Credentialing Resource Center Journal

Transcription

1 Credentialing Resource Center Journal P5 P8 P10 P10 Privileging dermatologists Subspecialties such as dermatopathology, pediatric dermatology, or procedural dermatology may require different privileging criteria. year in review Want to revisit your favorite article from last year? Forgot what issue that form you really liked was in? Browse through the Credentialing Resource Center Journal story index for 2014 to find what you need. ll in one place The Joint Commission s Patient Safety Systems CMH chapter puts patientsafety-related standards in one place, but the survey process won t change. Keeping things in perspective To know where credentialing is going, you have to know where it s been. Two CRC Symposium panelists explain why this is important to know, and what to expect at the March 2015 event. Volume 24 Issue No. 1 JNURY 2015 Q& Follow bylaws as precisely as possible to avoid problems Effective medical staff governance documents are more important than ever, but they are a problem area in many organizations. During a recent webcast, Medical Staff Governance Documents: The Increasing Importance of Contemporary Bylaws, Todd Sagin, MD, JD, offered guidance for differentiating among rules, regulations, policies, and bylaws. Following are questions and answers from this webcast. I ve heard that medical staff bylaws serve as a legal contract. What Q does this mean? You ve heard that term because it s widely used. It s used in a legal context do the bylaws, promulgated by the institution and signed by the practitioner, represent a binding set of requirements on both parties? nd is failing to follow what s in the bylaws considered a breach of contract, which is a legal action that can be brought against people who don t adhere to a contract? In general, bylaws are viewed as a contract in the sense that the intent is that the parties are bound by them. bout half the states in the country are jurisdictions that have formally identified bylaws as contracts between the medical staff and the hospital. In other states 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: Dermatology Practice area 132 Cytotechnologist Practice area 194 Registered nurse first assistant Practice area 101 Neurophysiological monitoring Practice area 187 Certified nurse midwife Practice area 164 Download the latest papers from

2 Credentialing Resource Center Journal January 2015 it has been determined that bylaws are not really a contract and still others are silent on the issue. By and large, the status of bylaws in a state really doesn t matter: You should treat these documents as if they are creating a binding set of mutual responsibilities between the practitioner, the medical staff and the parent hospital. Medical staff personnel, and medical staff and hospital leaders should attempt to follow the bylaws precisely and try not to deviate from them. From a risk management point of view, that s the position and attitude everyone ought to take as he works with these documents. Q Should our medical staff membership include providers who need hospital membership to be part of certain healthcare or insurance plans, but have no intention of using the hospital or being supportive? This condition for health plans is a holdover from time when insurers and managed care plans didn t want to do their own credentialing and wanted to rely on hospital credentialing. It s a silly requirement today because insurers have to do their own credentialing and can t rely on a medical staff to do it for them by proxy. I would suggest a little bit of prudent pushback on insurers in your community. You might challenge payers to drop such a requirement because it makes no sense and it s burdensome to everybody. If that can t be achieved, what most hospitals have done is create a privilege called refer and follow. It says physicians do indeed have a privilege here at the hospital. This is the privilege to send patients to the hospital, and they can come and see these patients but can t actually do any management of care. The downside to this tactic is these physicians become members of your medical staff with privileges. You can put them in a non-voting category, of course, and probably should if they re not active at your hospital. However, you still have to go through some minimal credentialing requirements, a National Practitioner Data Bank check and licensure and so forth. You don t have to worry about demonstrated current competence because you haven t granted them an actual clinical management privilege, but you do have to worry about some of those other basic credentialing requirements. If a hospital truly sees no benefit to supporting these physicians with privileges because they 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, 75 Sylvan St., Suite -101, Danvers, M Enrollment fee in the CRC is $499/year or $899/two years. Credentialing Resource Center Journal, P.O. Box 3049, Peabody, M 