North Carolina Association Medical Staff Services MAY 15, 2008

1. North Carolina Association Medical Staff ServicesMAY 15, 2008 Renee Aird Dengler, RN, MS, CPMSM, CPCS Advocate Health Care Director, Medical & Professional Affairs

2. The Joint Commission History 1910 – Ernest Codman, MD 1951 – American College of Physicians, American Hospital Association, American Medical Association, Canadian Medical Association 1965 - Social Security Amendments of 1965 – Deemed Status – accredited hospitals are in compliance with most of the Medicare Conditions of Participation for Hospitals

3. Centers for Medicare and Medicaid Services (CMS) History 1965 – Medicare and Medicaid enacted under Social Security Act 1973 – HMO Act 1977 – Health Care Financing Authority (HCFA)\ 1982 – PROs 1983 – Prospective Payment System 1985 – EMTALA

4. Centers for Medicare and Medicaid Services (CMS) 1996 – Health Insurance Portability and Accountability Act (HIPPA) 2001 – HCFA is renamed CMS - Center for Medicare Management - Center for Beneficiary Choice - Center for Medicaid and State Operations 2003 – Medicare Prescription Drug Improvement and Modernization Act

5. Centers for Medicare and Medicaid Services (CMS) • State Operations Manual • Conditions of Participation • Regulations and Interpretive Guidelines

6. Centers for Medicare and Medicaid Services (CMS) • Deemed Status • TJC • AOA - HFAP • DNV - NIAHO

7. Centers for Medicare and Medicaid Services (CMS) • Survey Process • Validation Survey • Web Sites • State Operation Manual / Interpretive Guidelines • http://cms.hhs.gov/manuals/Downloads/som107ap_a_hospitals.pdf • Email updates • http://www.cms.hhs.gov/AboutWebsite/20_EmailUpdates.asp#TopOfPage

8. Centers for Medicare and Medicaid Services (CMS) • “Familiar” Standards • Review of Conditions of Participation, Standards & Interpretive Guidelines

9. The Joint Commission & CMS • August 2008 Letter • Re: Deeming Authority

10. The Joint Commission & CMS • Revised 2009 Accreditation Requirements as of March 26, 2009 • MS.01.01.01 • MS.02.01.01 • MS.03.01.01 • MS.03.01.03 • MS.05.01.01 • MS.06.01.03

11. Clarifying Standards • Core Privileges • Telemedicine • H&Ps – APRNs, PA, Medical Students

12. Clarifying Standards • Expedited Credentialing • Health Care Industry Representatives (HCIR) • LIP Health Screening

13. Clarifying Standards • Ongoing Professional Practice Evaluation (OPPE) • Focused Professional Practice Evaluation (FPPE)

14. National Committee on Quality Assurance (NCQA) • Credentialing Standards • NPDB – Proactive Disclosure Service (PDS) • Verification of “lifetime” board certification

15. National Committee on Quality Assurance (NCQA) • Verification of CDS and DEA • Verification of Education & Training for Expired Board Certification • Pen or Pencil?