Making the most of telepsychiatry

Transcription

1 P5 P7 P9 P11 P12 Want to be an expert witness? Most MSPs have the skills to excel as expert witnesses in negligent credentialing cases, but they may not have the time to spare. FPPE and NPDB: What is reportable? Todd Sagin, MD, JD, demystifies the meaning of the National Practitioner Data Bank s revised guidelines. The year in review Want to revisit your favorite article or form from last year? Browse the 2016 CRCJ story index. Outpatient settings Credentialing practitioners for outpatient settings has its own challenges and they're probably heading your way. The MSP s voice In the second part of her look at core competencies for MSPs, Maggie Palmer, MS, CPMSM, CPCS, FCHE, advises readers to take their expertise (and data) to other departments. Volume 25 Issue No. 1 JNURY 2016 Making the most of telepsychiatry Know the requirements and regulations that apply and have a process for sharing quality information Telepsychiatry shows promise as a way for hospitals to deliver scarce services to vulnerable patients, particularly in medically underserved areas. Often, telepsychiatry enables practitioners to evaluate and treat people who otherwise might not receive mental healthcare. For most organizations, technology is not the biggest hurdle; often the limiting factor is piecemeal regulation and/or lack of reimbursement. The challenges for privileging telepsychiatry providers are similar to the issues with other practice areas in telemedicine, according to some MSPs. For originating sites, do they wish to credential all providers in-house, or are they going to accept the credentialing from the distant site, if the distant site is a Joint Commission accredited facility? says nne Roberts, CPMSM, CPCS, consultant, medical affairs at Children s Medical Center in Dallas. Children s is developing a telepsychiatry program to offer services to remote sites. Initially, we will be the distant site, and we fully credential all of our providers. Sites that enter into telemedicine agreements will delegate their credentialing to us, says Roberts. Children s is a large pediatric academic medical center, and it has been the distant site in all cases. The organization provides telemedicine services Clinical Privilege White Papers We are constantly updating our library of Clinical Privilege White Papers. Here are a few of the most recently updated papers: Liposuction Procedure 88 Infectious disease Practice area 140 Gynecologic oncology Practice area 112 Urgent care medicine Practice area 441 Pulmonary medicine Practice area 143 Musculoskeletal oncology Practice area 189 Nuclear medicine technologists Practice area 200 Download the latest papers from resourcecenter.com.

2 Credentialing Resource Center Journal January 2016 to rural hospitals in many of its subspecialty areas, Roberts says. She expects Children s to serve as the distant site for the new telepsychiatry program as well. The only time we would serve as the originating site (at this time) would be when a provider is delivering services via telemedicine to either one of our clinics or hospitals within our health system, located at one of our other campuses. nother challenge for privileging telemedicine providers is ensuring that there are mechanisms in place that allow sharing of quality information back to the distant site. This should be done on a regular basis and included in the provider s OPPE data, Roberts advises. For its current telemedicine services, the hospital sends copies of current privileges to the originating site and requires each originating site to complete a clinical evaluation on each telemedicine provider every six months. The hospital develops specialty-specific quality indicators for each telemedicine program, and these are a part of the measures included on the clinical evaluations that each site completes for each provider, she says. The patchwork of state medical board requirements for remote practice across state lines requires healthcare providers and MSPs to be extra vigilant. In Texas, for example, the state medical board requires an initial face-to-face visit between the practitioner and patient to establish the doctor-patient relationship in most circumstances, Roberts notes. Informed consent and disclosure Organizations need to also be aware of whether their state requires specific disclosures (such as privacy agreements, the process for filing complaints, etc.) to be made in writing prior to a provider delivering patient care via telemedicine. Obtaining informed consent is also different when delivering services via telemedicine; thus processes need to be implemented for ensuring appropriate informed consent is documented in the medical record, says Roberts. Some organizations consider originating sites to be contracted providers governed by a telemedicine agreement in which the credentialing is delegated, and they are contracted with the other hospital to provide services via telemedicine. Some organization opt to add them as consulting members of the medical staff, rather than consider telemedicine a contracted service. Portneuf Medical Center (PMC), in Pocatello, Idaho, began using telepsychiatry services in 2015; it currently uses telepsychiatry providers, according to Marna Sorensen, CPMSM, director of medical staff services at the community hospital. 