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 January 2015 Credentialing Resource Center Journal don't support the hospital, there s no requirement to give them privileges on the medical staff. You can continue to say, as a matter of membership qualification if your bylaws are properly written, that a physician has to demonstrate some basis for how he or she is going to help the institution meet its mission. Having such a requirement in the bylaw gives you the option not to grant every requesting physician this refer-and-follow privilege. Q We are a system of multiple hospitals, and each has its own medical staff bylaws. Is it advisable to allow individual hospital medical staff policies if our organization is trying to develop consistency across all hospitals? Or is it acceptable and recommended to have separate bylaws, but incorporate medical staff policies for consistency? There are a couple of issues here. Certainly, you could unify some of your medical staffs. Unifying them into one huge medical staff probably wouldn t make sense because my guess is your system covers a pretty broad geography. But there may be some clustering of medical staffs where it would make sense to unify them and allow them to work with a common set of medical staff bylaws. With regard to policies, it certainly makes sense at the system level to vet some real best practices and implement them through adoption of some policies that will be uniformly applied to all of your medical staffs. But it s always important to recognize that there are local cultures and local differences in practice, and local differences in the constellation of available resources, that would warrant some uniqueness in policies or justify specific local flavor in the policies. The goal should be to create system-ness in policies where it actually yields value where unique local issues yield value, then we want to preserve these local characteristics and preserve the ability to have some local control over policies. Increasingly, there are best practices that ought to be reflected across all of a system s institutions. If your goal is to reduce variance across your institutions, uniformity of policy and approach makes a lot of sense. The other question is, do you want to create some structures across your various medical staffs to provide a forum to reach consensus on those systemwide policies and procedures. That s generally wise, rather than simply handing policies down from on high. However, creating these structures can be a complicated task. Q What about adding language regarding conflict resolution between the medical executive committee (MEC) and medical staff? Is this a Joint Commission requirement? Yes, there should be some mechanism by which the medical staff can appeal to the MEC when members feel the MEC is making decisions that are not in concert with the general feeling of the medical staff. There should be a mechanism that can at least bring that concern to the fore and have it addressed. It does not require arbitration or mediation, or any particular approach to conflict resolution. You want to at least assure that, if there s a concern that some kind of a small cabal on the MEC is going off in its own direction and not being responsive to the general medical staff, there s a mechanism to raise the issue. This mechanism can be something as simple as an ability to petition for a special meeting of the medical staff. It can also be a mechanism to revisit policies that are passed by MEC that are contentious with a portion of the medical staff, and where the MEC is asked to reconsider. It s not a requirement that mandates arbitration or mediation in any formal sense. There just needs to be some recourse for dialog to occur between medical staff and MEC if a significant enough portion of the general medical staff has a concern. That can be something as simple as an ability to petition for a special meeting for the medical staff. It can also be a mechanism to revisit policies that are passed by MEC that are contentious with a portion of the medical staff, and ask the MEC to reconsider. It s not a requirement that requires arbitration or mediation in any formal sense. There just needs to be some recourse for dialog to occur between medical staff and MEC if a significant enough portion of the general medical staff has a concern 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 2015 Q Our system includes a hospital, with clinics across three cities. Should our bylaws, rules, and regulations stretch to include them, rather than have more focus on hospital practices and privileges? Increasingly, there are good best practices out there for bylaws, policies, rules and regulations. If it was as simple as there being one set of bylaws and one set of policies and procedures that were perfect for everyone, I m sure everyone would buy them and use them. It s not that simple, but there are well thought out, well vetted, widely used policies, policy language, and bylaws language. [Unfortunately,] what