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The Joint Commission Medical Staff Standards and FPPE/OPPE Compliance

The Joint Commission Medical Staff Standards and FPPE/OPPE Compliance. Stephen M. Dorman, M.D. www.redandgold.com. 2013 Scoring and Accreditation Decision Model.

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The Joint Commission Medical Staff Standards and FPPE/OPPE Compliance

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  1. The Joint Commission Medical Staff Standards and FPPE/OPPE Compliance Stephen M. Dorman, M.D. www.redandgold.com

  2. 2013 Scoring andAccreditation Decision Model

  3. A statement that defines the performance expectations and/or structures or processes that must be in place in order for a healthcare organization to provide safe, high quality care, treatment, and services. An organization is either “compliant” or “ not compliant” with a standard. Standard

  4. Element of Performance The specific performance expectation and/or structure or process that must be in place in order for a healthcare organization to provide safe, high quality care, treatment, and services. The scoring of EP compliance determines an organization’s overall compliance with a standard.

  5. 2013 Scoring/Accreditation Decision Model -Summary Elements of Performance (EP): types: A: one observation to cite: 100% compliance C: two observations to cite: 90% compliance (D): requires a document or documentation

  6. 2013 Scoring/Accreditation Decision Model -Summary Elements of Performance and other accreditation requirements will be tagged based on their “criticality” – immediacy of impact on quality of care and patient safety as the result of noncompliance.

  7. 2013 Scoring/Accreditation Decision Model -Summary • SITUATION DECISION (2): PDA • DIRECT impact: (3): 45 days for ESC • INDIRECT impact: (4): 60 days for ESC

  8. 2013 Scoring/Accreditation Decision Model -Summary If partial compliance or insufficient compliance is not resolved, a progressively more adverse accreditation decision may result: Provisional, Contingent, Preliminary Denial of Accreditation.

  9. 2013 Scoring/Accreditation Decision Model • Accreditation Follow Up Survey: • If any element of performance is cited twice in subsequent surveys, a 45 day follow up survey will occur: AFS 02 • Affects both direct and indirect findings

  10. 2013 Scoring/Accreditation Decision Model -Summary • Critical Levels: • Immediate threat to life: no a single standard, but condition (APR) • Falsification (APR) • Situational Decision Rule: immediate recommendation of Denial of Accreditation or Contingent accreditation alone.

  11. 2013 Scoring/Accreditation Decision Model -Summary • DIRECT impact standard: Sedation • INDIRECT impact standard: Policies • Labels on standards: • (D): Documentation required • (2): Situational Decision Rule • (3): Direct Impact Requirements • (4): Indirect Impact Requirements

  12. MS Chapter Outline I. Medical Staff Bylaws A. Bylaws (revised MS.01.01.01) (36 A/4) B. Unilateral Amendment (revised MS.01.01.03) (1 A/4) II. Structure and Role of Medical Staff Executive Committee (revised MS.02.01.01) (12 A/4)

  13. MS Chapter Outline III. Medical Staff Role in Oversight of Care, Treatment, and Services A. Oversight of Quality of Care (revised MS.03.01.01) (16 A/4, 1 A/3) B. Management and Coordination of Care (revised MS.03.01.03) (10 A/4, 2 A/3)

  14. MS Chapter Outline IV. Medical Staff Role in Graduate Education Programs (revised MS.04.01.01) (8 A/4, 1 C/4). V. Medical Staff Role in Performance Improvement A. Role in Performance Improvement Activities (revised MS.05.01.01) (12 A/4) B. Participation in Performance Improvement Activities (revised MS.05.01.03) (5 A/4)

  15. MS Chapter Outline VI. Credentialing and Privileging A. Determining Resource Availability (revised MS.06.01.01) (2 A/4) B. Collecting Information (revised MS.06.01.03)(10 A/4, 1 A/3) C. Decision Process (revised MS.06.01.05) (One A/2, 10 A/4, 1 C/4)

  16. MS Chapter Outline D. Reviewing Information (revised MS.06.01.07) (8 A/4), 1 C/4) E. Communicating Decision (revised MS.06.01.09) (5 A/4) F. Expedited Process (revised MS.06.01.11) (7 A/4) G. Temporary Privileges (revised MS.06.01.13) (6 A/4)

  17. MS Chapter Outline VII. Appointment to Medical Staff A. Recommending Appointment (revised MS.07.01.01) (5 A/4) B. Peer Recommendations (revised MS.07.01.03) (4 A/4).

  18. MS Chapter Outline VIII. Evaluation of Practitioners A. Monitoring Performance (revised MS.08.01.01) (9 A/4) B. Use of Monitoring Information (revised MS.08.01.03) (3 A/4)

  19. MS Chapter Outline IX. Acting on Reported Concerns About a Practitioner (revised MS.09.01.01) (2 A/4) X. Fair Hearing and Appeal Process (revised MS.10.01.01) (5 A/4) XI. Licensed Independent Practitioner Health (revised MS.11.01.01) (10 A/4)

  20. MS Chapter Outline XII. Continuing Education for Practitioners (revised MS.12.01.01) (5 A/4) XIII. Medical Staff Role in Telemedicine A. Credentialing and Privileging of Licensed Independent Practitioners (revised MS.13.01.01) (1 A/4) B. Recommending Clinical Services to be Provided (revised MS.13.01.03) (2 A/4)

  21. LEADERSHIP • The medical staff has been defined as one of the three components of “leadership”. There is no longer a medical staff leadership interview. When the standards address “leaders”, it is up to the organization to determine which leaders are involved.