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 drienne Trivers Product Director Follow Us Follow and chat with us about all things healthcare compliance, management, and Mary Stevens Managing Editor mstevens@hcpro.com Carol S. Cairns, CPMSM, CPCS Senior Consultant The Greeley Company Danvers, Massachusetts President PRO-CON Plainfield, Illinois 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 Consultant, Medical ffairs Children s Medical Center Dallas, Texas Elizabeth Libby Snelson, JD Legal Counsel to the Medical Staff St. Paul, Minnesota Marna Sorensen, CPMSM Director, Medical Staff Services Portneuf Medical Center Pocatello, ID 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 2016 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 2016 HCPro, a division of BLR. 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3 January 2016 Credentialing Resource Center Journal Portneuf s telepsychiatry providers are considered distant sites, and the medical center follows The Joint Commission's standards for credentialing and privileging telemedicine practitioners. (See p. 4 for sample bylaws language.) The medical center also uses teleradiology providers. If providers are contracted, we follow the contracted company s credentialing. If the provider doesn t have a contract, we have to do the whole thing ourselves, Sorensen says. In situations where there is a contract, the PMC medical staff services department checks expirables and puts practitioners through the hospital s review and approval process they still go through the credentials committee, the medical executive committee, and the board, and providers have to use comparable privileges to those at Portneuf. Telepsychiatric practitioners are privileged but are not members of the medical staff, Sorensen adds. Before they can provide services, telemedicine providers have to come to PMC for orientation and training on the remote systems. Once that s done, they provide service from their home or office to patients at PMC. We have portable computers with TV screens, like a [computer on wheels] that can go from room to room, says Sorensen. Providers can see their patients and interpret body language. Telepsychiatry providers can prescribe medications and are insured by the hospital corporation, she adds. One psychiatrist, who also works elsewhere, oversees the program. The telepsychiatry services are needed on a daily basis. The center also taps telemedicine for expertise that isn t available locally, including neurology. Specialists from the University of Utah, in Salt Lake City, provide some telemedicine specialties, Sorensen says. The regulatory picture State medical boards, CMS, and accreditors have varying requirements for telemedicine providers. lthough changes are planned or underway, the regulatory patchwork has kept the brakes on telemedicine adoption. s of 2013, medical boards in 48 states, the District of Columbia, Puerto Rico, and the Virgin Islands required that physicians engaging in telemedicine be licensed in the state in which the patient was located, according to a review by the Federation of State Medical Boards. Practitioner licensure in the patient's state is also a requirement of The Joint Commission. Twelve state medical boards issue a telemedicine license, certificate, or license to practice telemedicine across state lines, according to the review. In 41 states, Medicaid has included telepsychiatry as a benefit. Medicare beneficiaries are eligible for telehealth services if services are presented from one of the following: n originating site located in a rural Health Professional Shortage rea located outside of a Metropolitan Statistical rea (MS) or in a rural census tract n originating site located in a county outside of a MS In 2016, the ssociation of State and Provincial Psychology Boards (SPPB) board of directors introduced the Psychology Interjurisdictional Compact (PSYPCT), an interstate compact designed to facilitate telehealth and temporary face-to-face practice of psychology across jurisdictional boundaries, according to the SPPB. The compact is somewhat similar in concept to the Interstate Medical Licensure Compact (IMLC) that is currently working its way through state legislatures nationwide. However, where the IMLC covers all physicians who wish to practice in multiple states, PSYPCT applies exclusively to practitioners of telepsychology. If enacted, PSYPCT could be beneficial to organizations that allow psychologists to provide teleservices in a state that participates in this initiative, says Roberts. However, it won t be helpful in states that have mandatory face-to-face requirements unless the out-of-state provider is willing to travel to establish the doctorpatient relationship initially, then continue treatment via telemedicine moving forward. Changes in the law such as the IMLC and PSYPCT could help telemedicine providers at Portneuf, says Sorensen, but as a critical needs state in many specialties and areas, an expedited credentials verification process doesn t necessarily help with recruiting. For MSPs, the telepsychiatry takeaways are: Know your accreditor s requirements, and review your facility s bylaws and policies for these providers, say Roberts and Sorensen particularly the processes for determining competency and sharing information with the provider s organization site. It s crucial to be prepared as the regulatory spotlight shines brighter on access to and reimbursement for behavioral health services. H 2016 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 January 2016 Figure 1: Sample bylaws language for privileges in telemedicine Practitioners providing telemedicine services must be granted privileges at this center. pplicants who privileges are not making application for medical staff membership at [Hospital Name]. They are making application for privileges only. It is acknowledged that the distant site is accredited by The Joint Commission or other CMS-approved accrediting