happens at many medical staffs is that leaders recognize an issue and make up an approach to address it. This is not a bad thing, but when people try to create policy language and solve problems without any awareness of how the relevant issues has been tackled or approached in other places, they can t benefit from the lessons learned by their colleagues on other medical staffs. It really is worth trying to adopt well-vetted policies. If you ve got multiple institutions, you d want to see them adopt the best language and best practices, unless there is some kind of mitigating circumstance which warrants deviation. Sometimes that deviation is just local politics, which doesn t make sense and ought to be resisted. Sometimes it s local culture which actually is supportive of good practice and probably ought to be indulged. gain, there s no right or wrong here. Q Regarding corrective action policies: What s a good definition of in good standing or would an organization be better off not using that language at all? My own feeling is that it s a good idea to avoid using the language because there are so many interpretations of what it means. You ll often get queries: Is Dr. So-and-so in good standing? Or people will write to you that Dr. So-and-so was in good standing. It s not clear what they meant and it s not clear what you meant. If a physician is under FPPE because of concern about one of his cases, is he in good standing? If a practitioner is the subject of an ongoing fair hearing, but there s been no completed adverse action taken yet, is he in good standing? If he has not been suspended, is still holding his privileges, and it s being discussed at a fair hearing, is he in good standing? If you re going to use the term, it s important to define it. nd I would be careful, when you communicate to other places, that you include your definitions so they know what you re talking about. lot rests on how people interpret in good standing, and they may make decisions that are dangerous to patients and are harmful because they misunderstood what you meant when you implied somebody was in good standing. If a physician has received a reprimand or has had a long history of unprofessional conduct, but hasn t been subjected to a disciplinary suspension or some kind of corrective action, is he in good standing? There are medical staffs that say no and there are staffs that say yes. What happens more often than not is that whoever got the query makes his own decision, based on the practitioner s history, of whether he is in good standing or not. There is no single right or wrong definition out there. I m not aware of any regulatory body that uses a particular definition for in good standing, so it s up to each to each medical staff to decide what it wants that term to encompass. Q What language would you put in place of in good standing? The best practice is always to be absolutely clear about what s going on. So rather than say, Dr. Sagin is in good standing or in bad standing, say, Dr. Sagin is currently a member of our medical staff with full privileges and has been the subject of a FPPE because of concerns with regard to laparoscopic injuries, and has received two professional reprimand letters for unprofessional conduct. You won t usually get into trouble for sharing things that are factual, but when you imply things, you can get into trouble. Rather than use imprecise language, I d recommend that you just be as precise as you can be about any behavior or performance 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 January 2015 Credentialing Resource Center Journal that is of concern. If some asks you, on a request, is Dr. Sagin in good standing? I would either ask them for their definition of in good standing, or just respond with language like I just shared. If there s something going on in regard to a physician s performance at the institution that you think merits sharing, then share it. It s perfectly okay to do that. H EDITOR S NOTE Go to for more information or to purchase an on-demand copy of this presentation. White paper excerpt Subspecialties and procedures may be key to privileging dermatologists 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 specialty Clinical Privilege White Paper for Dermatology Practice area 132. Dermatologists are physicians who specialize in evaluating and managing adults and children with benign and malignant conditions and disorders of the skin, hair, nails, and adjacent mucous membranes, according to the merican Board of Dermatology (BD). Dermatologists have had additional training and experience in: Diagnosis and treatment of skin cancers, melanomas, moles, and other tumors of the skin Management of contact dermatitis and other inflammatory skin disorders Recognition of skin manifestations of systemic and infectious diseases Dermatopathology Surgical techniques used in dermatology Postgraduate training for dermatologists is four years in length. Physicians may enter a three-year