2009 Medical Staff Update John Herringer, Associate Director Standards Interpretation Group Joint Commission

1. 2009 Medical Staff Update John Herringer, Associate DirectorStandards Interpretation GroupJoint Commission

2. 2009 Medical Staff Update EPs not rewritten as part of the SSI project New numbering system for ease of electronic sorting

3. 2009 Medical Staff Update New Scoring Methodology All EPs are category A requiring 100% compliance except 4 which a category C scored on occurrences of non-compliance (90% for ESC)

4. 2009 Medical Staff Update Category C MS.02.02.02 EP 5—Medical Executive Committee--The MEC acts on behalf of the medical staff between meetings MS.04.01.01 EP 11– Graduate Education—The medical staff complies with residency committee review citations.

5. 2009 Medical Staff Update Category C MS.06.02.05 EP 11--Completed Applications for privileges are acted on with the time frame in the bylaws. MS.06.01.07 EP 3—Hospital completes the credentialing and privileging decision process in a timely manner.

6. 2009 Medical Staff Update Criticality Assignment Level 2—Situational rule—possible PDA MS.03.01.01 EP 2—Practitioners practice only within the scope of their privileges as determined through mechanisms defined by the organized medical staff MS.06.01.05 EP 1—Licensed independent practitioners possible a current license

7. 2009 Medical Staff Update Level 3—Direct Impact—None in the MS Chapter Likely to create an immediate risk to patient safety or quality of care Require a 45 day response Level 4—Indirect Impact—All medical staff standards except the two level 2 standards Require a 60 days response

8. 2009 Medical Staff Update 13 new EPs to sync with CMS—may be revised based on further discussion MS.01.01.01—Bylaws EP 20 The bylaws include requirements for completing the medical histories and physical examination EP 21 A statement of the duties and privileges related to each category of the medical staff (for example active, courtesy).

9. 2009 Medical Staff Update 13 new EPs to sync with CMS MS.02.01.02 EP 4—MEC--The majority of the voting member are license doctors of medicine or osteopathy

10. 2009 Medical Staff Update 13 new EPs to sync with CMS MS.03.01.01 Oversight of Quality of Care EP 12--The MS establishes and has continuing responsibility for written policies and procedures governing medical care provided in the emergency service or department EP 13—Provides ER services—MS has written P & P for Appraisals of emergencies Initial treatment of patients Referrals from off campus locations

11. 2009 Medical Staff Update 13 new EPs to sync with CMS MS.03.01.01—Organization does not provide ER service—MS has written P & P for Appraisals of emergencies Initial treatment of patients Referrals of patients when needed

12. 2009 Medical Staff Update 13 new EPs to sync with CMS EP12—A doctor of medicine or osteopathy is on-duty or on-call at all time EP13 Every patient is under the care of a licensed practitioner as defined: MD/DO, Dentist, Podiatrist, Optometrist, Chiropractor, Clinical Psychologist (but only for clinical psychology)

13. 2009 Medical Staff Update 13 new EPs to sync with CMS MS.03.01.03 EP 14—A doctor of medicine/osteopathy is responsible for care of Medicare patients for medical or psychiatric problems present on admission or develops MS.05.01.01 EP 17—The medical staff attempt to secure autopsies for all unusual deaths and medical legal and education interest

14. 2009 Medical Staff Update 13 new EPs to sync with CMS MS.05.01.01 EP 18—The Medical staff, specifically the attending physician is informed of autopsies that the hospital intends to perform.

15. 2009 Medical Staff Update 13 new EPs to sync with CMS MS.06.01.03 EP 9—A FT, PT or consultant radiologist qualified by education and experience supervises ionizing radiology services MS.06.01.03 EP 10—The radiologist supervision ionizing radiology services interprets tests that are determined by the medical staff to require a radiologist’s specialized knowledge

16. 2009 Medical Staff Update  MS.01.01.01(old Ms.1.20)—Medical Staff Bylaws EP 19 Implementation date of July 2009 suspended May 2008 pending work of the MS.01.01.01 Task Force—continues to not be in effect

17. 2009 Medical Staff Update The MS.01.01.01 Task Force, formed in January 2008, continues its work of determining the best approach to revising the standard relating to Medical Staff bylaws. Key issues, include: The relationship between the organized medical staff and the medical executive committee. What needs to appear in the medical staff bylaws and how such decisions are made. How to manage conflict that may arise between the organized medical staff and the governing body, and between the organized medical staff and the medical executive committee, regarding medical staff bylaws, rules and regulations, and policies. The definitions of terms that appear in the standard.