body as an accredited organization for the provision of healthcare services. However, the following credentialing processes will be completed at [Hospital Name] in order to ensure the organization possesses the necessary documentation to be in compliance with CMS and Joint Commission requirements related to acute care hospitals. Practitioners providing official readings of images, tracings, or specimens through a telemedicine mechanism must do so under the following arrangement. In order for a practitioner to be eligible to request telemedicine privileges, the following requirements must be met: 1. The Medical Executive Committee (MEC) has recommended that the scope of telemedicine services provided at this hospital and the distant site hospital* include the privileges requested by the practitioner. Both the originating site MEC and the distant site MEC must approve this scope of services and the privilege form. 2. The practitioner must concurrently maintain privileges, at a minimum, for the same scope of services at the distant site hospital as he or she is requesting at the originating site hospital. (*The distant site hospital is the site from which the prescribing, interpretation, or treating services are provided.) In order for the originating site to utilize credentialing and privileging information from the distant site in credentialing and privileging decisions, the following three conditions must be fulfilled: 1. The distant site hospital or ambulatory care organization is accredited by The Joint Commission or other CMS-approved accrediting body; 2. The practitioner is privileged at the distant site hospital for those services to be provided at the originating site hospital; and 3. The originating site hospital has evidence of an internal review of the practitioner s performance of these privileges from the distant site, and sends to the distant site hospital information that is useful to assess the practitioner s quality of care, treatment, and services for use in privileging and performance improvement. t a minimum, this information will include all adverse outcomes related to sentinel events considered reviewable by The Joint Commission that result from the telemedicine services provided and complaints about the distant site hospital from patients, other licensed independent practitioners, and staff at the originating site hospital. In addition, individuals granted telemedicine privileges shall be subject to the Center s performance improvement and professional and peer review activities. The distant site may use [Hospital Name] s application and privilege forms or the other forms as approved by the Credentials Committee. Requests for telemedicine privileges at the originating site hospital will be processed through the established procedure for reviewing and granting privileges at the originating site hospital. Information included in the completed practitioner application for telemedicine privileges at the originating site hospital may be collected in the usual manner or may be collected from the distant site hospital. [Hospital Name] may query the National Practitioner Data Bank, verify the practitioner s [State] medical license with the primary source, and obtain an M Profile Report that confirms education, training, and board certification. Once the file is complete, the evaluation and decisionmaking process will follow the process specified in these Bylaws for all applications for medical staff membership and/or privileges. dapted from a form used at Portneuf Medical Center. Used with permission. 4 HCPRO.COM 2016 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 January 2016 Credentialing Resource Center Journal Good MSPs make good expert witnesses Necessary skills include expertise, patience, focus, and the ability to sift through thousands of documents to find relevant facts. Sound familiar? Most medical staff services professionals build their careers on helping their hospital medical staffs avoid situations that could lead to accusations of negligent credentialing. Yet the credentialing knowledge and expertise they amass can make them uniquely capable expert witnesses in negligent credentialing cases. The work can be rewarding, but it can also take copious amounts of time and patience, and it demands extreme attention to detail, according to Kathy Matzka, CPMSM, CPCS, medical staff services consultant in Lebanon, Illinois. The first question that MSPs interested in becoming expert witnesses should ask themselves is: Do I have the time to do this? Matzka said during a presentation at the NMSS 2015 Educational Conference and Exhibition. Serving as an expert witness can mean investing many hours reviewing thousands of paper and electronic documents and s not all of which may be relevant to a case. s expert witnesses, MSPs need to understand what s relevant to a case, and must be organized enough to keep accurate, very detailed notes about their findings. Initially, you ll get a copy of the claim, so you can see what they claim the negligent act is, and you usually get governing body and hospital bylaws, rules and regulations, and policies and procedures on credentialing or privileging, Matzka says. You might get peer review policies and procedures, or anything that happened [from] initial appointment all the way up to current reappointment. Or you may just get information from certain time frames, maybe just from the last reappointment leading up to an alleged negligent act. The information disclosed from credentials files also differs by state and depends on what the state and the individual court consider to be protected peer review documents. Sometimes