2002-22 DATE: July 10, 2002 DOCUMENT TITLE: Clarificatin f Bureau f Primary Health Care Credentialing and Privileging Plicy utlined in Plicy Infrmatin Ntice 2001-16 TO: Cmmunity Health Centers Migrant Health Centers Health Care fr the Hmeless Grantees Health Services fr Residents f Public Husing Grantees Primary Care Assciatins Primary Care Offices Federally Qualified Health Center Lk-Alikes Plicy Infrmatin Ntice (PIN) 2001-16, Credentialing and Privileging f Health Center Practitiners requires that all Health Centers assess the credentials f each licensed r certified health care practitiner t determine if they meet Health Center standards. This plicy applies t all health center practitiners, emplyed r cntracted, vlunteers and lcum tenens, at all health center sites. Questins have arisen regarding the specific requirements fr credentialing and privileging these individuals. This PIN explains these requirements in mre detail fr all Bureau f Primary Health Care-supprted Health Centers. A. DEFINITIONS Credentialing: the prcess f assessing and cnfirming the qualificatins f a licensed r certified health care practitiner. Licensed r Certified Health Care Practitiner: an individual required t be licensed, registered, r certified by the State, cmmnwealth r territry in which a Health Center is lcated. These individuals include, but are nt limited t, physicians, dentists, registered nurses, and thers required t be licensed, registered, r certified (e.g., labratry technicians, scial wrkers, medical assistants, licensed practical nurses, dental hygienists, nutritinists). The definitin will vary dependent upn legal jurisdictin. Licensed r certified health care practitiners can be divided int tw categries: a) licensed independent practitiners (LIPs) and b) ther licensed r certified practitiners. As explained in this PIN, the credentialing and privileging requirements f these tw grups may vary.
BPHC Plicy Infrmatin Ntice 2002-22 Licensed Independent Practitiner: physician, dentist, nurse practitiner, and nurse midwife r any ther individual permitted by law and the rganizatin t prvide care and services withut directin r supervisin, within the scpe f the individual s license and cnsistent with individually granted clinical privileges (frm Jint Cmmissin n Accreditatin f Healthcare Organizatins (JCAHO) 2002-2003 Cmprehensive Accreditatin Manual fr Ambulatry Care). It is the Health Center that shuld determine which individuals (including staff that may nt be cvered under Federal Trt Claims Act such as vlunteers, certain part-time cntractrs, medical residents, and lcum tenens) meet this definitin based n law and the rganizatin s plicy. Other Licensed r Certified Health Care Practitiner: An individual wh is licensed, registered, r certified but is nt permitted by law t prvide patient care services withut directin r supervisin. Examples include, but are nt limited t, labratry technicians, scial wrkers, medical assistants, licensed practical nurses, dental hygienists. Primary Surce Verificatin: Verificatin by the riginal surce f a specific credential t determine the accuracy f a qualificatin reprted by an individual health care practitiner. Examples f primary surce verificatin include, but are nt limited t, direct crrespndence, telephne verificatin, internet verificatin, and reprts frm credentials verificatin rganizatins. The Educatin Cmmissin fr Freign Medical Graduates (ECFMG ), the American Bard f Medical Specialties, the American Ostepathic Assciatin Physician Database, r the American Medical Assciatin (AMA) Masterfile can be used t verify educatin and training. The use f credentials verificatin rganizatins (CVOs) r hspitals that meet JCAHO s Principles fr CVOs (see Appendix A) is als an acceptable methd f primary surce verificatin. Secndary Surce Verificatin: Methds f verifying a credential that are nt cnsidered an acceptable frm f primary surce verificatin. These methds may be used when primary surce verificatin is nt required. Examples f secndary surce verificatin methds include, but are nt limited t, the riginal credential, ntarized cpy f the credential, a cpy f the credential (when the cpy is made frm an riginal by apprved Health Center staff). Privileging/Cmpetency: The prcess f authrizing a licensed r certified health care practitiner s specific scpe and cntent f patient care services. This is perfrmed in cnjunctin with an evaluatin f an individual s clinical qualificatins and/r perfrmance. B. CREDENTIALING REQUIREMENTS 1. Credentialing f LIPs requires primary surce verificatin f the fllwing: Current licensure; Relevant educatin, training, r experience; Current cmpetence; and Health fitness, r the ability t perfrm the requested privileges, can be determined by a statement frm the individual that is cnfirmed either by the directr f a training prgram, chief f staff/services at a hspital where privileges exist, r a licensed physician designated by the rganizatin. 2