18. 2009 Medical Staff Update Two New Elements of Performance EP 20 The bylaws include requirements for completing the medical histories and physical examination EP 21 A statement of the duties and privileges related to each category of the medical staff (for example active, courtesy).

19. 2009 Medical Staff Update MS.03.01.03 EP 2 (New not CMS) Education of LIPs on assessing and managing pain

20. 2009 Medical Staff Update Credentialing and Privileging Overview Three new concepts introduced in revised standards Six areas of general competencies (may be included, not must be included) Focused professional practice evaluation Ongoing professional practice evaluation

21. 2009 Medical Staff Update Six Core Competencies Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialists (ABMS) General Competencies Patient care Medical/clinical knowledge Practiced-based learning and improvement Interpersonal and Communication Skills Professionalism Systems-based practice

22. 2009 Medical Staff Update Six Core Competencies Organizations Define Methods to Integrate Peer Recommendations (MS.06.01.05 and MS.07.01.03) address: Medical Clinical Knowledge Technical and clinical skills Clinical judgment Interpersonal skills Communication skills Professionalism Only Practiced-Based Learning and Systems-based practice not addressed

23. 2009 Medical Staff Update Six Core Competencies Methodologies for Data Collection From MS.08.01.03 Periodic chart review Direct Observation Monitoring of Diagnostic and Treatment Techniques Discussion with other care staff

24. 2009 Medical Staff Update Core Privileges MS.06.01.07—Core Privileges—Joint Commission Position Core Privileges—activities for which the majority of practitioners who meet the defined criteria should be able to perform Core terminology must define the specific activities included and any limitations, e.g. those that are outside the core

25. 2009 Medical Staff Update Core Privileges MS.06.01.07—Core Privileges Cannot assume an applicant can perform all core activities Applicant specific evaluation required Method for the applicant to request less than full core Core modification as necessary at the point of granting Applicant and staff notification

26. 2009 Medical Staff Update Core Privileges MS. 06.01.07—Core Privileges CMS issues on acceptability November 2004 position letter FAQ on jointcommission.org

27. 2009 Medical Staff Update MS.08.01.01 Focused Professional Practice Evaluation Defines Circumstances requiring monitoring and evaluation EP 1--Focused professional practice evaluation is done for all initial privileges effective January 1, 2008

28. 2009 Medical Staff Update MS.08.01.01 Focused Professional Practice Evaluation EP 1 All new privileges meaning all privileges for new applicants and all new privileges for existing practitioners.  All applicants for new privileges must have a period of focused evaluations No exemption for board certification, documented experience, or reputation. 

29. 2009 Medical Staff Update MS.08.01.01 Focused Professional Practice Evaluation Option: Multi-tiered approach Different for different levels of documented training and experience, e.g. practitioners coming directly from an outside residency program practitioners coming directly from the organization’s residency program practitioners coming with a documented record of performance of the privilege and its associated outcomes practitioners coming with no record of performance of the privilege and its associated outcomes

30. 2009 Medical Staff Update MS.08.01.01 Focused Professional Practice Evaluation Option group very similar activities together evaluate a set number of any mix of the privileges, e.g., any ten from the group will be evaluated to determine competence for the whole group, cannot just look at one privilege from the group.

31. 2009 Medical Staff Update MS.08.01.01 Focused Professional Practice Evaluation EP 2--Criteria are developed for evaluating performance when issues affecting care are identified, e.g., small number of admissions/procedures over an extended period of time that raise the concern of continued competence increasing lengths of stay compared to other practitioners Increasing number of returns to surgery Frequent/repeat readmission for the same issue possible suggesting inadequate/ineffective initial management/treatment patterns of unnecessary diagnostic testing/treatments failure to follow approved clinical practice guidelines--may or may not indicate care problems but the variance needs explanation

32. 2009 Medical Staff Update MS.08.01.01 Focused Professional Practice Evaluation EP 5--Triggers indicating need for performance monitoring are defined The very obvious, e.g., infection rates sentinel events complaints other events that aren't sentinel such as sponges left in during surgery, etc.

33. 2009 Medical Staff Update MS.08.01.01 Focused Professional Practice Evaluation EP 3 Clearly defined Process method for establishing the monitoring plan specific to the requested privilege Predefined for new privileges Determined at time of review Review committee Department chair MEC

34. 2009 Medical Staff Update MS.08.01.01 Focused Professional Practice Evaluation EP 3 Clearly defined process method to determine the duration of performance monitoring Activities vs. time period Volume may be excessive or insufficient when using time periods -12 month provisional period could be burdensome for high volume activity 

35. 2009 Medical Staff Update MS.08.01.01 Focused Professional Practice Evaluation Activity numbers allow flexibility method to determine the duration of performance monitoring defined number of admissions e.g., 5, 10, 20 defined number of procedures, such as 5, 10, 20 short time period of time such as 1, 2 or 3 months for infrequently performed privilege, numbers might work better than a time period especially if the privilege isn't performed in that time period.