when information is missing, you won t be able to get it because it s protected by peer review statutes, but you won t know if you don t ask, Matzka advises. Some courts will require the hospital to provide the entire credentials file, some will allow documents with redactions, and in some states you just get an application that the practitioner filled out and maybe a redacted privilege form, she says. In addition, hospitals may be ordered by the court to provide complete credentials committee meeting minutes, redacted meeting minutes, or none at all. Boxes of documents Be prepared for boxes of paper documents, or thousands of electronic copies, but focus on things that have to do with the deposition. MSPs know what information they need in order to make a decision about whether credentialing and privileging practices were reasonable, but the party you re working for may not know exactly what you need, says Matzka. For example, an attorney might send many pages of testimony related to patient care that aren t germane to the case. It s up to the expert witness to winnow the relevant information from potentially huge caches of electronic and printed material, to form an opinion based on the facts of the case. He or she should keep detailed notes to support this opinion, including a reference to the documents that corroborate it. The person taking your deposition will ask you to bring in everything you ve reviewed. They ll ask you if you made notes on any of the documents. If you did, then you have to remember what documents you made notes on and may be asked to identify the notes. Keeping your notes on separate sheets of paper makes this process much easier, Matzka says. Flexibility is a requirement as well. n expert witness can review a prodigious number of documents, then hear nothing for months only to be asked, sometimes with short notice, to appear for deposition. You need to have the time to handle that. MSPs are deadline-oriented, but sometimes there isn t enough time in the day to get everything done, Matzka says. To prevent overload, she advises MSPs to consider taking one case at a time if they already have a full-time job 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 January 2016 Expert witness testimony can help the two sides settle before litigation happens. They re hiring you because they want someone to evaluate the incident and tell them whether or not the hospital met the standard of practice, she says. The attorney needs to know this in order to help with the determination of whether or not they want to take the case to trial. In fact, the vast majority of cases involving negligent credentialing are settled before they ever get to trial. In almost 40 cases, I ve provided testimony as an expert witness at a trial in only one. I was the last witness, and after my testimony, while the jury was deliberating, the case was settled, she says. nswering the call Sometimes, finding work as an expert witness can be as easy as answering the phone. I received two calls out of the blue between May and June I had not put my name out as an expert witness, so the calls were unexpected, says Patti Gilcher, CPMSM, Expert advice If you re interested in being considered an expert witness, keep these tips in mind, says Patti Gilcher, CPMSM, director of medical staff services at the University of Maryland Upper Chesapeake Health in Bel ir, Maryland: Know the standards of the healthcare accrediting bodies, as well as best practices. Have plenty of credentialing experience, and be able to recognize red flags when you see them. Keep an open mind when you are reviewing these files. You want to be able to include in your report whether the hospital has done its job during the credentialing and re-credentialing processes; but you also need to be able to communicate the bad news if the credentialing was not done well. Be organized, particularly if you are handling more than one case at a time. Keep in mind that these cases can drag on for a year or more. Keep good notes when you are reviewing the documents so that you are ready if and when you re deposed. Keep track of your time you will need it when it comes time to send your bill! director of medical staff services at the University of Maryland Upper Chesapeake Health (UMUCH) in Bel ir, Maryland. Both of the firms that contacted Gilcher in 2010 were looking for an expert witness to provide an opinion for cases involving credentialing, she says. One case was a malpractice suit alleging negligent credentialing; in the other case, a client hospital was being sued by a physician who had been denied privileges. I had done a few consulting jobs for hospitals that were preparing for surveys by The Joint Commission, but nothing as an expert witness. I was told my name had been given to them by an attorney I knew from the firm that provides legal counsel for the healthcare system where I work. Gilcher had frequent interactions with UMUCH s attorneys over the years regarding a variety of medical staff matters, including fair hearings and appeals procedures, she says. They felt I would be able to help as an expert. fter these first two cases in 2010, Gilcher says she was contacted again in 2011, 2013, 2014, and February The firms that requested her expertise have all been different. While all of her expert witness work has been for hospitals defense teams, the work required has varied. Some cases come with relatively few documents mainly bylaws and policies. Others involve reams of paper, and include multiple interrogatories and depositions as well as the hospital s documents, according to Gilcher. She has taken on these cases in addition to her fulltime