CREDENTIALING & PRIVILEGING A Legal Primer

1. CREDENTIALING & PRIVILEGINGA Legal Primer Marcy Auclair BUMED Attorney Advisor for Health Care Law October 23, 2013

2. Fundamental Principles Patient Safety Quality Assurance / Risk Management Compliance with requirements of The Joint Commission

3. Implementing Regulations DoD Level: DOD Instruction 6025.13 (17 Feb 11) Medical Quality Assurance (MQA) in the Military Health System (MHS) DOD 6025.13-R – MHS CQA Program Regulation (being reissued as a Manual)

4. Implementing Regulations Service Level: Navy BUMEDINST 6320.66E,“Credentials Review and Privileging Program” BUMEDINST 6320.67A, Ch1, “Adverse Privileging Actions, Peer Review Panel Procedures, and Health Care Provider Reporting”

5. Implementing Regulations Air Force AFI 44-119, “Medical Quality Operations” • Army AR 40-68, “Clinical Quality Management”

6. Definitions Credentials: Documents that constitute evidence of appropriate education, licensure, experience, and expertise of health care providers/practitioners. Clinical Privileges: Permission to provide medical and other patient care services in the granting institution, within defined limits, based on an individual’s education, professional license, experience, competence, ability, health, and judgment.

7. Definitions Adverse Privileging Action: Denying, suspending, restricting, reducing, or revocation of clinical privileges based upon misconduct, impairment, or lack of professional competence. Adverse Practice Action: Restricting, reducing, or revoking the clinical practice of a non-privileged healthcare provider based upon professional misconduct, impairment, or lack of professional competence.

8. Disciplinary Actions Misconduct: Military: Violations of the Uniform Code of Military Justice (UCMJ); allegations handled through Non-Judicial Punishment, Courts-Martial, and/or Administrative Separation Boards Civilians: Allegations of lying, stealing, assault, etc. will be investigated and actions coordinated with HRO (i.e. suspensions, termination, etc.) Contractors: Similar to civilians; allegations need to be investigated and actions coordinated with contracting officer

9. Disciplinary Actions If misconduct is not related to patient safety or the delivery of a health care item or service, no further professional action is required. If misconduct is related to patient safety or the delivery of a health care item or service then consideration must be given to initiating an adverse privileging action (if privileged provider),notifying the state licensing board (if not privileged provider), and reporting to the National Practitioner Data Bank.

10. Disciplinary Actions DoD requires the Surgeons General to report UCMJ actions, adverse civilian personnel actions, and contract terminations for default of any healthcare provider, supplier or practitioner where the acts or omissions were related to the delivery of a healthcare item or service. Anyone involved in patient care can be reported to the NPDB; it is not limited to licensed healthcare practitioners (i.e. dental techs, corpsmen can be reported)

11. Disciplinary Actions Misconduct reports were formally made to the Healthcare Integrity and Protection Data Bank (HIPDB); however, in May 2013, the HIPDB merged with the National Practitioner Data Bank (NPDB). The requirements to report provider misconduct remain in effect.

12. Reporting Final actions resulting in the denial, suspension, restriction, reduction, or revocation of a provider’s clinical privileges are reported to the National Practitioner Data Bank, state(s) of licensure, Federation of State Medical Boards, professional organizations, and DoD Health Affairs. Final actions resulting in the restriction, reduction, or revocation of a non-privileged healthcare provider’s clinical practice, are reported to state(s) of licensure, professional organizations, and DoD Health Affairs.

13. Reporting Reporting of adverse professional/clinical information to outside entities and licensing bodies is performed by the Surgeons General Headquarters staff; local reporting in not authorized.

14. Questions ??? Contact Info: Marcy Auclair Phone: (703) 681-8972 DSN: 761-8972 Email: marcy.auclair@med.navy.mil