, she says. These standards weren t familiar, and when they first came out, this was the place to talk about them. There are a lot of ahas because people don t know what other groups are doing. That happens every year. Small is effective The NCF is not a money-making venture: Meeting attendees pay enough to cover the cost of the event, and it s run entirely by volunteers. There are no plans to expand or become a real organization, according to Van Veen Gippe. s credentialing has expanded and deepened over the years, the forum has grown and more organizations have been invited to participate. However, the meeting is still small enough that when it s over, we go back to our desk better equipped to do our jobs and know who to contact if we have questions, she says. fter the forum, volunteers post content as available. There are enough influential people in the room that if there s a good idea, they ll definitely take it back. There s a lot of infusion of new ideas. People go back with new ideas. Everyone helps each other, she concludes. Will NCF stay this way? If it were up to me, it would. H 2015 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 3

4 Credentialing Resource Center Journal March 2015 Policy and procedure for medical records completion Medical records completion has long been a difficult area for hospitals, but there s a lot more than convenience on the line if these records aren t completed in a timely manner. Following is a sample policy and procedure for medical records completion from The Top 45 Medical Staff Policies and Procedures, Fifth Edition, by Todd Sagin, MD, JD. For more inforamtion, click on Introduction The consequences of incomplete medical records are significant, with possible patient care, legal, regulatory, and financial repercussions. With increased federal reimbursements based on accurate and adequate documentation, hospitals are motivated to create medical records appropriately and implement a policy for medical records completion requirements. Policy and Procedure Policy: It is the policy of the [Hospital] medical staff to ensure timely completion of medical records in accordance with the following regulations and quality-ofcare standards: Disclaimer This sample policy is intended as a resource to assist in the development of medical staff- and hospital-specific policies. It is meant to serve as a sample document and should not be adopted without being customized for the unique needs of a particular organization. Because laws and regulations differ across the 50 states and accreditation standards are constantly evolving, unmodified use of this policy cannot ensure compliance with applicable laws, regulations, or standards. I. History and Physical. Components of the history and physical (H&P) The documentation of the H&P examination shall be consistent with the current guidelines for the documentation of evaluation and management services as promulgated by CMS or comparable regulatory authority. Traditionally, the H&P examination includes the following information: Chief complaint or reason for admission or procedure description of the present illness Past medical history, including past and present diagnoses, illnesses, operations, allergies, medications, and health risk factors n age-appropriate social history pertinent family history review of systems Relevant physical findings Documentation of medical decision-making, including a review of diagnostic test results, response to prior treatment, assessment, clinical impression, or diagnosis Plan of care, evidence of medical necessity and appropriateness of diagnostic and/or therapeutic services, counseling provided, and coordination of care B. Responsibility for H&P The H&P shall be performed and recorded by a physician (as defined in section 1861(r) of the ct), oral and maxilofacial surgeon, or other qualified licensed individuals in accordance with [State] law and hospital policy [CMS (c)(5)(i)]. Section 1861(r) defines a physician as a doctor of medicine or osteopathy; doctor of dental surgery or of dental medicine; doctor of podiatric medicine; doctor of optometry; or a chiropractor. The physician may delegate all or part of the physical examination and medical history to other practitioners who are granted privileges to complete an H&P. If [State] and hospital regulations allow nonphysician providers to perform H&Ps independently, they need not be cosigned by the physician of record. Where the [State] and/or hospital do not allow this independent performance of H&Ps by nonphysicians, then the physician must sign for and assume full responsibility for these activities. The hospital may accept a history and physician 4 HCPRO.COM 2015 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

5 March 2015 Credentialing Resource Center Journal examination performed within 30 days prior to admission by a physician without current hospital privileges as long as a practitioner with current hospital privileges endorses the findings and enters an interval note within 24 hours after admission and prior to an operative or other invasive procedure involving general or major regional anesthesia. C. H&P examination time frames and required updates Operative procedures and select invasive procedures: Except in an emergency, a current H&P will be documented in the medical record prior to: ll invasive procedures performed in [Hospital s] surgical suites Designated procedures performed in the radiology department and cath lab (e.g., angiography, angioplasty, myelograms, abdominal and intrathoracic biopsy or aspiration, pacemaker and defibrillator implantation, electrophysiologic studies, and ablations) Designated procedures performed in other treatment areas (e.g., bronchoscopy, gastrointestinal