full-time residency program after completing a broadbased clinical year of training in an ccreditation Council for Graduate Medical Education (CGME) accredited program. lternatively, they may enter a four-year dermatology training program during which the first year is spent on broad-based clinical education. Osteopathic physicians must complete a one-year merican Osteopathic ssociation (O) approved internship year and three years of dermatology residency training in an O-accredited program. The BD is the certifying board for dermatologists. The merican Board of Medical Specialties (BMS) recognizes two subspecialties of dermatology: pediatric dermatology and dermatopathology. Physicians who have completed additional training and are certified in dermatology may become boardcertified by the BD in either subspecialty. The merican Osteopathic Board of Dermatology (OBD) offers certification for dermatologists, as well as certificates of added qualifications (CQ) in dermatopathology, pediatric dermatology, and Mohs micrographic surgery (MMS). Dermatologists may also complete an CGMEaccredited procedural dermatology fellowship. Procedural dermatology is the subspecialty that is concerned with the study, diagnosis, and surgical treatment of diseases of the skin and adjacent mucous membranes, cutaneous appendages, hair, nails, and subcutaneous tissue. This one-year program includes dermatologic surgery, which may occur in an CGME-accredited dermatology residency training program. lthough the CGME recognizes procedural dermatology, currently there is no certification examination process for procedural dermatology 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 2015 Minimum threshold criteria for requesting core privileges in dermatology Basic education: MD or DO Minimum formal training: Successful completion of an CGME-, O-, CO-, or RCPSC-accredited residency in dermatology ND/OR Current certification or active participation in the examination process (with achievement of certification within [n] years) leading to BD certification or OBD CQ in dermatology Required current experience: Inpatient, outpatient or consultative care reflective of the scope of privileges requested, to at least [n] patients during the past 12 months, or successful completion of an CGME-, O-, CO-, or RCPSC-accredited residency or clinical fellowship within 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 in dermatology Core privileges for dermatology include the ability to admit, evaluate, diagnose, treat, and provide consultation to patients of all ages, with benign and malignant disorders of the skin, mouth, external genitalia, hair, and nails, as well as sexually transmitted diseases. Core privileges also include the diagnosis and treatment of skin cancers, melanomas, moles, and other tumors of the skin, management of contact dermatitis and other allergic and nonallergic skin disorders, cosmetic disorders of the skin such as hair loss and scars, the skin changes associated with aging, and recognition of skin manifestations of systemic and infectious diseases. Privileges also include the ability to assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include performance of these core procedures: Botulinum toxin injection Chemical face peels Collagen injections Cryosurgery Destruction of benign and malignant tumors Electrosurgery Excision of benign and malignant tumors with simple, intermediate, and complex repair techniques, including flaps and grafts Interpretation of specially prepared tissue sections, cellular scrapings, and smears of skin lesions by means of routine and special (electron and fluorescent) microscopes Intralesional injections Patch tests Perform history and physical exam Photomedicine, phototherapy, and topical/systemic pharmacotherapy Potassium hydroxide examination Scalp surgery Sclerotherapy Skin and nail biopsy Soft tissue augmentation Tzanck smears Special noncore privileges in dermatology 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 may include: Laser use MMS Liposuction Dermabrasion dministration of sedation and analgesia Minimum threshold criteria for requesting core privileges in dermatopathology Basic education: MD or DO Minimum formal training: Successful completion 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 January 2015 Credentialing Resource Center Journal of an CGME- or O-accredited residency in dermatology, followed by a successful completion of a fellowship in dermatopathology ND/OR Current certification or board eligibility (with achievement of certification within [n] years) leading to BD subspecialty certification in dermatopathology or CQ in dermatopathology by the OBD Required current experience: [Full-/part-time] dermatopathology services reflective of the scope of privileges requested for the past 12 months, or successful completion of an CGME- or Oaccredited residency within the past 12 months Minimum threshold criteria for requesting core privileges in procedural dermatology Basic