Medical Staff Bylaws and Credentialing/Privileging Issues PROGRAM OBJECTIVES

Transcription

1 Medical Staff Bylaws and Credentialing/Privileging Issues Naomi Nelson Director, Medical Staff Administration Ochsner Clinic Foundation Phone: (504) PROGRAM OBJECTIVES Define the requirements for medical staff involvement with the new Joint Commission Standards. Define the Joint Commission requirements for Medical Staff Bylaws and Rules and Regulations. Identify Joint Commission Medical Staff Standards Hot Spots. Identify legal issues to be considered with the appointment, reappointment, peer review and fair hearing processes. Unannounced survey process. January 17 18,

2 Shared Visions/New Pathway Survey Process related to the Medical Staff Medical Staff Involvement Requirement. Expectations that your medical staff leadership will have knowledge about the survey process Medical Staff involvement-tracer methodology-follows the experience of care for a number of individuals through the organization s entire health care process; Allows surveyors to witness hand-offs. Physicians may be requested to participate more actively in the process Make sure your MEC understands the tracer methodology concept; They should have broad based knowledge of processes in the organization The joint will have daily briefings, you may want to have your Chief of staff in daily briefings each day & exit conf. Shared Visions/New Pathway Survey Process related to the Medical Staff Survey Process The numbering system has changed, example: MS 2.1, is now MS Numbering system changed to be consistent with the method used for the accreditation standards. No longer have Type I s, you will now receive Requirements for improvements, when the organization does not fully meet the standard. Failure to resolve an RFI affects a hospital s accreditation status, which could lead to loss of accreditation. January 17 18,

3 Shared Visions/New Pathway Survey Process related to the Medical Staff Three major new concepts for Medical Staff Services are: ACGME competencies Focused Professional Practice Evaluation (FPPE) Ongoing Professional Practice Evaluation (OPPE) Shared Visions/New Pathway Survey Process related to the Medical Staff Revisions for 2009 to the Medical Staff Chapter Medical Staff Bylaw (MS & MS Structure and Role of MEC (MS ) Medical Staff Role in Oversight of Care, Treatment & Services (MS , MS ) Medical Staff Role in GE programs (MS ) Credentialing & Privileging (MS , MS , MS , MS , MS , MS , MS ) Appointment to Medical Staff (MS , MS Evaluation of Practitioners (MS , MS ) Acting on Reported Concerns about a Practitioenr (MS ) January 17 18,

4 Shared Visions/New Pathway Survey Process related to the Medical Staff Revisions for 2009 to the Medical Staff Chapter Fair Hearing & Appeal Process (MS ) Licensed Independent Practitioner Health (MS ) Continuing Education for Practitioners (MS ) Medical Staff Role in Telemedicine (MS , MS ) Revisions to 12 of the 13 sections in the Medical Staff Chapter! Shared Visions/New Pathway Survey Process related to the Medical Staff Medical Staff Bylaws Requirements Ensure that bylaws or credentialling policies are updated to include the general competencies particularly in language related to appointment & reappointment to the medical staff, granting of privileges Update peer evaluation forms and include the general competencies on the forms January 17 18,

5 Shared Visions/New Pathway Survey Process related to the Medical Staff Credentialing Current licensure Education and training Experience, ability, and current competence Patient Care Medical/Clinical Knowledge Practice-based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-based Practice TAKE A BREAK! 15 MINUTES! January 17 18,

6 Performance-Bylaws, Credentialing, Peer Review and Allied Health Professionals Medical Staff Bylaws (Content requirement for 2009) OLD- MS.1.20 NEW- MS Address self-governance/accountability to GB MS Specifies that the medical staff must determine the minimal content of H&P Validated and countersigned H&P Defines the scope of H&P for non-inpatients Ensure that medical staff bylaws or rules & regs.. reflects these requirements; Surveyors will review bylaws for language. Medical Executive Committee/Roles MS Expedited credentialing process Must have a documented process; Ensure that EOP s outlined in the standards are addressed in your policy Governing body may delegate the authority to render credentialling decisions to a committee of at leatw two voting members of the governing body Performance-Bylaws, Credentialing, Peer Review and Allied Health Professionals Focused Professional Practice Evaluation A process whereby the organization evaluates the privilege specific competence of the practitioner who does not have documented evidence of competently performing the requested privilege at the organization. Include the EOP s in your policy, MS January 17 18,