  22. LD.01.02.01 • 1: Senior managers and leaders of the organized medical staff work with the governing body to define their shared and unique responsibilities and accountabilities. (A/4)

  23. LD.01.05.01 (A/4) • 1: NO EP • 2: Self-governing • 3: Conforms to guiding principles • 4: Governing body approves structure • 5: Medical staff oversees quality care provided by individuals with clinical privileges • 6: Accountable to governing body

  24. LD.01.05.01 • 7: MD/DO/Dentist/Podiatrist responsible for the organization and conduct of the medical staff. • 8: There is a SINGLE organized medical staff.

  25. LD.01.07.01 • 1. Governing body, senior managers, and leaders of the organization medical staff work together to identify the skills requires of individual leaders.

  26. LD.01.07.01 • 2: …leaders of the organized medical staff are oriented to: • Mission/Values • Safety and Quality goals • Structure and decision making process • Budget • Population served • Responsibility • Law and Regulation

  27. LD.02.02.01 • 1. Define conflict of interest. • 2. Policy on management of conflict of interest. • 3. Obtain disclosures of conflicts of interest. • This standard applies to LEADERSHIP

  28. LD.02.04.01 • 1: Ongoing process for conflict management.

  29. LD.04.01.05 • CMS REQUIRED PHYSICIAN DEPARTMENT DIRECTORS: • Anesthesia • Emergency Medicine Services • Respiratory Care Service • Radiology • Nuclear Medicine

  30. LD.04.01.05 • 6: Emergency services are directed and supervised by a qualified member of the medical staff. • 7: Physicians direct: anesthesia, nuclear medicine, respiratory care. • 9: Anesthesia responsible for ALL anesthesia services (ref. deep sedation)

  31. LD.04.02.01 • 1. Define conflict of interest • 2. Policy on conflict of interest • 3. Disclosures of conflicts of interest.

  32. LD.04.03.09 • 1: Clinical leaders and medical staff have an opportunity to provide advice about sources of clinical services to be provided through contractual agreement.

  33. MS.01.01.01 What is required in the bylaws and new Medical staff communication processes

  34. The doctors of medicine and osteopathy and, in accordance with medical staff bylaws, other practitioners are organized into a self-governing medical staff that oversees the quality of care provided by all physicians and by other practitioners who are privileged through a medical staff process.

  35. The organized medical staff and the governing body collaborate in a well-functioning relationship, reflecting clearly recognized roles, responsibilities, and accountabilities, to enhance the quality and safety of care, treatment, and services provided to patients.

  36. This collaborative relationship is critical to providing safe, high quality care in the hospital. While the governing body is ultimately responsible for the quality and safety of care at the hospital, the governing body, medical staff, and administration collaborate to provide safe, quality care.

  37. To support its work, and its relationship with and accountability to the governing body, the organized medical staff creates a written set of documents that describes its organizational structure and the rules for its self-governance.

  38. These documents are called medical staff bylaws, rules and regulations, and policies. These documents create a system of rights, responsibilities, and accountabilities between the organized medical staff and the governing body, and between the organized medical staff and its members.

  39. Because of the significance of these documents, the medical staff leaders should strive to ensure that the medical staff members understand the content and purpose of the medical staff bylaws and relevant rules and regulations and policies, and their adoption and amendment processes.

  40. Of the members of the organized medical staff, only those who are identified in the bylaws as having voting rights can vote to adopt and amend the medical staff bylaws.

  41. The voting members of the organized medical staff may include within the scope of responsibilities delegated to the medical executive committee the authority to adopt, on the behalf of the voting members of the organized medical staff, any details associated with Elements of Performance 12 through 36 that are placed in rules and regulations, or policies.

  42. MS.01.01.01Medical staff bylaws address self-governance and accountability to the governing body Approved. Effective date: 3/31/2011

  43. 1: The organized medical staff develops medical staff bylaws, rules and regulations, and policies.

  44. 2: The organized medical staff adopts and amends medical staff bylaws. Adoption or amendment of medical staff bylaws cannot be delegated. After adoption or amendment by the organized medical staff, the proposed bylaws are submitted to the governing body for action. Bylaws become effective only upon governing body approval.

  45. 3: Every requirement set forth in Elements of Performance 12 through 36 is in the medical staff bylaws. These requirements may have associated details, some of which may be extensive; such details may reside in the medical staff bylaws, rules and regulations, or policies. The organized medical staff adopts what constitutes the associated details, where they reside, and whether their adoption can be delegated. Adoption of associated details that reside in medical staff bylaws cannot be delegated.

  46. 3: (cont): For those Elements of Performance 12 through 36 that require a process, the medical staff bylaws include at a minimum the basic steps, as determined by the organized medical staff and approved by the governing body, required for implementation of the requirement. The organized medical staff submits its proposals to the governing body for action. Proposals become effective only upon governing body approval.

  47. 4: The medical staff bylaws, rules and regulations, and policies, the governing body bylaws, and the hospital policies are compatible with each other and are compliant with law and regulation.

  48. 5: The medical staff complies with the medical staff bylaws, rules and regulations, and policies.

  49. 6: The organized medical staff enforces the medical staff bylaws, rules and regulations, and policies by recommending action to the governing body in certain circumstances, and taking action in others.

  50. 7: The governing body upholds the medical staff bylaws, rules and regulations, and policies that have been approved by the governing body.

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