education: MD or DO Minimum formal training: Successful completion of an CGME- or O-accredited residency in dermatology, followed by a successful completion of a fellowship in procedural dermatology ND/OR Current certification or board eligibility (with achievement of certification within [n] years) leading to certification in dermatology by the BD or OBD [and successful completion of a fellowship in procedural dermatology] Required current experience: [n] dermasurgical procedures, reflective of the scope of privileges requested for the past 12 months, or successful completion of an CGME- or O-accredited residency or clinical fellowship within the past 12 months Reappointment Reappointment should be based on unbiased, objective results of care according to a hospital s quality assurance mechanism. pplicants must demonstrate current competence and provision of care to [n] inpatient/outpatient/consultative patients with acceptable results, reflective of the scope of privileges requested for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges. In addition, continuing education related to dermatology is required. [Maintenance of certification is required.] 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. H Wanted: FPPE forms HCPro is working on a new book about focused professional practice evaluations (FPPE), and we re inviting you to be a part of it! Our goal for this book is to feature the field-tested policies, dashboards, indicator lists, and other forms that organizations are already using to conduct FPPE both for initial applicants and for members of the medical staff. The new book will be structured similarly to the recently released The OPPE Toolbox by Juli Maxworthy, DNP, MSN, MB, RN, CNL, CPHQ, CPPS. Your FPPE policies and forms could be reviewed by our field experts and included in our book. If you d like to be considered as a contributor to HCPro s new book of field-tested FPPE tools, please us your forms with a few paragraphs about your organization s experience, including: How long has your organization had an FPPE policy? Did you implement your FPPE policy at the same time as your OPPE policy? What roadblocks did you face implementing your FPPE policy? How involved were you in developing and implementing your FPPE policy? Did you have any FPPE policy? Did you have any outside help (i.e., consultants)? Has The Joint Commission surveyed you on this policy? (if applicable) Please send replies to Mary Stevens, CRCJ managing editor, at mstevens@hcpro.com, by January 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 January 2015 CRCJ 2014 index: year in review Want to revisit your favorite article from last year? Forgot what issue that form you really liked was in? Browse the Credentialing Resource Center Journal story index for ccreditation MSPs will find familiar concepts in new HFP requirements. May, p. 1. NCQ s PCMH standards boost alignment, data collection. June, p. 1. What to look for in CMS revised medical staff related CoPs. ug., p. 1. Credentialing Survey: Public is open to wider roles for NPs. Jan., p. 2. ICD-10 and credentialing. Jan., p. 3. Navigating the pitfalls of PP credentialing and competency assessments. Jan., p. 7. Oregon gets to work building a credentialing database. Feb., p. 1. Data Commons partnership creates a new resource for credentialing committees. Feb., p. 9. Determine which competencies and time frames would work in your organization. Nov., p. 5. Prepare to credential and manage in a virtual world. Dec., p. 1. Legal Preparing for an aging physician workforce. March, p. 4. Court cases highlight the need to ensure appropriate disclosure. pril, p. 1. NPDB Director: Updated Guidebook will take commenters concerns into account. pril, p. 5. There may be legal baggage hiding behind in good standing. Sept., p midnight rule draws concerns about emergency physician admitting privileges. Sept., p. 9. Interstate Licensure is ready for state votes. Dec., p. 8. The MSP s voice Incorporate new skill sets in Jan., p. 12. I have to ask my doctor about what? Feb., p. 12. Information symmetry is the goal. March, p. 12. The end of OPPE and FPPE (pril Fools!) pril, p. 12. The Northridge Effect. May, p. 12. Taking a vacation from distractions. June, p. 12. smooth relationship with medical staff leaders. July, p. 12. When a picture IS worth a thousand words. Sept., p. 12. Prep your medical staff leaders with a pre-survey boot camp. Oct., p. 12. Taking things bird by bird. Dec., p. 12. MSSD MSP Planner: Familiar issues, new twists. Jan., p. 1. With changes in care delivery, a unified competency committee may be in your future. Jan., p. 5. Look for detailed assessment, education plan for smoother credentialing. Feb., p. 1. Late-practice physicians pose new challenges. March, p. 1. Medical boards continue to struggle with managing poorly performing physicians. March, p. 7. Physician assessment shouldn t be an age thing. May, p. 5 NPDB reporting 101. pril, p. 4. Resolve turf conflicts. pril, p. 6. Take the 