position as medical staff services director, but has been able to accommodate the added work. So far, for the small number of cases that I have had, I have been able to handle the preparation by working evenings and weekends when necessary, and using vacation time when I need to be out of the office, she says. The skills that make a good MSP make an excellent expert witness for those who can follow a paper trail and know where to look for missing information. The work is also rewarding because it enables MSPs to contribute to expertise of the legal system and the pursuit of justice. You benefit the public interest because you work to make hospitals better and right situations where people have been wronged. nd it pays very well, Matzka adds. But you re going to do a lot of work to earn that money. H 6 HCPRO.COM 2016 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 January 2016 Credentialing Resource Center Journal NPDB, reporting, and the NPDB revisions Editor's note: The following questions and answers are from the recent HCPro webcast, "FPPE and the Revised NPDB Guidebook: How to ddress New Reporting Challenges," presented by Todd Sagin, MD, JD, national director of Sagin Healthcare Consulting, LLC, and HG Consultants, LLC. Regarding categories: Is it necessary to query the NPDB for emeritus, honorary, or retired members of a medical staff? If you define them as members of your medical staff, then you need to query the Data Bank every two years. It doesn t matter what their category is, if they re on the medical staff, all physicians and dentists must be queried. ueries are also not a function of whether the physician is licensed or not; again, it s a matter of whether they have been made a member of your medical staff or your healthcare organization. What I ve done with some medical staffs is create something called a professional staff designation. These practitioners are not part of the traditional organized medical staff: They re part of a larger community of practitioners that want to relate to an institution. They don t need formal membership or privileges, but we want them to feel part of our medical community. There are no obligations, but the designation entitles people to get newsletters or updates about the hospital. They can come to CME if they want and participate in public events from time to time. It s a way to connect with a group of practitioners retired or just loosely connected to the hospital without putting them on the organized medical staff. But if you put them on the medical staff, the Data Bank requires you to make the query. What is the reporting requirement regarding nonrenewal of privileges? If a physician simply doesn t ask for renewal of membership or privileges, then that s not reportable UNLESS an investigation is underway. If it s at the end of their two-year reappointment cycle and an investigation is underway, and they don t file an application, that s considered a surrender of privileges in the face of an investigation, and it IS reportable. routine failure to reapply is not an issue. Is it reportable if there s a recommendation from peer review or FPPE that a physician voluntarily restrict privileges, but it is not mandated? It s not reportable if the physician voluntarily restricts privileges. If the leadership suggests that a physician restrict privileges or not renew, and he or she does so, that s also not reportable. It s only reportable if the physician is under investigation or if he or she relinquishes privileges in return for not having an investigation done. What should a medical staff professional do if they know a physician has been made an offer to resign in lieu of being suspended or terminated? If they re aware that the offer has been made, it s important to discuss with the people who made the offer, and at some point with the physician, the consequences of that resignation because the organization is obligated to report that resignation. They may still choose to make the offer, and a report to the Data Bank that somebody resigned in the face of an investigation is not evidence that somebody is incompetent or unprofessional in their conduct, only that there was an concern. If they re pretty sure the investigation will result in a definite decision that they were incompetent or unprofessional, maybe they d still decide to resign and not go forward with analysis. But they need to know it will be reported to the Data Bank. s a general rule, I think it s important to educate our medical staff leaders and administrative leaders that those kinds of offers are not appropriate and that s not a particularly professional way to handle the circumstance. It s being done because people are trying to avoid making reports to the Data Bank, and it s precisely because of that kind of under-reporting that the Data Bank puts the requirement that you have to report a surrender that s done in exchange for not proceeding with an investigation 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 We have a two-hospital system and one medical staff with two divisions. How should we handle NPDB reporting? If the two hospitals conduct separate credentials assessments, then they each have to query the Data Bank. If they are using one shared credential review process, they can do one Data Bank request. Even if you re in a system, if you have multiple nodes doing credentialing, they each have to query the Data Bank. But if you have one credentials evaluation and approval process, then one Data Bank request is sufficient. If direct proctoring is required for remedial monitoring, does this need to be completed within 30 days in order for it to not be