COMPARATIVE DIFFERENCES OF MEDICAL STAFF and CREDENTIALING STANDARDS

1. COMPARATIVE DIFFERENCES OF MEDICAL STAFF and CREDENTIALING STANDARDS Debra R. Green, MPA, CPMSM, CPCS Director, Medical Staff Services and General Pediatric Residency Program Stanford University Medical Center Stanford Hospital & Clinics Lucile Packard Children’s Hospital

2. Background • Director of Medical Staff Services and Pediatric Residency Program for Stanford University Medical Center which includes Stanford Hospital and Clinics and Lucile Packard Children’s hospital in Palo Alto, CA. • Oversight of a combined medical staff of approximately 2000 physicians, 300+ Advanced Practice Professionals and 78 General Pediatric Residents. • CPMSM and CPCS in addition to a Masters of Public Administration(MPA) degree with a concentration in Health Care Management and Policy • 20+ years of healthcare administrative experience; primarily academic. • Held previous leadership positions in New Jersey and Michigan. • Served as an Expert Witness in negligent credentialing and privileging legal cases • NAMSS Director at Large on the NAMSS Board for 5 consecutive years.

3. Objectives • Overview of the main regulatory bodies • Who they are? • What they do? • Why they exist? • Overview of Credentialing/Privileging Standards • Requirements • Compliance

4. Center for Medicare/Medicaid (CMS) • Who are they? • Government Organization • Surveyors are typically State DOH employees • Gives deeming authority to TJC, HFAP and DNV • What do they do? • Validate TJC • Can Survey For Cause • Why do they exist? • To ensure patient care and quality

5. The Joint Commission (TJC) • Who are they? • Private Organization • What do they do? • - Unannounced Surveys • - Tracer Methodology • - Can Survey “For Cause” • Why do they exist? • To ensure patient care and quality

6. Other Authorities Deemed by CMS • Det Norske Veritas Healthcare, Inc (DNV) • Deemed status since 9/08 • Certifies other companies in additional to healthcare • Existed since 1864 (began in Norway) in US since 1898 • World wide reputation for quality and integrity • Healthcare Facilities Accreditation Program (HFAP) • Deemed Authority since 1965 • Surveyors are experienced healthcare professionals • Recognized by Fed Gov, State DOH, Ins Carriers and Managed Care Organizations (MCO) • Surveys are unannounced

7. National Committee for Quality Assurance (NCQA) • Who are they? • Private Organization • What do they do? • Accredits: MCO’s, MBHO’s, PPO’s, NHP’s etc. • Certifies: CVO’s • Delegated Credentialing Agreements • Hospital does the work for MCO or Health Plan

8. The Accreditation Association for Ambulatory Health (AAAHC) • Who are they? • Private Organization, non-profit • What do they do? • - Accredit Ambulatory Healthcare Organizations, Surgery Centers, Community Health Centers and Medical/Dental Group Practices • - US Air Force and Coast Guard • Why do they exist? • To promote patient safety, quality and value for Ambulatory health care

9. URAC • Who are they? • Private Organization, non-profit • What do they do? • - Accredit Health Plans and Preferred Provider Organizations (PPO) • Why do they exist? • To promote healthcare quality through accreditation education and measurement programs

10. Verification of Medical Education

11. Post Graduate Training

12. PEER RECOMENDATIONS

13. Work/Affiliation History Verifications • How many organizations perform Work/Affiliation History Verifications?

14. Work/Affiliation History

15. Privileges

16. Temporary Privileges

17. Ongoing Performance Monitoring

18. DEA/CDS

19. CONTINUING MEDICAL EDUCATION(CME)

20. MALPRACTICE INSURANCE

21. MALPRACTICE HISTORY

22. NATIONAL PRACTITIONER DATA BANK(NPDB)

23. BACKGROUND CHECKS

24. BOARD CERTIFICATION

25. LENGTH OF APPOINTMENT PERIOD

26. LICENSURE

27. LICENSURE SANCTIONS

28. MEDICARE/MEDICAID SANCTIONS

29. Disaster Privileging

30. Compliance Tips and Tools #1 • Be prepared to implement disaster privileges in the event of an Emergency ……develop a process, not just a policy • Tool # 2 – Disaster Credentialing Tool Kit

31. Disaster Credentialing Tool Kit • Includes: • Disaster Credentialing Policy • Employee Roster with Phone #s • Disaster Privileging Tracking Logs (multiple copies) • Disaster Privilege Forms (multiple copies) • Excerpt from Bylaws regarding Disaster Privileges • List of Links for licensure verification • Written process for staff to follow • Name Badges • Markers • Ink Pens

32. DISASTER PRIVILEGES TRACKING LOG FOR VOLUNTEER LIP’S ID Type Key A – Govt issued ID – REQUIRED B – ID from another HC Org C – License to practice D – ID from DMAT/MRC/ESARVHP E – ID from Govt entity granting authority to provide care F – Confirmation from another Medical Staff Member

34. Health Status Assessment

35. Allied Health Professionals

36. Applicant Identity

37. Attestation Statement

38. Complaints

39. Compliance with Law

40. Use of a CVO

41. Use of Designated Equivalent Sources

42. Felony Convictions

43. Site Visits

44. Compliance Tips and Tools #2 • Audit, Audit and More Audits!!! • Tool # 3 – Credentialing Audit Forms

45. EMPLOYEE #123

48. Telemedicine • Not addressed under: NCQA URAC AAAHC • Very detailed standards for: TJC HFAP CMS DNV

49. Telemedicine – TJC, HFAP, CMS • Prior to Last year, hospitals were required to credential and privilege all telemedicine providers at the “Distant location”. (Even Tele-radiologists in Australia). • CMS changed the rule and revised the standard in Last year; published May 2011 • New standard effective July 2011 • Hospitals can now rely on the credentialing and privileging of “Distant Site” • The Joint Commission and HFAP are derived from the CMS • Distant Site:The site where the practitioner providing the telemedicine services is located. • Originating Site:The location where the patient is being treated.

50. Telemedicine – TJC, HFAP, CMS • Here are the options that hospitals and CAHs have under the new rule: • Option 1: Credentialing and Privileging Provided under ContractA distant-site telemedicine entity, acting as a contractor of services, furnishes its services in a manner that enables the originating-site hospital to comply with all applicable Medicare conditions of participation and standards (via contract).OROption 2: Credentialing and Privileging Provided without a ContractThe distant-site hospital providing the telemedicine services is another Medicare-participating hospital.ANDThe individual distant-site physician or practitioner is privileged at the distant-site hospital providing telemedicine services, and that this distant-site hospital provides a current list of the physician’s or practitioner’s privileges.ANDThe individual distant-site physician or practitioner holds a license issued or recognized by the State in which the hospital whose patients are receiving the telemedicine services is located.ANDThe originating-site hospital has evidence of an internal review of the distant-site physician’s or practitioner’s performance under these telemedicine privileges and provides the distant-site hospital this information for use in its periodic appraisal of the individual distant site physician or practitioner. (Sounds like OPPE to me!!)OROption 3: Originating Site Credentials and Privileges practitioners at the distant siteOrganizations can credential telemedicine practitioners the same way that they would credential and privilege any other practitioner who provides patient care services to patients at the organization Source: The Searcy Exchange June 2011