2014 MSP Salary Survey. May, p. 10. Getting to a Just Culture. June, p. 4. The best solution is prevention. June, p. 11. clearer picture of work and compensation. July, p. 1. It s all in a day s work. July, p. 9. Q&: Keep an eye on practice drift. ug., p. 10. Documentation: Two strategies for holding physicians accountable. ug., p. 12. Is it time to revisit your hospital s autopsy policies? Sept., p. 1. Physician engagement tip: Include a resignation letter with the reappointment package. Sept., p 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 January 2015 Credentialing Resource Center Journal Simulation training is taking flight in medical learning and practitioner competence assessment. Oct., p. 5. NPDB lowers query rates for its information. Oct., p. 11. Follow best practices for processing temporary privileges and locum tenens. Nov., p. 11. Time measurement is the first step to time management. Dec., p. 5. Privileging Developing a training up policy. Jan., p. 8. MSPs, physicians, and hospital-owned clinics: No easy answers. Oct., p. 1. Privileging physician assistants in radiology. Feb., p. 10. Putting disaster planning to the test. March, p. 5. dvanced heart failure and transplant cardiology. March, p. 10. Physician assistants in critical care. pril, p. 8. Privileging nurse practitioners. June, p. 8. Privileges for pediatric gastroenterology. July, p. 10. Customizing criteria-based core privileges for your organization. ug., p. 5. Privileging audiologists: Through HR or medical staff? Oct., p. 8. standardized privilege project is on the move at MaineHealth. Nov., p. 1. Sample forms CRC draft criteria for practitioners. June, p. 10. Sample resignation letter to include with the physician reapplication form. Sept., p. 11. Standardized operating procedures. Nov., p. 4. Sample medical staff office time study. Dec., pp New Clinical Privilege White Papers dolescent medicine Practice area 185, pril. dvanced heart failure and transplant cardiology Practice area 437, January. Clinical investigator Practice area 415, January. Nurse practitioners in bariatrics Practice area 461, ugust. Nurse practitioners in cardiovascular surgery Practice area 465, June. Physician assistants in cardiovascular surgery Practice area 447, May. Physician assistants in critical care Practice area 442, March. Physician assistants in endocrinology Practice area 444, February. Physician assistants in urology Practice area 453, July. Physician assistants in women s health Practice area 445, pril. Updated Clinical Privilege White Papers: Procedures Colposcopy Procedure 224, June. Cryoplasty therapy Procedure 235, February. Endovascular grafts Procedure 29, ugust. Extracorporeal shock wave therapy for heel pain (formerly Orthotripsy) Procedure 211, May. Wound debridement Procedure 416, July. Updated Clinical Privilege White Papers: Specialties and subspecialties Dermatology Practice area 12, November. General laser surgery Practice area 175, March. Medical oncology (formerly Oncology) Practice area 142, June. Oral and maxillofacial surgery Practice area 131, January. Otolaryngology Practice area 150, February. Pediatric gastroenterology Practice area 427, May. Radiation oncology Practice area 121, September. Vascular and interventional radiology Practice area 107, July. Updated Clinical Privilege White Papers: dvanced practice professionals and clinical assistants udiologist Practice area 179, September. Certified nurse midwife Practice area 164, replaces September. Cytotechnologist Practice area 194, November. Neurophysiological monitoring Practice area 187, October. Nurse practitioner Practice area 167, March. Orthotics and prosthetics Practice area 402, pril. RN first assistant Practice area 101, October. 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 9

10 Credentialing Resource Center Journal January 2015 New Patient Safety Systems chapter includes two existing Medical Staff standards The Joint Commission s 2015 Comprehensive ccreditation Manual for Hospitals includes a new chapter, Patient Safety Systems, the organization announced recently. The purpose of the chapter is to inform and educate hospital leaders about the importance and structure of an integrated, patientcentered system that aims to improve quality of care and patient safety, according to the Joint Commission website. The chapter is included only in the CMH because most patient safety events occur in hospitals, according to a recent Joint Commission Perspectives. There are no new requirements in the Patient Safety Systems chapter, and the standards in the new chapter are found in other CMH chapters, including Leadership, Performance Improvement, Environment of Care, and Medical Staff. The included standards will continue to be published in their respective chapters as well as in the Patient Safety Systems chapter. The standards will be evaluated according to guidelines in their originating chapter during on-site surveys, according to The Joint Commission. The new chapter includes