BPHC Plicy Infrmatin Ntice 2002-22 Credentialing f LIPs als requires secndary surce verificatin f the fllwing: Gvernment issued picture identificatin; Drug Enfrcement Administratin registratin (as applicable); Hspital admitting privileges (as applicable); Immunizatin and PPD status; and Life supprt training (as applicable). The Health Center shuld als query the Natinal Practitiner Data Bank (NPDB) (as applicable) fr these LIPs. If the health center is ineligible t query, they shuld have the LIP prvide the results f a self-query f the NPDB. The determinatin that a LIP meets the credentialing requirements shuld be stated in writing by the Health Center s gverning bard (r alternative mechanism as described in a gverning bard apprved waiver). Ultimate apprval authrity is vested in the gverning bard which may review recmmendatins frm either the Clinical Directr r a jint recmmendatin f the medical staff (including the clinical directr) and the Chief Executive Officer. Alternatively, the gverning bard may delegate this respnsibility (via reslutin r bylaws) t an apprpriate individual t be implemented based n apprved plicies and prcedures (including methds t assess cmpliance with these plicies and prcedures). 2. Credentialing f ther licensed r certified health care practitiners requires primary surce verificatin f the individual s license, registratin, r certificatin nly. Educatin and training may be verified by secndary surce verificatin methds. Verificatin f current cmpetence is accmplished thrugh a thrugh review f clinical qualificatins and perfrmance. Credentialing f ther licensed r certified health care practitiners als requires secndary surce verificatin f the fllwing: Gvernment issued picture identificatin; Immunizatin and PPD status; Drug Enfrcement Administratin registratin (as applicable), Hspital admitting privileges (as applicable), and Life supprt training (as applicable). Please Nte: These requirements are a minimum and d nt prevent the Health Center frm credentialing these individuals similarly t LIPs. Credentialing f ther licensed r certified health care practitiners shuld be cmpleted prir t the individual being allwed t prvide patient care services. C. PRIVILEGING REQUIREMENTS Plicy Infrmatin Ntice 2001-16 requires privileging f each licensed r certified health care practitiner specific t the services being prvided at each f the Health Center s care delivery settings. 3
BPHC Plicy Infrmatin Ntice 2002-22 1. The initial granting f privileges t LIPs is perfrmed by the health center (see PIN 2001-16 fr specifics) with ultimate apprval authrity vested in the gverning bard which may review recmmendatins frm either the clinical directr r a jint recmmendatin f the medical staff (including the Clinical Directr) and the Chief Executive Officer. Alternatively, the gverning bard may delegate this respnsibility (via reslutin r bylaws) t an apprpriate individual t be implemented based n apprved plicies and prcedures (including methds t assess cmpliance with these plicies and prcedures). 2. Fr ther licensed r certified health care practitiners, privileging is cmpleted during the rientatin prcess via a supervisry evaluatin based n the jb descriptin. 3. Temprary privileges may be granted if the Health Center fllws guidelines specified by JCAHO (see Appendix B). D. PRIVILEGING REVISION OR RENEWAL REQUIREMENTS 1. The revisin r renewal f a LIP s privileges shuld ccur at least every 2 years and shuld include primary surce verificatin f expiring r expired credentials, a synpsis f peer review results fr the 2 year perid and/r any relevant perfrmance imprvement infrmatin. Similar t the initial granting f privileges, apprval f subsequent privileges is vested in the gverning bard which may review recmmendatins frm either the clinical directr, r a jint recmmendatin f the medical staff (including the Clinical Directr) and the Chief Executive Officer, r delegate this respnsibility (via reslutin r bylaws language) t be implemented accrding t apprved plicies and prcedures (including methds t assess cmpliance with these plicies and prcedures). 