endoscopy, transesophageal echocardiography, therapeutic nerve blocks, central arterial line insertions, and elective electrical cardioversion) If a H&P has been performed and documented within 30 days of the scheduled operative or invasive procedure, a legible copy of that H&P may be used in the patient s medical record provided that an update is performed by a licensed independent practitioner or designee with privileges to perform an H&P immediately prior to (on the day of) the operative procedure. Inpatients that subsequently require surgery: These patients should already have an admission H&P on their chart. The surgeon should enter a progress note or consultation note documenting the provisional diagnosis, the indications for the procedure, and any changes in the patient s condition and physical findings since the admission H&P. dmission to hospital If a H&P has been performed and documented within 30 days of the patient s admission to [Hospital], a legible copy of that H&P may be used in the patient s medical record, provided that an update is performed by a licensed independent practitioner or designee with privileges to perform an H&P at the time of or within 24 hours of admission. The updated H&P examination preoperative and admission must: ddress the patient s current status and/or any changes in the patient s status (if there are no changes in the patient s status, this should be specifically noted) Include an appropriate physical examination of the patient to update any components of the exam that may have changed since the H&P, or to address any areas where more current data is needed Confirm that the necessity for the admission, procedure, or care is still present Be written or otherwise recorded on, or attached to, the previous H&P, or written in a progress or consult note Be placed in the patient s medical record prior to the operative procedure or at the time of or within 24 hours of admission Day/observation patient surgical admission: Outpatient surgery: The surgeon may complete a Focused preoperative H&P form as approved by the medical executive committee. If the focused preoperative H&P was performed prior to the day of the procedure, the surgeon must, on the day of surgery, note any changes in the patient s condition since the focused preoperative H&P. If there are no changes in the patient s condition, this should be specifically noted. Outpatient surgery patient subsequently admitted to observation/inpatient: The surgeon should have already completed a Focused preoperative H&P form. Upon admission, an admission H&P as described in section must be documented within 24 hours by the attending physician or his/her designee, specifically addressing any changes in the patient s condition since completion of the focused preoperative H&P. II. Operative notes Operative notes must be documented immediately after surgery. If the note is dictated and not immediate HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 5

6 Credentialing Resource Center Journal March 2015 ly transcribed, a written progress note must be entered into the record to include the name of the surgeon and any assistant, the procedure(s) performed, finding(s), postoperative diagnosis, specimen(s) removed, if any, and estimated blood loss. III. Discharge summaries Discharge summaries must be dictated within 14 days of discharge to allow for transcription and signing within 30 days of discharge. IV. Medical record completion Medical records must be completed and signed within 30 days after discharge. V. Delinquent medical record documentation Health information management systems (HIMS) responsibilities: The HIMS department shall provide physicians and dentists with weekly notices of records that remain incomplete. The department will not generate other notices, letters, phone calls, or lists. If a record has been dictated within the above guidelines but has not been available to the physician or dentist for signature, the practitioner will not be considered to have a delinquent medical record until the chart has been made available for one week. ction for delinquent medical record documentation: ny physician or dentist with more than four delinquent H&Ps (not dictated within 24 hours of admission) in a two- month period shall be notified and placed on intensified review for the next 12 months. The physician or dentist is allowed five delinquent H&Ps during this 12-month period. Each additional delinquent H&P shall result in one appearance on non-admit status*. The absence of prenatal records on delivery charts more than 24 hours after admission is considered a delinquent H&P. ny physician or dentist with more than four delinquent operative notes (not dictated within 24 hours of surgery) in a two-month period shall be notified and placed on intensified review for the next 12 months. The physician or dentist is allowed five delinquent operative notes during this 12-month period. Each additional delinquent operative note shall result in one appearance on non-admit status. ny physician or dentist with records incomplete more than 30 days after discharge shall be placed on non-admit status until the records are complete. Four appearances on non-admit status in the past 12-months constitute an automatic voluntary resignation from the medical staff. Multiple consecutive weeks on non-admit status shall be counted as one appearance per week. The [department chair/medical staff president] shall contact physicians who reach four appearances on non-admit status to review this policy. Nonadmit status shall be strictly enforced. The only exceptions will be previously scheduled surgeries and obstetrical admissions for delivery. It is the responsibility of the physician or dentist on non-admit