QUALITY ASSURANCE AND CREDENTIALS

QUALITY ASSURANCE AND CREDENTIALS Return to Administrative Section Welcome Page References SECNAVINST 6320.2 Joint Commission Accreditation Manual for Hospitals, current edition BUMEDINST 6320.66B Credentials Review and Privileging Program BUMEDINST 6320.67 Adverse Privileging Actions, Peer Review & Provider Reporting NAVMEDCOMINST 6010.13 Quality Assurance Program Introduction The references cited above form the framework for the Navy Medical Department's Quality Assurance and Credentials Review and Privileging Programs. These programs establish policies and procedures to be followed in the pursuit of quality care and the credentialing and privileging process. It applies to all Medical Treatment Facilities (MTFs) and Dental Treatment Facilities (DTFs) whether they be fixed, as hospitals and branch clinics, or nonfixed, such as field medical facilities or shipboard medical departments. These instructions apply to all military health care practitioners, both active duty and reserve, as well as civilian contractors to the Navy. The Privileging Authority Chain 1. The Assistant Chief for Health Care Operations (MED-03) at the Bureau of Medicine and Surgery has the responsibility for administrative and technical oversight of the Credentials Review and Privileging program. A number of divisions of MED-03 as well as Personnel (MED-05), Dental (MED-06) and special assistants from the Inspector General and Medico- Legal divisions of MED-00 interact to coordinate, plan, monitor quality and provide education to keep the program working. MED-03 also acts as the privileging authority for any practitioner who is the Commanding Officer of a fixed medical or dental treatment facility 2. In fixed medical and dental treatment facilities, the Commanding Officer is the privileging authority

3. If assigned to the fleet, excluding the FMF, the privileging authority is the fleet TYCOM, or type commander. In the case of the Seabees the TYCOM is the privileging authority, with delegation of that management to the Brigade medical officer. 4. If assigned to the FMF, the privileging authority is the Commanding General of the Marine Division (MARDIV), Marine Aircraft Wing (MAW) or the Force Service Support Group (FSSG). Notice that in the last two cases, the privileging authority is a line officer who has complete control over privileging and has custody of the practitioner's Individual Credential File. (ICF). All commanding officers who are privileging authorities, whether they be at MTF's or in the field, have a responsibility to make available all the necessary resources to assure that each practitioner receives the necessary training required to meet his or her responsibilities. Internal Committees Within any command which is a privileging authority, the Executive Committee of the Medical Staff (ECOMS) or Dental Staff (ECODS) has the responsibility of carrying out the credentials review and privileging process. The committee is composed of privileged physicians (Dentists if ECODS). In the case of the Seabees, these committees are at the CINC level and consist of the CINC medical officer and medical officers from all the TYCOMs. In small commands the entire staff may serve on the committee. In commands where nonphysicians are privileged, i.e. PA's, Nurse Practitioners, and Independent Duty Corpsmen, there may be representation from among these groups on the committee when matters concerning their peers may be under consideration. In some commands, a separate credentials committee may be established under the ECOMS or ECODS to perform the review and credentialing function. Professional Affairs Coordinator (PAC) This is an individual who provides administrative and clerical assistance to the ECOMS or the credentials committee. Individual Credentials Files (ICF's) and Individual Privilege Files (IPF's) are maintained in this office, along with all program instructions, directives, forms, minutes and working papers of the ECOMS or credentials committee. Clinical Directorate Clinical directors monitor and review the credentialing and privileging process within their directorates and act as department heads within their directorates if a new department head is

undergoing the credentialing and privileging process prior to taking over duties. Department Heads Thus far, the discussion has been focused on policy and organizational structure of the credentialing and privileging program. At the department head level, Quality Assurance is added. That is not to say that QA is not considered at higher levels, but rather that it is continuously and most effectively monitored at the departmental level. The department has is in the best position to provide continuous surveillance of the health status, conduct and performance of the professional staff within the department. In the case of nonprivileged practitioners and clinical support staff, the department head can also assure appropriate clinical supervision. The department head maintains a copy of the individual's staff appointment and delineated privileges and is able to make recommendations about types of privileges and supplemental privileges based on qualification and performance. Quality Assurance and risk management information are recorded in the Clinical Performance Profiles (CPPs) and Clinical Activity Files (CAFs), which are used to complete the individual's Performance Appraisal Report (PAR). Each of these reports will be discussed in greater detail later. Individual Practitioners The individual practitioner must apply for membership to the professional staff and request the broadest scope of privileges for which he or she are qualified and is current. Failure to maintain those qualifications leads to administrative separation from military service. Any changes in status which might impair performance or ability to effectively and safely provide care, such as illness or injury, must be reported immediately. All practitioners are responsible for the accuracy of their credentials and privileges files, licensure status and so on. Each is also required to abide by the professional staff bylaws, participate in the QA program, and participate in professional education programs. Core Privileges Privileges granted may be divided into core and supplementary types. The criteria for physician core privileges are: 1. Graduation from an approved medical school or osteopathic school. 2. Completion of a GME - 1 program. 3. Completion of an approved residency program (for specialty core privileges).