7 Focused Professional Practice Evaluation (FPPE) Applicant applies for staff And/or request special procedures Or existing applicant s professional practice raises concerns Special Procedure Request Professional Practice Concerns MSO request additional information from applicant to obtain special procedures, in addition, to verifying w/institution where physician was trained MSO works w/cos, Dept. Chair, VPMA, Legal to notify physician of concern and development of proctoring/monitoring is implemented. Length of monitoring is determined by parties mentioned above. Applicant provides documentation of training for special procedures and institution verifies, physician is granted privilege. Monitoring completion and review of cases must occur before full privileges can be reinstated. Applicant s first five (5) cases are monitored and reviewed by Dept. Chair to measure competence for privilege request. Review of cases or report from Dept. Chair regarding physician performance is forwarded to Medical Staff Office for Quality/Peer Review File. If physician satisfactorily performs cases within established criteria, Dept Chair and Credentials recommends reinstatement of privileges to Board. If physician does not satisfactorily perform cases, privileges are removed until such time that physician can display competence. All information is forwarded to Credentials SEC Committees and Performance-Bylaws, Credentialing, Peer Review and Allied Health Professionals Ongoing Professional Practice Evaluation The ongoing professional practice evaluation allows the organization to identify professional practice trends that impact on quality of care and patient safety. January 17 18,

8 Ongoing Professional Practice (OPPE) OPPE is used for the following reasons: Maintenance of existing privileges Revisions to existing privileges (Special Procedures) Removal of existing privileges at reappointment Member of Medical Staff is appointed to staff and every quarter, performance measures are reviewed Member of medical staff reappoints to the medical staff and requests a procedure, but hasn t performed procedure since last reappointment or request a special procedure. Performance measures include, but not limited to review of operative procedures, LOS, mortality, morbidity, blood utilization Information is forwarded to the Dept. Chair and/or Credentials quarterly. If a problem arises with physician s practice, a focused professional practice evaluation is conducted for a defined period of time. Privileges may be limited during this time. Physician is requested to provide documentation of competence, if not able to, physician is placed on OPPE monitoring for the noted privilege for a defined period of time. Dept. Chair will review cases and provide a report of competence to Credentials Committee. If physician s FPPE satisfies Dept. Chair/Cred. Cmte., physician s privileges are reinstated. All privileges requests are forwarded to Credentials/SEC committees for recommendation, then to Board for final approval. Performance-Bylaws, Credentialing, Peer Review and Allied Health Professionals Ensure all EOP s are included in your policies for the following areas: Privileging, MS Temporary Privileges, MS Expedited Privileges, MS Telemedicine/Contract Services MS Graduate Medical Students Written process for supervision, roles and responsibilities Impaired Physician Policy Absence of a policy to address physician impairment could result in RFI s in LD and MS standards, specifically, LD , , , MS, , January 17 18,

9 Overview of HOT SPOTS Problematic Issues at Survey and Implementation Strategies Verbal orders, RC Qualified individuals receive and record them They are authenticated within the time frame specified by law and your organization s rules & regulations/policy Bylaws components Peer review Written documentation to include: Medical/clinical knowledge Technical/clinical judgment Clinical judgment Interpersonal skills Communication skills professionalism Credential/ Privileging process Analysis/use of information Privilege decision notification Focused professional practice evaluation Overview of HOT SPOTS Problematic Issues at Survey and Implementation Strategies Expedited credentialing process Ongoing professional practice evaluation Credentialing (2 year reappointment date) Verification of Licenses & ID (MS ) ID should be current picture hospital ID or valid picture ID issued by a state or federal agency (i.e driver s license or passport) Experience, ability, current competence, peer-topeer references Disaster Privileging Verification of licensure, certification, or registration Oversight of care, treatment, and services provided Identification in medical staff bylaws Primary source verification not required if LIP has not rendered care, treatment of services under the disaster privileges January 17 18,