status to notify the HIMS department when documentation is completed. If a physician or dentist demands admission of a patient despite his or her non-admit status, the HIMS department will direct the physician or dentist to contact his or her department chair. If a physician or dentist is on non-admit status for dictation that has not been transcribed, his or her admitting status may be changed, but the department chair shall monitor to determine the accuracy of such statements. physician will not be placed on no-admit status while on vacation. However, the physician must complete his or her delinquent records within 72 hours of return. It is the physician s responsibility to notify the HIMS department of vacation plans. Physicians on non-admit status shall not be exempt from taking emergency department calls. VI. Review and revision This policy shall be reviewed, revised, and amended as necessary in accordance with the provisions identified in the medical staff organization and function manual. It is the responsibility of the chief of staff to ensure the initiation of those review provisions. H *Non-admit status means that the physician may not schedule elective admissions and surgeries, nor may the physician order any diagnostic or therapeutic interventions for a period of one week or until all delinquent medical records have been completed. 6 HCPRO.COM 2015 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

7 March 2015 Credentialing Resource Center Journal White paper excerpt Physician assistants in the emergency department Editor s note: HCPro s Credentialing Resource Center is constantly adding to and updating its library of Clinical Privilege White Papers, which outline sample privileging criteria and background research for a wide range of medical specialty and subspecialty areas, procedures and new technologies, and allied health practice areas. The following is an excerpt from the Clinical Privilege White Paper for physician assistants in the emergency department Practice area 409. Physician assistants (P) in the emergency department (ED) are licensed to practice under physician supervision. ccording to the merican College of Emergency Physicians (CEP), Ps have a number of responsibilities in the ED, including out-of-hospital patient care, patient triage, patient care in the ED, and administrative functions. To qualify for practice, all Ps must first complete an educational program accredited by the ccreditation Review Commission on Education for the Physician ssistant (RC-P) or its predecessor organizations. P educational programs are offered at medical schools, colleges and universities, and teaching hospitals, as well as through the U.S. rmed Services. These programs average about 27 months in length, according to the merican cademy of Physician ssistants (P). Ps are required to have an associate s or bachelor s degree. In some cases, programs require a certain number of hours working in the medical field. Ps are required to have state licensing and seek clinical privileges. Privileges are granted based on education, training, experience, and competence. P s delineation of privileges usually closely resembles the privileges of his or her supervising physician. Ps in the ED undergo specific training and continuing education in emergency care. By law, Ps are dependent practitioners, but they often have significant autonomy in clinical decision-making, according to the Society of Emergency Medicine Physician ssistants (SEMP). lthough state laws vary, physician supervision may be provided by physical presence or reasonable access by telephone or electronic media. Physicians and Ps in the ED typically operate under the guidelines of supervision agreements, which provide an outline for how supervision is documented and what is expected of the P. Ps are granted privileges and should be members of the medical staff, according to P. Medical staff bylaws should specify professional criteria for clinical privileges, including evidence of national certification, letters of recommendations, logs of clinical procedures, evidence of professional liability insurance, and past or pending professional liability or disciplinary actions. P privileges are often delineated using a process similar to that used for physicians, according to the P. CRC draft criteria The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding Ps in the ED. The core privileges and accompanying procedure list are not meant to be all-encompassing. They define the types of activities, procedures, and privileges that the majority of practitioners in this specialty perform. dditionally, it cannot be expected or required that practitioners perform every procedure listed. Instruct practitioners that they may strikethrough or delete any procedures they do not wish to request. Minimum threshold criteria for requesting privileges for Ps in the ED Basic education: Master s, baccalaureate, or associate s degree Minimal formal training: Completion of an RC-Papproved program (prior to January 2001, completion of a CHEP-approved program) that included training in ED procedures for which privileges are sought, or demonstrated completion of an accredited emergency medicine P residency program ND 2015 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 7