reported, or is it reportable no matter how long it takes to be completed? If the proctoring is, in essence, a restriction on privileges, and it is if it s remedial, if that lasts for more than 30 days, it s reportable; less than 30 days, it s January 2016 not reportable. If the proctor is just there to capture as much observation as possible, with no limitations on the practitioner, then it s not reportable under any circumstance because it s not a limitation of any kind or the practitioner s exercise of his or her privileges. If a provider has signed a waiver for fair hearing rights and is no longer scheduled to work due to clinical or behavioral issues, is this reportable? If a decision is made to take professional review action, but the physician has waived his right to fair hearing, and a professional review action was taken but not challenged, that would be reportable. It s dependent on whether a final professional review action occurred, not on the fair hearing process. H EDITOR S NOTE For more information or to order this webcast on demand, go to com/fppe-and-the-revised-npdb-guidebook-how-to-address-new-reporting-challenges. Data Bank reporting: Is it a correction or a revision? Correction Report Corrects an error or omission in a previously submitted report by replacing it. The reporting entity must submit a Correction Report as soon as possible after the discovery of an error or omission in a report. The reporting entity may submit a Correction Report as often as necessary. When submitted, the NPDB sends a notification of the correction to the subject of the report and a copy of the corrected report to all queriers who received the previous version of the report within the past three years. Example: hospital mistakenly enters the wrong date of action on an Initial Report. Correction Report must be submitted to make the necessary change to the date. Revision-to-ction Report Modifies an adverse action previously reported to the NP- DB. The Initial Report and the Revision-to-ction Report become part of the disclosable record. The entity that reports an initial adverse action also must report any modification of that action. The NPDB sends a notification of the Revision-to-ction to the subject of the report but does not notify queriers, because the report does not replace a previously reported adverse action. It is treated as a separate action that pertains to the previous action. ueriers that have enrolled the subject into Continuous uery will receive this report. Example: hospital reports an initial action to the NPDB to suspend a physician s clinical privileges for 60 days, but subsequently reinstates the physician s privileges after reducing the suspension to 45 days. The hospital must submit a Revisionto-ction Report regarding the reinstatement. The Revision-to- ction Report is treated as an addendum to the Initial Report. Source: U.S. Health Resources and Services dministration. 8 HCPRO.COM 2016 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 January 2016 Credentialing Resource Center Journal CRCJ 2015 index: year in review Want to revisit your favorite article or form from last year? Browse through the Credentialing Resource Center Journal story index for 2015 to find what you need. ccreditation HC acquisition of HFP doesn t mean immediate changes for medical staffs. Dec., p. 5. DNV accreditation gains ground. ug., p. 5. New Patient Safety Systems chapter includes two existing Medical Staff standards. Jan., p. 1. Credentialing SPPB readies telepsychology compact for 2016 legislative sessions. Sept., p. 11. Credentialing HPs: Stick to specifics. pril, p. 10. Credentialing policies regarding aging practitioners. June, p. 8. Forum brings wide range of stakeholders to the same table. March, p. 1. Interstate Medical Licensure Compact hits state legislatures. pril, p. 1. Know your red flags when you see them. Sept., p. 4. Leadership s role in credentialing. May, p. 5. The more credentialing changes. Feb., p. 10. NBPS offers new recertification option. Sept., p. 6. The past and future of credentialing. Jan., p. 10. They re here to teach. Should they be fully credentialed? Nov., p. 1. Legal Compact won t replace state processes. Sept., p. 1. Court cases highlight the need to ensure appropriate disclosure. pril, p. 1. Follow bylaws as precisely as possible to avoid problems. Jan., p. 1. NPDB director: Updated Guidebook will take commenters concerns into account. pril, p. 5. NPDB Guidebook changes could mean shifts in reportable actions. ug., p. 1. Proctoring and precepting. Dec., p. 6. Urgent care privileges emerge. Dec., p. 8. Medical staff The best solution is prevention. June, p. 11. Creating a committee for HPs. Oct., p. 5. Compensation is on the rise for some MSPs. June, p. 11. Competency recommendations should be taken as just that. Nov., p. 5. Documentation: Two strategies for holding physicians accountable. ug., p. 12. Games MSPs play. May, p. 1. Generate case histories to prevent future medical staff office emergencies. May, p. 8. Keeping the credentials committee on track. Oct., p. 1. Make sure medical staff members are informed of unification options and document it. Feb., p. 4. Managing temporary and locum tenens privileges. March, p. 9. Meaningful indicators are key to robust OPPE, FPPE processes. June, p. 1. Optimal orientation requires flexibility, face time. Dec., p. 1. Pay is rising and more facilities are credentialing more practitioners. July, p. 1. Policy and procedure for medical records completion. March, p. 4. Proctoring and FPPE: Doctors Hospital of Manteca. pril, p. 5. &: Keep an eye on practice drift. ug., p. 10. Simulation training is taking flight