SAMPLE Credentialing, Privileging and Peer Review Self-Evaluation

Transcription

1 1. The following professionals are credentialed: Physicians Residents Advanced Practice Providers (e.g., CRNA, PA, CMW) Dentists Podiatrists Chiropractors Others 2. The credentialing process includes the following individuals: Governing body members Chief Executive Officer (CEO) Chief of staff/chief medical officer Medical executive committee (MEC) members Credentials committee members Medical department chairman Other Appointment-Credentialing/Privileging 3. Medical staff bylaws and/or approved policies and procedures address the following: Appointment and delineation of privileges (privileges are based on criteria) Privileging criteria include the minimum amount of education, training and experience necessary for an individual to request or be granted certain privileges Use of temporary privileges o To fulfill an important patient care need or when a qualified applicant is waiting review and approval by either the governing body or the MEC (refer to bylaws/rules and regulations) Expedited appointment process, if appropriate for the organization Responsibilities of medical staff leaders for appointment and initial privileging and reappointment and renewal of privileges Responsibility of medical staff leadership for the ongoing monitoring of practitioner performance

2 Bylaws address medical professional liability insurance requirements for the medical staff 4. Medical staff bylaws and/or medical staff approved policies and procedures on specifically require obtaining and evaluating the following applicant information: Proof of Identify (government issued) Current licensure and lifetime licensure history (including licenses in the allied disciplines), past and pending challenges, including voluntary/involuntary relinquishment (verified in state of practice) DEA registration Lifetime medical education training history (including all medical or osteopathic schools attended and all approved or nonapproved residency programs attended) Specialty board status (including no status, eligibility to take the exam, taken part I and/or II, passed or failed, number of times, or certified) Clinical experience, including disclosure of past and present membership/privileges at other healthcare facilities Most recent 12 months of clinical activity (if possible, obtain approximate numbers and types of procedures, location, and type of patients treated) Past and pending challenges to medical staff membership/privileges at other healthcare facilities, including voluntary/involuntary relinquishment Healthcare-related employment history (including terminations, challenges, decisions pending, and voluntary resignation and relinquishments) Professional liability coverage and policy limits (including denial of professional liability coverage and/or policy cancellation or non-renewal). Previous 10-year medical professional liability history (including claims, suits, notices of intent, and settlements) allegations and outcomes; past and pending

3 Health status as related to ability to perform the privileges requested and medical staff duties, with verification by references Lifetime criminal history OIG sanctions (review of OIG sanction list, NPDB or AMA physician master file with Medicare/Medicaid sanctions) Professional references (addressing the adequacy of clinical knowledge, technical skill, judgment, ability to relate to others, overall performance, adherence to rules, and health status) by practitioners who have observed the applicant first hand 5. Medical staff bylaws and/or medical staffapproved policies and procedures provide a framework for disciplinary action including: Grounds for each type of disciplinary action Procedures for reduction, suspension and termination of privileges (including emergency suspension/termination) Fair hearing/due process for physicians Fair hearing/due process for advanced practice providers, as applicable (may be different then physicians) Internal/external reporting of final actions Reappointment Credentialing/Privileging 6. Medical staff bylaws and/or medical staffapproved policies and procedures on address at least the following: Responsibilities of the medical staff for reappointment and renewal of privileges (renewal of privileges is based on criteria) Reappointment and renewal of privileges at least every two years Use of temporary privileges o To fulfill an important patient care need or when a qualified applicant is waiting review and approval by either the governing body or the MEC o Or when the failure to allow the practitioner to continue to provide care would result in a problem meeting an important patient care need Expedited reappointment process, if appropriate for the organization

4 7. Medical staff by-laws and/or medical staff approved policies and procedures on require obtaining the following information from reappointment applicants: Current licensure and past and pending challenges to licensure including voluntary and involuntary relinquishments DEA registration Past (two years) and pending medical professional liability history (including claims, suits, notices of intent, and settlements) Past (two years) and pending challenges to medical staff membership/privileges at other healthcare facilities (including voluntary/involuntary relinquishment) Healthcare-related employment/appointment history (including terminations, challenges, decisions pending, and voluntary resignations and relinquishments; generally for two years) CME activity Past 24 months of internal clinical activity (if internal activity is limited, obtain external activity, if possible, or external references) Results of aggregated peer review activities and volume (or external references when appropriate), to be utilized to provide for practitioner-specific appraisal of competency when determining whether to renew clinical privileges Health status as related to ability to perform professional and medical staff duties, with verification by the department chief or chief of staff OIG sanctions (review of OIG sanction list, NPDB or AMA Physician Master file with Medicare/Medicaid sanctions) Specialty board status and/or recertification (if applicable) NPDB query

5 Medical Staff Peer Review 8. Peer review policy and practice includes the following components: Purpose of peer/professional review, scope, confidentiality, timeline, reviewing committee composition, use of external reviewers when applicable, and reporting process Peer review activities are utilized in the hospital-wide performance improvement process Peer review conclusions, outcomes, and actions are evaluated The following criteria are reviewed, as may be applicable: o Unexpected deaths o Post-op deaths o Unexpected complications o Anticipated complications defined for review o Post-op complications defined for review o Severe drug reactions o Transfusion reactions o Patient suicides o Inappropriate transfer (as defined by EMTALA) o Patient complaints against a member of the medical staff o Staff member complaints or concerns about medical staff management of patient care o Hospital-acquired conditions o Established service-specific indicators o Other