8 Credentialing Resource Center Journal March 2015 Current certification by the NCCP ND Current licensure to practice as a P in the state in which applicant is requesting privileges ND Professional liability insurance coverage issued by a recognized company and of a type and in an amount equal to or greater than the limits established by the governing body, (if applicable to the facility) ND [Current CLS and pediatric advanced life support (PLS) certification] Required current experience: pplicants for initial appointment must be able to demonstrate provision of care, treatment, or services reflective of the scope of privileges requested for at least 50 patients in the past 12 months or completion of an RC-P-approved program in the past 12 months References If the applicant is recently trained, a letter of reference should come from the director of the applicant s training program. lternatively, a letter of reference may come from the applicable department chair and/or clinical service chief at the facility where the applicant most recently practiced. Core privileges for Ps in the ED Core privileges for Ps in the ED include the ability to assess, evaluate, diagnose, and initially treat patients of all ages who present in the ED with any symptom, illness, injury, or condition; provide services necessary to ameliorate minor illnesses or injuries; stabilize patients with major illnesses or injuries; and assess all patients to determine if additional care is necessary. Privileges do not include long-term care of patients on an inpatient basis. Privileges do not include ability to admit or perform scheduled elective procedures with the exception of procedures performed during routine emergency room follow-up visits. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills. Core procedures include: dminister medications and perform other emergency treatment ssess levels of comfort (e.g., pain, palliative care, end of life, bad news) and initiate appropriate interventions Complete EMTL-specified medical screening examination Perform sexual assault examination Specifically assess and initiate appropriate interventions for violence, neglect, and abuse (e.g., physical, psychological, sexual, substance) Specifically assess and initiate appropriate interventions and disposition for suicide risk Triage patients health needs/problems Inject local anesthetics Perform regional nerve block, including double cuff method/bier block, digital nerve block noscopy rthrocentesis (e.g., knee, elbow) Compartment pressure measurement Perform slit lamp examination Tonometry Control of epistaxis Removal of rust ring Cardiopulmonary resuscitation Neonatal resuscitation Insert and remove arterial catheters Insert and remove central venous catheters Intra-osseous infusion Peripheral venous cutdown Laceration repair simple, intermediate, complex ssist with imminent childbirth and post-delivery maternal care Patient evaluation rterial puncture and blood gas sampling Special noncore privileges for Ps in the ED If desired, noncore privileges are requested individually in addition to requesting the core. Each individual requesting noncore privileges must meet the specific threshold criteria governing the exercise of the privilege requested, including training, required previous experience, and maintenance of clinical competence. Noncore privileges include: dministration of sedation and analgesia Perform lumbar puncture Perform endotracheal intubation and extubation 8 HCPRO.COM 2015 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

9 March 2015 Credentialing Resource Center Journal Perform thoracentesis Perform paracentesis Insert thoracostomy tube Perform fluoroscopy Prescriptive authority in accordance with state and federal law Reappointment Reappointment should be based on unbiased, objective results of care according to a hospital s quality assurance mechanism. To be eligible to renew core privileges as a P in emergency medicine, the applicant must have an adequate volume of experience (care of [n] ED patients) in the past 24 months based on results of ongoing professional practice evaluation and outcomes. Experience must correlate to the privileges requested. Evidence of current ability to perform privileges requested is required of all applicants for renewal of privileges. [Maintenance of CLS and PLS certification is required.] In addition, current certification by the NCCP is required and continuing education related to Ps in emergency medicine should be required. H CRC Symposium Managing temporary and locum tenens privileges Healthcare organizations facing staffing shortages may resort to granting temporary privileges and using locum tenens physicians. However, without full credentials verification, credentialing and privileging professionals may clinically and legally endanger patients and healthcare organizations. t the Credentialing Resource Center Symposium, panelist Sally Pelletier, CPMSM, CPCS, will address this and several other hot-button credentialing and privileging issues throughout the two-day seminar March CRCJ recently sat down with Pelletier to ask her about the risks associated with temporary and locum tenens privileges. What makes temporary and locum tenens privileges risky for hospitals? Very often the impetus for granting temporary privileges or locum tenens privileges is driven by a short term or immediate need (substantiated or not) for coverage. Organizations either fail to properly plan for these circumstances or fail to develop a culture that is supportive of adhering to established policies and procedures. The risk is not that they are granting temporary privileges or privileges to locum tenens, but whether or not they fail to follow a full vetting process with appropriate due diligence to determine current competency for requested privileges. re you seeing these practices often in healthcare organizations? It is getting better. I would say that right now I m seeing about 50% of facilities still struggling with the issue of temporary privileges and 50% who have figured out solutions proactively to foster risk prevention in these situations. Do you think some organizations don t fully understand the implications of temporary and locum tenens privileges? Yes, their structure (medical staff bylaws and policies and procedures) may allow for less than a full credentialing process, and their environment may place undue pressure to credential and privilege practitioners quickly thus creating the perfect storm. Is one more prevalent than the other? In order to answer this question, we have to first understand the nomenclature. The granting of temporary privileges for a new applicant is by far the most prevalent. However, because the process requires a complete file pending medical executive committee review if processed in accordance with The Joint Commission requirements, this type of temporary privileges, while burdensome for the medical staff ser HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 9