10 Overview of HOT SPOTS Problematic Issues at Survey and Implementation Strategies Management of Care, Treatment, and Services MS , Ensuring that the organized medical staff is intricately involved in carrying out all patient care functgions conducted by practitioners privileged through the medical staff process. Graduate Education Programs, MS Written process for supervision, roles and responsibilities Performance Improvement,MS Leadership role Organization-wide LUNCH TIME! 12:00-12:45, Enjoy! January 17 18,

11 How to Spot Red Flags on the application Time Gaps Missing dates on application Inconsistencies between application and CV Yes answers to attestation questions Licensing board limitations, suspensions, arrests, privilege limitations Databank submissions OIG, EPLS entries Malpractice Claim History Information Licensing Board Entries Neutral/Negative references Other facilities and peers Legal Considerations in the Peer Review Process Ask the questions! Seek to obtain as much information as possible Applicant is applying for privileges at your institution and legally you have a right to obtain information If the applicant is unwilling to provide satisfactory details about previous history/ yes questions, privileges can be denied Depending on how your bylaws are written the applicant may be eligible to a fair hearing process. Each of you have a responsibility to provide reasonable information to other facilities that contact your organization. Check with your legal counsel to see how they prefer you to respond. January 17 18,

12 Legal Considerations in dealing with disruptive physicians Make sure you have a disruptive physician policy. Ensure that someone in your organization, (in addition to your attorney) follows the policy. Can be in a policy or in bylaws Recommend placing in a policy that can change without going to the full medical staff Physician can challenge legality of the process if the organization has not: 1. Provided the applicant a copy of the policy upon initial appointment 2. Followed the policy during the disruptive period JCAHO implications Could result in RFI s in LD and MS standards, specifically, LD , , , MS, , Legal Considerations in applying the Fair Hearing process. Ensure that the fair hearing process is in the bylaws All physicians should receive a copy of your bylaws when they join the staff Physicians should sign a statement acknowledging agreement to function under the bylaws are written Usually a statement on the application consent form Physicians have a right to the fair hearing process when the following occurs: Denial of appointment/reappointment, clinical privileges; suspensions that last more than 30 days; revocation of privileges Create a timeline for the physician that outlines all of the activity leading up to the request for fair hearing-label it, Attorney-client/Privileged Keep the physician file organized When copying files for the hearing, review all aspects of the files, ie. Sticky notes, handwritten notes, internal memos January 17 18,

13 UNANNOUNCED SURVEY The Joint Commission surveys in an unannounced fashion between 18 and 39 months after its previous full unannounced survey The hospital receives no notice of the survey date prior to the start of the survey For example, if your organization is scheduled to have their survey in Dec. 2010, the survey could occur as early as June On the day of the unannounced survey, by 7:30am local time, the Joint Commission will post on their extranet their agenda and biographies for the unannounced survey. Stay Survey Ready!!!!!!!! January 17 18,

14 REFERENCE SOURCES JAYCO website Survey Activity Guide JCAHO Comprehensive Manual (CAMH)/Updates Simplifying Compliance Activities CAMH references Perspectives Review carefully each month Additional Web Sites downloads.asp (Documents in various languages) (Emergency Preparedness) htm (Discharge Planning Drills and Readiness Assessment) January 17 18,

15 Web Resources (risks of awareness under anesthesia) m107_appendixtoc.pdf (CMS Standards) Appendix A (Hospitals), AA (Psych), W (CAHs) asp?id=112 (State Licensing Regulations/Standards) January 17 18,