in medical learning and practitioner competence assessment. Oct., p. 5. Strong policies make navigating practitioner contracts (and termination) less rocky. June, p. 5. Take the 2016 MSP Salary Survey. May, p. 11. To report or not to report: What to do about the recent NPDB Guidebook update. Oct., p. 7. The MSP s voice Bringing that something extra to the table. July, p. 12. Dare to fail, and share the lessons you ve learned. Sept., p. 12. Getting and sharing relevant data. March, p. 12. Letting leaders come to their own conclusions. ug., p 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 January 2016 Make the onboarding process everyone s responsibility. Nov., p. 12. Meetings are part of a healthy diet. Oct., p. 12. reorganized, re-energized medical staff. June, p. 12. The six core competencies for MSPs, Part 1. Dec., p. 12. The upsides of change. Feb., p. 12. Use an expanded onboarding tour to boost physician engagement. May, p. 11. Privileging CGME education requirements for musculoskeletal oncology are set to change. Nov., p. 8. nother look at locums. Nov., p. 6. Cardiovascular technologists get a variety of training. Sept., p. 9. Check medical staff policy for diagnostic radiologists requirements. pril, p. 8. If you re considering privileges for dietitians, check state laws. Feb., p. 1. Manage the entire locum tenens process. ug., p. 8. NMTCB, RRT update requirements for nuclear medicine technologists. Oct., p. 10. Pediatric radiologists must certify as diagnostic radiologists first. May, p. 10. Physician assistants in the emergency department. March, p. 7. Subspecialties and procedures may be key to privileging dermatologists. Jan., p. 5. Training varies widely for specialists in allergy/immunology. Feb., p. 7. Test your knowledge with this MSP quiz. ug., p. 10. Sample forms rkansas Children s Hospital bylaws for visiting physicians (excerpt). Nov., p. 3. rkansas Children s Hospital visiting staff application. Nov., p. 4. Focused professional practice evaluation/proctorship report: For admitting practitioners. pril, p. 6. Interstate Medical Licensure Compact draft language. pril, p. 3. Leave of absence policy for medical staff. Oct., p. 4. Medical staff services and credentialing medical staff coordinator competency quiz. May, p. 3. Policy and procedure for medical records completion. March, p. 4. Sample bylaws or policy and procedure language. March, p. 12. Sample new physician survey. Dec., p. 4. Sample policy & procedure for expansion of privileges for advanced practice professionals. pril, p. 11. Wayne Memorial Hospital Professional Practice uality Report. June, p. 3. New and updated Clinical Privilege White Papers Procedures Procedure 86 Intrathecal baclofen pump implantation Procedure 88 Liposuction Procedure 212 Transcranial Doppler ultrasonography Specialties and subspecialties Practice area 426 ddiction psychiatry Practice area 171 Clinical Psychology Practice area 127 Colon and rectal surgery Practice area 188 Developmental-behavioral pediatrics Practice area 159 Diagnostic radiology Practice area 104 Endovascular surgical neuroradiology Practice area 134 Family medicine Practice area 113 Geriatric medicine Practice area 112 Gynecologic oncology Practice area 105 Hyperbaric medicine Practice area 140 Infectious disease Practice area 189 Musculoskeletal oncology Practice area 145 Neurology Practice area 146 Nuclear medicine Practice area 147 Obstetrics and gynecology Practice area 459 Pediatric nephrology Practice area 152 Pediatrics Practice area 158 Psychiatry dvanced practice professionals and clinical assistants Practice area 412 nesthesiologist assistants Practice area 182 Hospital chaplains Practice area 196 Medical physicists Practice area 200 Nuclear medicine technologists Practice area 409 Ps in the emergency department Practice area 181 Pathologists assistants Practice area 173 Physical therapists Practice area 165 Physician assistants Practice area 192 Polysomnographic technologists Practice area 199 Specialists in blood banking technology H 10 HCPRO.COM 2016 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 January 2016 Credentialing Resource Center Journal Credentialing, peer review in outpatient settings Many organizations have only a vague idea of what clinical activity is going on in physician office practices Editor s note: With the rise of healthcare and services outside traditional hospital settings, outpatient practitioner credentialing and peer review are challenging medical staff services departments nationwide. We spoke with 2016 CRC Symposium presenter Todd Sagin, MD, JD, national medical director of Sagin Healthcare Consulting, LLC, and HG Healthcare Consultants, LLC, about some of the challenges. Can you talk about the unique challenges of credentialing and peer review in outpatient settings? The real challenge on the outpatient side comes when we try to apply the principles of inpatient privileging to the ambulatory world. Many organizations have only a vague idea of what clinical activity is going on in physician office practices. Then there is the question of what activities should have their own competency criteria, who should determine these criteria, and who should assure they are being met. Regarding peer review, there is very little meaningful ambulatory/office-based competency evaluation going on. This is troubling because most clinical care is delivered outside the peer review processes of hospitals. The fact that ambulatory medicine is largely delivered in geographically dispersed small office settings is another barrier to the effective deployment of historically utilized peer review techniques. What questions are you hearing