2. The revisin r renewal f privileges f ther licensed r certified health care practitiners shuld ccur at a minimum f every 2 years. Verificatin is by supervisry evaluatin f perfrmance that assures that the individual is cmpetent t perfrm the duties described in the jb descriptin. 3. The health center shuld have an appeal prcess fr LIP s if a decisin is made t discntinue r deny clinical privileges. An appeal prcess is ptinal fr ther licensed r certified health care practitiners. The fllwing table summarizes the credentialing and privileging requirements f bth categries f licensed r certified health care practitiners, Licensed Independent Practitiners, and ther licensed r certified health care practitiners. NOTE: The requirements specified in this PIN are nt identical t accreditatin-related standards pertaining t credentialing and privileging. Therefre, Health Centers that are accredited r seeking accreditatin shuld als review the applicable credentialing and privileging standards t insure apprpriate cmpliance. 4
BPHC Plicy Infrmatin Ntice 2002-22 TABLE: COMPARATIVE SUMMARY OF REQUIREMENTS FOR CREDENTIALING AND PRIVILEGING LICENSED OR CERTIFIED HEALTH CARE PRACTIONERS CREDENTIALING OR PRIVILEGING ACTIVITY LICENSED OR CERTIFIED HEALTH CARE PRACTITIONER Licensed Other licensed r Independent certified practitiner Practitiner (LIP) Examples f Staff Physician, Dentist, RN, LPN, CMA, Registered Dietician A. CREDENTIALING METHOD 1. Verificatin f licensure, Primary surce Primary Surce registratin, r certificatin 2. Verificatin f educatin Primary surce Secndary surce 3. Verificatin f training Primary surce Secndary surce 4. Verificatin f current cmpetence 5. Health fitness (Ability t perfrm the requested privileges) Primary surce, written Cnfirmed statement 6. Apprval authrity Gverning Bdy (usually cncurrent with privileging) 6. Natinal Practitiner Required, if Data Bank Query 7. Gvernment issued picture identificatin, immunizatin and PPD status, and life supprt training (if applicable) 8. Drug Enfrcement Administratin (DEA) registratin, hspital admitting privileges reprtable Secndary surce Secndary surce, if applicable Supervisry evaluatin per jb descriptin Supervisry evaluatin per jb descriptin Supervisry functin per jb descriptin Required, if reprtable Secndary surce Secndary surce if applicable 5
BPHC Plicy Infrmatin Ntice 2002-22 CREDENTIALING OR PRIVILEGING ACTIVITY B. INITIAL GRANTING OF PRIVILEGES LICENSED OR CERTIFIED HEALTH CARE PRACTITIONER Licensed Other licensed r Independent certified Practitiner practitiner (LIP) METHOD 1. Verificatin f current cmpetence t prvide services specific t each f the rganizatin s care delivery settings Primary surce, based n peer review and/r perfrmance imprvement data. 2. Apprval authrity Gverning Bdy (usually cncurrent with credentialing) Supervisry evaluatin per jb descriptin Supervisry evaluatin per jb descriptin C. RENEWAL OR METHOD REVISION OF PRIVILEGES 1. Frequency At least every 2 yrs At least every 2 2. Verificatin f current licensure, registratin, r certificatin 3. Verificatin f current cmpetence Primary surce Primary surce based n peer review and/r perfrmance imprvement data. yrs Primary surce Supervisry evaluatin per jb descriptin 4. Apprval authrity Gverning Bdy Supervisry functin per jb descriptin 5. Appeal t discntinue appintment r deny clinical privileges Prcess required Organizatin ptin If yu have any questins, please cntact CAPT. Martin Bree, Directr, Center fr Risk Management at (215) 861-4373 r mbree@hrsa.gv. Attachments William D. Hbsn Acting Directr, Bureau f Primary Health Care 6