4. Possession of a current license or license waiver. 5. Have current clinical competence. 6. Currently be in good health. Practitioners are not required to be credentialed in "emergency medicine" to provide care necessary to save the life or protect a patient in an emergency to the degree permitted by their training. Supplemental Privileges Supplemental privileges are facility specific, and lie outside the scope of care of core privileges because of level of risk, or some unique facility support staff or equipment or technically sophisticated procedure. More simply, you can't do something in a facility that doesn't have the capability of handling it. These privileges are endorsed by the ECOMS or ECODS and approved by the privileging authority. Denial of privileges You may possess the necessary qualifications and competence to perform certain procedures beyond the scope of core privileges, but be denied those privileges because of the limitation of the facility. Such a denial is not an adverse action. Make sure that if you are ever denied privileges for that reason, that the reason be clearly stated as beyond the capability of the facility to support. New Practitioners Staff appointments and clinical privileges for new acquisitions to the Navy system who have not held an active staff appointment within the last 2 years are initially granted "provisional" staff privileges for a period up to one year. TAD Practitioners It is not at all unusual, especially for operational medical officers, to be assigned to temporary duty at a location far from his or her permanent station. In the event that there is a treatment facility at the new location and temporary privileges at that facility are desired, there is a process by which such can be accomplished. The practitioner sends a letter, speedletter, message or NAVGRAM to the gaining facility requesting exercise of privileges while at that facility. There is a standard format for such application, known as "Appendix Q", which derives its name from the sample letter in the appendix Q of BUMEDINST 6320.66B The practitioners privileging authority sends information regarding qualifications and privileges

held to the gaining command. This information is also sent by letter, message or NAVGRAM in the "Appendix N" format from the appendix of the same name in the instruction. Theoretically, one should be able to walk in to the gaining facility and go to work provided the above two steps have taken place and been approved, without going through an entirely new privilege application process. Clearly, the rules of the gaining facility apply, and certain procedures may not be done if there are facility limitations. Practitioner Records A number of documents are required for the credentialing and privileging program. Some are internal working documents, summaries of which are included in the practitioners permanent record. Clinical Activity File (CAF) This internal working document is maintained on each practitioner and contains information regarding productivity, treatment outcomes, performance assessments and results of peer review activities. Also recorded are documentation of training or CME, various certifications such as BLS and ACLS and the practitioner's health status. Clinical Performance Profiles (CPP) The clinical performance profile is a summary of information from the CAF, prepared every 6 months. In training programs, an annual report is used for specific recommendations for promotion to the next academic year level by the program director. Performance Appraisal Report (PAR) The PAR is completed on each practitioner at intervals not to exceed 2 years, and is placed in the Individual Credential File (ICF) as part of the permanent record. This document is an appraisal of performance and conduct and provides the basis for the granting and renewal of staff appointments. The PAR must be updated upon detachment from the command, after TAD periods of over 5 days and prior to completion of training programs as well as times of reappointment to the professional staff. Once the PAR is completed with the information derived from the CAF and CPP, the latter two are no longer required and can be destroyed. Individual Credentials File (ICF) The individual credentials file is a permanent record of professional qualifications, continuing education, health status, professional conduct and professional performance throughout his or her medical career in the Navy. All initial information supplied during acquisition of the member must be verified for accuracy and maintained in the ICF. Updates are required periodically when the

status of the individual changes in any way. As previously discussed, performance appraisal reports are added to the ICF at intervals. No information other than the documents specified in the BUMED instruction may be placed in the ICF. There can be no "unofficial record" maintained by the command for any purpose. To do so is illegal and has gotten more than one commanding officer into difficulty. The practitioner has a right to access or have copies of any information in the ICF. Before adverse material can be added to an ICF, it must go through review at two levels. Only the Executive Committee of the Medical or Dental Staff at the treatment facility may include adverse material (with approval of the Privileging Authority). The practitioner must also be provided a copy and may make any statement desired regarding the adverse action, to be included in the permanent record. When transferring from one command to another, the detaching command is required to send the updated ICF and retain a copy until receipt of the original is verified by the gaining command. The copy is then destroyed. ICF Structure and Contents The ICF is required to be maintained in a six section folder using the appropriate format as outlined in BUMED 6320.66B appendices as follows: Section I: Background Information 1. A recent (2 years) photograph 2. Personal and professional information 3. Personal and professional information updates Section II: Current Practice Information 1. Copies of credential and privileging information (Appendix N) attached to the PAR for any TAD assignments during the tour of duty at that station. 2. Clinical privileges granted, privilege sheets, application for staff appointments with endorsement and PAR's generated by the current command, with previous command's packages below it.

Section III: Professional Education and Training 1. The verified qualifying degree 2. Verified postgraduate training 3. Verified specialty board certifications Section IV Licensure Verified State licensures for last 10 years. Section V Professional Experience 1. Previous privileges 2. Letters of reference 3. Responses to credentials inquiries 4. Previous Appendix N's with PAR's Section VI Other Practice Information 1. Misconduct or adverse privileging actions 2. Documentation of medical malpractice claims with disposition and statements 3. Responses to inquiries from professional clearing houses such as the National Practitioner Data Bank. Credentialing and privileging to practice medicine in the Navy is closely tied to the Quality Assurance program to maintain a high level of documentable performance. Personal and professional conduct and performance are part of a permanent record which follows the practitioner from one command to the next and beyond to the civilian world when one decides to return to civilian life. This is simply one part of a much larger plan which seeks to assure some consistency and standardization of quality health care throughout the nation, both civilian and military. The foregoing discussion will help you understand how the programs work, and the often confusing array of acronyms and required forms.