the most with regard to credentialing these providers? MSPs and physician leaders are questioning which traditional credentialing procedures are applicable and required for outpatient practitioners. Other questions include what kind of competency monitoring should be used, how frequently should assessments take place, who should do collegial interventions with outpatient practitioners, and when should this work fall under the purview of the organized medical staff, an CO [accountable care organization] board, or the governing body of a CIN [clinically integrated network]. Do different accreditation standards apply for these practitioners? Hospital accreditation standards will apply to outpatient practices delivered under the license of a hospital. Other ambulatory facilities may be expected to meet standards promulgated by an alphabet soup of other entities ranging from the HC [ccreditation ssociation for mbulatory Health Care] to the NC [National Committee for uality ssurance]. Some outpatient entities will have to meet credentialing and peer review regulatory requirements such as those that apply to official CINs and Medicare COs. H EDITOR S NOTE The 2016 CRC Symposium will take place pril 7 8 at the Hyatt Regency Orlando in Orlando, Florida. Click here for more information. Save the date! If you missed the 2015 CRC Symposium in Las Vegas, mark your calendar now for the 2016 event, to be held pril 7 8 in Orlando, Florida. Refine and strengthen your medical staff policies and procedures with guidance from experts Hugh Greeley; Carol S. Cairns, CPMSM, CPCS; Sally Pelletier, CPMSM, CPCS; and Todd Sagin, MD, JD. In-depth sessions, inspiring keynotes, and engaging rapidfire question-and-answer sessions address a spectrum of topics, including: Credentialing and peer review in the outpatient world Privileging advanced practice professionals and physician assistants Running an effective credentials committee Managing disruptive practitioner behavior Focused professional practice evaluations (FPPE) and ongoing professional practice evaluations (OPPE) Top industry concerns and pain points Check the Credentialing Resource Center website ( for more 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 January 2016 The MSP s voice by Maggie Palmer, MS, CPMSM, CPCS, FCHE The six core competencies for MSPs, Part 2 Maggie Palmer, MS, CPMSM, CPCS, FCHE, presented MSP Competencies at NMSS 39th nnual Educational Conference and Exhibition, held in Seattle in October. The following is adapted from her presentation. Part one, which appeared in last month s CRCJ, included the first three core competencies. With a few word changes, the familiar six core competencies for clinicians can become the six core competencies for MSPs. Customize these competencies to gauge your job performance and to help others understand the importance of what you do and what you can offer to your organization. 4. Interpersonal and communication skills: MSPs must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with leadership, other departments, organizations, and professional associates. We have options for information exchange telephone, fax, and but what is most effective? I think is the end of society as we know it. People read between the lines of messages and say things they don t mean. good rule of thumb is that if you have two exchanges in , the third should be a telephone call. Many misunderstandings can be avoided through a single call. Keep a mirror near your phone so when you pick up the receiver, you look in the mirror and smile. People on the other end of the phone can hear the smile. I've defused bad situations by using a mirror and smiling on the phone. Pre-meetings can be another way to communicate effectively. lways meet with your chair and others beforehand. Get outside your office or cube, even if it s just for a few minutes, just to clear your brain. You never know who you might meet outside your office. 5. Professionalism: MSPs must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diverse organizational relationships. Have a trusted colleague assess your performance of what you do, including specific job duties. Don t just do this once and forget about it. You can implement an assessment schedule that matches OPPE. Look at your facility s job descriptions for MSPs. Is yours even close to what you do? It might be time to show leadership what you really do this can be very important for making sure you re earning what you should be earning. sk HR to see a pay scale for tasks that are comparable to what you do. If you re CPMSM- or CPCS-certified, know your certification description and requirements, and make sure they re included in your job description. Look at MSP salary surveys or make your own survey of MSPs in your area. 6. Systems-based practice: MSPs must demonstrate an awareness of and responsiveness to the larger context and system of healthcare and the ability to effectively call on system resources to provide service that is of optimal value. What does the finance department do? What about quality and risk management? You don t need to be an expert, but you are more valuable to your organization if you can see the big picture and can talk about it with other departments. Take customer service classes. You do have customers! Read the employee handbook, and read the policies for HR too. Be a contributor as well: Keep reaching out to meet the needs of your internal and external customers. H EDITOR S NOTE Palmer is National Director of Credentialing at Tenet Health, an international multihospital health system based in Dallas. 12 HCPRO.COM 2016 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