the following medical staff standards: The organized medical staff defines circumstances that require monitoring and evaluation of a practitioner s professional performance (MS ) The organized medical staff, in accordance with the organization s medical staff bylaws, evaluates and takes action on reported concerns regarding a privileged practitioner s clinical practice and/or competence (MS ) H Perspective The past and future of credentialing Editor s note: CRC Symposium panelists Hugh Greeley and Todd Sagin, MD, JD, discuss what will differentiate this event from others. The context of credentialing might be an important distinction, as they explain below. The CRC Symposium will take place March at Caesar s Palace in Las Vegas. For the complete agenda and additional information, see p. 12 or go to for more information. Why is it important to look at the history of credentialing? It s been said that those who don t study and understand history are bound to repeat it sometimes to their detriment. Knowing where the various procedures used in our modern credentialing programs came from will help us constantly evolve systems to ensure that they are serving credentialing s triple aim: Patient protection Facilitation of practice Meeting organizational goals and objectives It might seem like a product of modern healthcare, but credentialing actually has a long history, dating back to early Roman times when physicians were selected based upon their pedigree and references. Of course, more recently circa the early 1900s credentialing practices were put into place as a natural consequence of hospital development in the United States. Owners and boards of hospitals were generally restrictive in terms of which physicians were permitted to use the facilities of their hospitals. In many locales, once a core group of physicians had established practices in the area, they used their influence to carefully control the number of additional doctors who would be permitted to compete for patients. The years 1917 to 1920 saw the formal development 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 January 2015 Credentialing Resource Center Journal of credentialing as a result of the work of the merican College of Surgery s most noble experiment, the Hospital Standardization Program, which established standards for hospitals in many areas, including the vetting of new physicians who wished to practice in the facility. familiar story? Fast forward to today, which might seem like a world away from those earliest efforts to vet new applicants. In this modern scenario, CRC Symposium attendees will be introduced to a fictitious provider, Jane dele, MD. Throughout this event, her progress from applicant to disgraced physician demonstrates many of the problems encountered by both medical staff service professionals and physician leaders in the course of normal medical staff business. Some of the challenges she presents might sound familiar, and the saga of Dr. dele might help medical staff leaders and medical staff services professionals tackle tough practitioner issues in their own facilities. Observing how these problems arise, how they are mishandled, and how they are ultimately solved will assist participants in understanding some of the nuances of successful credentialing. Utilizing this evolving case scenario will more fully engage CRC Symposium attendees in the educational course and will permit them to follow the credentialing process as its mechanisms are used either to prevent or to resolve many of the dilemmas and challenges which occur or could occur back home. s the story unfolds and symposium attendees gain perspective on their own challenges, the process will help unite MSPs and medical staff leadership. History has shown that those who play and study together often forge more successful working relationships. Shared knowledge of systems, requirements, and roles and responsibilities nearly always leads to better overall performance. This educational event will provide attendees with significant opportunities to learn team skills. It will also promote respect and appreciation for the contributions to the medical staff and hospital made by the various players in the process. CRC Symposium attendees may take away other insights from this event as well. Credentialing is not a static process and will constantly evolve to become more efficient and supportive. New best practices are constantly emerging and old practices are being retired. This symposium will bring attendees the most current understanding of what constitutes excellent credentialing. ttendees will understand how important institutional goals of patient safety and high-quality care are facilitated by a well-managed credentialing process. They will also appreciate how to balance the need for rigor with the desire for efficient procedures that don t overburden busy clinicians. Most importantly, attendees will understand the critical role effective physician leadership plays in ensuring that credentialing is a constructive activity that benefits everyone. The MSP s Voice column will return in the February issue. H Join us in March for the CRC Symposium! Register today for the CRC Symposium, March 12 and 13, at Caesar s Palace in Las Vegas. Get your toughest credentialing, privileging, and medical staff leadership questions answered by industry experts Carol Cairns, CPMSM, CPCS; Hugh Greeley; Todd Sagin, MD, JD; and Sally Pelletier, CPMSM, CPCS. Learn cutting-edge best practices for tackling medical staff challenges and network with colleagues. Here s a sample of what you ll get during the two tracks and general sessions: 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 11