10 Credentialing Resource Center Journal March 2015 vices department, is not typically risky. The second circumstance allowed by The Joint Commission is the granting of privileges for patient care need. The standards allow for a lesser process to be conducted thus increasing the risk. nd while The Joint Commission does not utilize the words locum tenens within its standards, very often locum tenens [practitioners] are the ones filling these gaps for patient care need. t The Greeley Company, we would be more inclined to recognize locum tenens as a type of practitioner contract service similar to telemedicine versus a type of privilege. Privileges are the defined scope of clinical services that the locum tenens is authorized to perform. The Merriam-Webster Dictionary defines locum tenens as one filling an office for a time or temporarily taking the place of another used especially of a doctor or clergyman. Do certain types of facilities rely more heavily on temporary privileges? You are less likely to find temporary privileges in an academic environment. Organizations that have a difficult time recruiting or that are in a more rural area may heavily utilize temporary privileges. Organizations wanting to increase market share and competing to onboard practitioners quicker also may rely very heavily on temporary privileges. Does criteria-based core privileging have a role to play in lowering the risks associated with locum tenens and temporary privileging? Criteria-based privileging lowers risks associated with any kind of privileging, including temporary privileges and privileges granted to locum tenens, by providing predefined objective eligibility criteria that establish the minimum qualifications for the core and other non-core privileges. Is there anything else you d like to add? There are many extremely well-qualified practitioners who are granted temporary privileges and who work as locum tenens. Organizations mitigate risk by following well-established and complete processes for granting clinical privileges regardless of whether it is for temporary privileges, locums, or otherwise (e.g., full membership and privileges). H EDITOR S NOTE To learn more about the 2015 Credentialing Resource Center Symposium, visit or call There's still time! Reserve your seat at the Credentialing Resource Center Symposium! Join us March for the return of the Credentialing Resource Center Symposium at Caesar s Palace in Las Vegas. Be a part of the conversation as we bring MSPs and medical staff leaders together to discover innovative approaches to top medical staff challenges. Industry experts Hugh Greeley; Carol S. Cairns, CPMSM, CPCS; Sally Pelletier, CPMSM, CPCS; and Todd Sagin, MD, JD, will offer best practices and winning strategies to overcome the most challenging issues facing the field today. This two-day seminar will help attendees conquer credentialing and privileging challenges, expertly educate and support their medical staff, protect their institution from negligent credentialing suits, learn from experts in the credentialing and medical staff services field, and bridge the gap between MSPs and medical staff leaders. Credentialing has evolved, and so has the CRC Symposium! Don t miss it! Go to or call to reserve your seat at the table. 10 HCPRO.COM 2015 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

11 March 2015 Credentialing Resource Center Journal The MSP s voice by Kathy Matzka, CPMSM, CPCS Getting and sharing relevant data One of the biggest challenges facing hospital medical staffs today is obtaining sufficient information to accurately document practitioner competency. It is easy to confirm that a practitioner held medical staff appointment at a healthcare facility and whether or not he or she was subject to any disciplinary action, but it can be much harder to obtain relevant practitioner-specific, aggregated data and objective opinions from other facilities. There are several reasons why this data can be hard to get. Organizations may not have their quality assessment/performance improvement (PI) data in a format that allows it to be easily shared, or they may lack the staffing necessary to respond to data requests. Voluntary medical staff leaders may not have the intimate knowledge to complete lengthy questionnaires, or may not want to take the time. Some organizations fear that if they share peer review information, they will lose the legal protections of the peer review statute. Many hospitals therefore opt to send a standard template letter in lieu of completing the verification letters that they receive. Some organizations have software that generates these letters directly from their website, or they may upload their provider information to the NMSS PSS website. These template letters provide valuable information, but don't typically provide information regarding clinical competency. Peer review protections It s worth noting that protections are built into state peer review