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CREDENTIALING Where does the Board fit in?. Robert P. Redwine President, Board of Directors Blount Memorial Hospital Maryville, Tennessee.
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CREDENTIALING Where does the Board fit in? Robert P. Redwine President, Board of Directors Blount Memorial Hospital Maryville, Tennessee
At the top of a hospital’s organization is a governing board. The legal status of the board of any American corporation is relatively clear in that the board functions as the owner of the entity. So the board functions as the owner and is accountable to the community and/or the patients that are treated at the hospital.
Joint Commission Leadership Standard LD.01.03.01 • The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
The governing board delegates credentialing of the physicians and allied health professionals to the Medical Staff.
What is credentialing? Credentialing makes sure that the healthcare provider is who they say they are, they have been trained to do the privileges they are requesting, and they are physically able and competent to do those privileges.
BOTTOM LINE: Primary reason for credentialing—Patient Safety
MS.4.10 Credentialing Process • Designed to ensure that patients receive care, treatment, and services from qualified providers • Follows the steps outlined in the bylaws or other documents as previously approved by the governing body • Includes a mechanism to ensure that the individual requesting approval is the same individual identified in the credentialing documents by viewing current picture hospital ID, valid state or federal ID
MS.4.10 Credentialing Process (Cont.) • Requires that the hospital verifies in writing from the primary source whenever feasible • Current licensure at the time of granting and renewal of privileges, and at the time of expiration/renewal • Relevant training • Current competence
MS.4.15 Clinical Privileges • Privileges: “Authorization granted by the appropriate authority (for example, the governing body) to a practitioner to provide specific care, treatment, and services in an organization within well-defined limits, based on the following factors, as applicable: license, education, training, experience, competence, health status, and judgment.” • The decision to grant or deny a privilege(s), and/or renew an existing privilege(s), is an objective evidenced-based process
MS.4.15 Clinical Privileges (Cont.)The process for granting privileges includes: • Clearly defined procedure approved by the organized medical staff for the processing of applications for granting, renewal, or revision of privileges • The procedure is approved by the organized medical staff • Applicant submits information that no health problems exist that could affect his or her ability to perform the privileges requested
MS.4.15 Clinical Privileges (Cont.)The process for granting privileges includes: • National Practitioner Data Bank (NPDB) query (initially granted, renewal of privileges, and when a new privilege is requested) • Peer recommendations
MS.4.15 Clinical Privileges (Cont.)Before recommending to the governing board that privileges be granted, the Medical Staff Evaluates: • Challenges to any licensure or regulation • Voluntary and involuntary relinquishment of any license or registration • Voluntary and involuntary limitation, reduction, or loss of clinical privileges • Any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant
MS.4.15 Clinical Privileges (Cont.)Before recommending to the governing board that privileges be granted, the Medical Staff evaluates: • Documentation as to the applicant’s health status • Relevant practitioner-specific data as compared to aggregate data, when available
MS.4.70 Peer Recommendations • Obtained from a practitioner in the same professional discipline as the applicant with personal knowledge of the applicant’s ability to practice • Obtained/evaluated for all new applicants for privileges • On renewal of privileges, when insufficient practitioner-specific data are available must be able to comment on: • Medical/clinical knowledge • Technical and clinical skills • Clinical judgment • Interpersonal skills • Communication skills • Professionalism
The governing board needs:a Medical Executive Committee that is dedicated to quality patient care
A Credentials Committee that is dedicated to quality patient care
Medical Staff Services personnel that are dedicated to quality patient careBECAUSE:
Blount Memorial’s Credentialing Process • Pre-application to the Medical Staff Services Office • Full application packet to the Medical Staff Services Office • Verifications and competency reviewed by Medical Staff Services personnel • Review of the complete file and signature by the Department Chair
Blount Memorial’s Credentialing Process (Continued) • Review of the complete file and signature by the Credentials Committee • Review of a summary of the complete file and signature by the Medical Executive Committee • Review of a summary of the complete file and signature by the Board of Directors
Blount Memorial’s Credentialing Process (Continued) Temporary Privileges may be granted if the file is complete, it fulfills the criteria set forth in the Bylaws, and the chair of the Department and the chairs of the above Committees and the President of the Board reviews and gives their signatures for approval. The file must still go thru the above process, but the applicant will have temporary privileges until the Board grants the applicant membership and privileges.