12 Credentialing Resource Center Journal January 2015 Join us in March for the CRC Symposium! Track 1: Credentialing & Privileging, Legal & ccreditation Two High Risk Credentialing Situations to Manage: Temporary and Locum Tenens Privileges Credentialing and privileging professionals are tasked with ensuring all privileging requests no matter how temporary are thoroughly reviewed. During this session, the speakers explain how granting temporary privileges and using locum tenens physicians without full credentials verification may clinically and legally endanger patients and healthcare organizations. ttendees will learn strategies for reducing medico-legal risks often associated with temporary and locum tenens privileges. PRNs and Ps: Here to Stay and Part of the Team While privileging processes parallel physicians, PRNs and Ps present unique challenges. During this session, attendees will learn how to create strategies to address these challenges such as: How will the performance of advanced practice professionals (PP) be evaluated? Will PPs be allowed to learn new skills? If so, what methodology will be used? Is there a privileging model that provides for increasing specialization of PPs? Track 2: Practitioner Performance Turf Battles: Then and Now and New Procedures In the past, turf battles erupted only when specialties fought over exclusive rights to a procedure. Nowadays, turf battles occur between HPs and physicians, hospitalists and lowvolume providers, employed and non-employed physicians, etc. What role does the MSP play in turf battles? During this session the speakers will examine the process for vetting new procedures and deciding if new privileges are necessary. ttendees will gain tips to stop new procedures from happening before they have been reviewed and proper privileges have been granted. The MSP Then, Now, and in the Future s healthcare organizations seek to deliver higher-quality care at a lower cost and with greater efficiency, MSPs are playing a crucial role as part of the healthcare team. This session looks at the origins of the profession, recognizes the current challenges that result from the implementation of integrated care delivery systems, and discuss how those changes are transforming MSPs traditional roles. ttendees will learn what steps to take to approach the medical staff services department of the future. General sessions The Effective Credentials Committee Member detailed look at the crucial role of the credentials committee and its responsibilities related to credentialing, privileging, and practitioner performance. This session, with input from all our expert speakers, will help attendees develop the right framework to support the credentials committee from orientation and training for committee members, to policy and procedure development, to strategies to streamline and manage effective credentials committee meetings. Speakers will present the audience with case scenarios and ask that they put themselves in the shoes of the credentials committee to address the challenges presented in the case studies. Focus on OPPE and FPPE ttendees will join the speakers to continue the saga of fictional practitioner Jane dele. This session will focus on Jane s experience with ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE). By examining Jane s experiences, attendees will learn how to ensure OPPE and FPPE at their organization is relevant, useful, and practical. Using the case study, the speakers will make clear that collecting OPPE and FPPE data is the first step, but the challenge doesn t end there. Organizations must also know what to do with the data once they have it and understand how to deal with identified competency issues. Credentialing and Privileging Rapid Fire In five- to 10-minute segments, our panel of speakers will discuss the top industry concerns, including Federal Tort Claims ct medical malpractice protection, criminal history checks, accreditors then and now, application fees, Internet searches, and the mericans with Disabilities ct. ttendees will gain effective compliance tools and best practice strategies that they can employ the first day back on the job. For the complete agenda or to reserve your CRC Symposium seat, go to 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