statutes. s long as exchange of data is performed in a manner designed to preserve confidentiality and statutory privileges and is consistent with state peer review/quality improvement regulations, these protections will exist. Some state statutes provide immunity for reporting and disclosures that are made in connection with medical peer review, but these need to be reviewed carefully, including what is defined as peer review. Facilities should work with their attorneys to draft appropriate bylaws language and language in consent and release forms to address the exchange of information. Planning for process changes The first step in making any change is discussing the concept with the medical staff and facility leaders. The medical executive committee is an excellent starting point for this discussion. Medical staff leaders should determine what kind of information they require in order to make a reasoned decision regarding whether a practitioner is competent and qualified. They should also determine how far back they want to go with this information request. fter the medical staff makes its determination, the facility s governing body should take up the discussion. When the medical staff and governing body agree to accept only applicants for whom they can get adequate PI data and recommendations to support competency, some additional work may be needed: New medical staff bylaws language may be needed to address collection of PI data from other facilities for applicants and reapplicants, and for sharing information with other medical staffs. Letters sent to other facilities to verify appointment and clinical privileges may need to specify that template letters will not be accepted and the facility must complete the questionnaire included and provide the requested PI data. Consent and release forms completed by applicants and reapplicants may need new language that authorizes sharing information with other facilities. Work with legal counsel to draft appropriate language to address that exchange of information HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 11

12 Credentialing Resource Center Journal March 2015 The MSP s voice (cont.) Providing data to other facilities will take additional resources. Facilities should keep this in mind when preparing their budgets and should staff accordingly. Sharing data In addition to requiring this information from practitioners, the facility should develop a policy and procedures specifying which data it will share, and how, and the healthcare entities with which it will be shared. n important step is to evaluate the state peer review confidentiality statutes to determine if the information to be disclosed is protected as confidential peer review. If it is, the facility should work with its legal counsel to determine under what circumstances the information may be disclosed without losing the peer review privilege. Bylaws also may need to be amended to include specific language authorizing the sharing and receipt of such information. (See sidebar, below.) Verification letters are often sent directly to medical staff leaders, so it is helpful to have a policy addressing responses to these letters and completion of questionnaires. This policy should include forward- ing to the medical staff office any third-party queries or evaluations prepared by a medical staff leader for inclusion in the credentials file. Turnaround time for applications Requiring PI information will certainly increase the turnaround time for applications. Facilities must keep this in mind, especially those that track metrics for completion of applications and reapplications. pplicants must be notified that these requests will be made to other facilities and that the applicant will be asked to help if the facility refuses to provide the information or does not provide it in a timely fashion. Keeping the end goal in mind lthough requiring receipt of competency data and sharing such data with other facilities consumes hospital resources and requires more work by the medical staff, the patient will be the ultimate beneficiary of these actions. H EDITOR S NOTE Kathy Matzka is a medical staff consultant and Credentialing Resource Center Journal editorial advisor. Sample bylaws or policy and procedure language Facilities seeking competency data may need to amend their policies or medical staff bylaws. These samples can be customized for most facilities, but consult with counsel first. For obtaining information from other facilities: Each practitioner, as a condition for obtaining and maintaining staff appointment and/or privileges at [hospital name], must authorize the disclosure of restrictive action taken, peer review information, results of focused and ongoing professional practice evaluations, and quality assessment/performance improvement activities by the medical staffs of hospitals where the practitioner has privileges or to which the practitioner has applied or is employed. For releasing information to other facilities: Each practitioner, as a condition for obtaining and maintaining staff appointment and/or privileges at [hospital name], must authorize the disclosure of restrictive action taken pursuant to Bylaws section [refer to bylaws definition of restrictive action, i.e. suspension, termination, mandatory consultation, agreement by a practitioner to withdraw his/her application, etc.], peer review information, results of focused and ongoing professional practice evaluations, and results of quality assessment/performance improvement activities to the medical staffs of hospitals where the practitioner has privileges or to which the practitioner has applied or is employed. H 12 HCPRO.COM 2015 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or