BPHC Plicy Infrmatin Ntice 2002-22 APPENDIX A Jint Cmmissin n Accreditatin f Healthcare Organizatins Principles fr CVOs 2002-2003 Cmprehensive Accreditatin Manual fr Ambulatry Care (p. HR-11) Any rganizatin may use the services f a credentials verificatin rganizatin (CVO). While using such agencies may relieve the rganizatin frm the prcess f gathering the infrmatin, it des nt relieve the rganizatin frm the respnsibility f having cmplete and accurate infrmatin. An rganizatin that bases its decisins in part n infrmatin btained frm a CVO shuld achieve a level f cnfidence in the infrmatin prvided by the CVO, by evaluating the fllwing: The CVO makes knwn t the user what data and infrmatin it can prvide. The CVO prvides dcumentatin t the user describing hw its data cllectin, infrmatin develpment and verificatin prcess(es) are perfrmed. The user is prvided with sufficient, clear infrmatin n database functins that includes any limitatins f infrmatin available frm the CVO (fr example, practitiners nt included in the database), the time frame fr CVO respnses t requests fr infrmatin; and a summary verview f quality cntrl prcesses related t data integrity, security, transmissin accuracy, and technical specificatins. The user and CVO agree n the frmat fr the transmissin f credentials infrmatin abut an individual frm the CVO. The user can easily discern which infrmatin, transmitted by the CVO, is frm a primary surce and what is nt. Fr infrmatin transmitted by the CVO that can g ut f date (fr example, licensure, bard certificatin), the date the infrmatin was last updated frm the primary surce is prvided by the CVO. The CVO certifies the infrmatin transmitted t the user accurately presents the infrmatin btained by it. The user can discern whether the infrmatin transmitted by the CVO frm a primary surce is all the primary surce infrmatin in the CVO's pssessin pertinent t a given item r, if nt, where additinal infrmatin can be btained. The user can engage the quality cntrl prcesses f the CVO when necessary t reslve cncerns abut transmissin errrs, incnsistencies, r ther data issues that may be identified frm time t time. 7
BPHC Plicy Infrmatin Ntice 2002-22 APPENDIX B Jint Cmmissin n Accreditatin f Healthcare Organizatins GUIDELINES FOR ISSUING TEMPORARY PRIVILEGES (Based 3/15/02 Standards Clarificatin: Use f Temprary Privileges CAMAC Standard HR.7.2) The Jint Cmmissin has reviewed its psitin n the use f temprary privileges and has determined that there are tw circumstances fr which the granting f temprary privileges wuld be acceptable: t fulfill an imprtant patient care need when an applicant with a cmplete, clean applicatin is awaiting review and apprval f the medical staff executive cmmittee and the gverning bdy In the first circumstance temprary privileges can be granted n a case by case basis when there is an imprtant patient care need that mandates an immediate authrizatin t practice, fr a limited perid f time, while the full credentials infrmatin is verified and apprved. Examples wuld include, but are nt limited t: a situatin where a physician becmes ill r takes a leave f absence and an LIP wuld need t cver his/her practice until he/she returns (lcum tenens) a specific LIP has the necessary skills t prvide care t a patient that an LIP currently privileged des nt pssess In these circumstances, temprary privileges may be granted by the CEO upn recmmendatin f either the applicable clinical department chairpersn r the president f the medical staff prvided there is verificatin f: current licensure current cmpetence In the secnd circumstance temprary privileges may be granted when the new applicant fr medical staff membership r privileges is waiting fr a review and recmmendatin by the medical staff executive cmmittee and apprval by the gverning bdy. Temprary privileges may be granted fr a limited perid f time, nt t exceed 120 days, by the CEO upn recmmendatin f either the applicable clinical department chairpersn r the president f the medical staff prvided: there is verificatin f current licensure relevant training r experience current cmpetence ability t perfrm the privileges requested ther criteria required by medical staff bylaws the results f the Natinal Practitiner Data Bank query have been btained and evaluated the applicant has: a cmplete applicatin 8
BPHC Plicy Infrmatin Ntice 2002-22 n current r previusly successful challenge t licensure r registratin nt been subject t invluntary terminatin f medical staff membership at anther rganizatin nt been subject t invluntary limitatin, reductin, denial, r lss f clinical privileges Temprary privileges are nt t be rutinely used fr ther administrative purpse such as the fllwing situatins: the LIP fails t prvide all infrmatin necessary t the prcessing f his/her reappintment in a timely manner failure f the staff t verify perfrmance data and infrmatin in a timely manner In the abve situatins, the LIP wuld be required t cease prviding care in the facility until the reappintment prcess is cmpleted. 9