36. 2009 Medical Staff Update MS.08.01.01 Focused Professional Practice Evaluation EP 3 Defined Process Multi-tiered approach Different for different levels of documented training and experience, e.g. practitioners coming directly from an outside residency program practitioners coming directly from the organization’s residency program practitioners coming with a documented record of performance of the privilege and its associated outcomes practitioners coming with no record of performance of the privilege and its associated outcomes

37. 2009 Medical Staff Update MS.08.01.01 Focused Professional Practice Evaluation Circumstances under which monitoring by an external source is required No other qualified practitioner Those available would be biased

38. 2009 Medical Staff Update MS.08.01.01 Focused Professional Practice Evaluation EP 7 Criteria to determine type of monitoring Review type can vary, e.g. direct observation for certain privileges vs. chart audits for other privileges periodic chart review direct observation monitoring of diagnostic and treatment techniques discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, nursing, and administrative personnel.  EP 8 Defined measure to resolve performance issues EP 9 Resolution measures consistently implemented

39. 2009 Medical Staff Update MS.08.01.01 Focused Professional Practice Evaluation Historical peer review process triggered by practice indicators or performance issues or untoward outcomes could meet EP's 2 – 9 would not meet EP 1 for a review for all privileges

40. 2009 Medical Staff Update MS.08.01.03 Ongoing Professional Practice Evaluation Traditional credentialing and privileging process: Cyclical: every two years Procedure activities Revised process Ongoing continuous evaluation Identify Performance problems early and resolved Results in Evidence-based privileging at time of renewal

41. 2009 Medical Staff Update MS.08.01.03 Ongoing Professional Practice Evaluation Information for Decisions to Maintain privileges Process includes Evaluation of each practitioner’s professional practice Type of data to be collected determined by departments and approved by organized medical staff—not just negative/outlier/trending data but also data on good performance Use of information from ongoing evaluation to determine status of privileges

42. 2009 Medical Staff Update MS.08.01.03 Ongoing Professional Practice Evaluation EP 1. Clearly defined process, e.g., Who will be responsible for reviewing performance data. department chair, department as a whole, the credentials committee, the MEC, or a special committee of the organized medical staff. how often the data will be reviewed. frequency defined by the organized medical staff three months, six months, nine, months, etc. twelve months would be periodic rather than ongoing. the process to use the data to make decision whether to continue, limit or revoke privileges. the department chair, credentials committee, MEC, governing body how data will be incorporated into the credentials files

43. 2009 Medical Staff Update MS.08.01.03 Ongoing Professional Practice Evaluation EP 2. The type of data to be collected defined by individual medical staff departments and approved by the organized medical staff Standards require evaluation for all practitioners not just those with performance issues. Departments will know best what type of data will reflect both good and problem performance for the various practitioners in their departments.

44. 2009 Medical Staff Update MS.08.01.03 Ongoing Professional Practice Evaluation The standard's rationale outlines suggested data that the organization may choose to collect along with the following suggestions for methodologies for collecting information: period chart review direct observation monitoring of diagnostic and treatment techniques discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, nursing, and administrative personnel.

45. 2009 Medical Staff Update MS.08.01.03 Ongoing Professional Practice Evaluation Most practitioners perform well Data on their actual good performance As well as those practitioners with performance issues Failure to fall out on pre-defined screening criteria is not sufficient to comply with performance data on every practitioner.

46. 2009 Medical Staff Update MS.08.01.03 Ongoing Professional Practice Evaluation Zero data is in fact data. Can be evidence of good performance, e.g., no returns to the OR, no complications, no complaints, not infections, etc. It is also important to know when someone is not performing certain privileges over a given period of time Not be acceptable to find at the two year reappointment that someone has not performed a privilege for two years.

47. 2009 Medical Staff Update MS.08.01.03 Ongoing Professional Practice Evauation Zero performance of a privilege should be evaluated to determine possible reasons is the practitioner no longer performing the privilege, e.g., no open cholecystectomies because they are now done laproscopically is the practitioner taking patients needing the privilege to other organizations is the privilege typically a low volume procedure that has yet to be done

48. 2009 Medical Staff Update MS.08.01.03 Ongoing Professional Practice Evaluation EP 3. Information resulting from the evaluation needs to be used to determine whether to continue, limit, or revoke any existing privilege (s) at the time the information is analyzed. Based on analysis, several possible actions might occur, including but not limited to: revoking the privilege because it is no longer required suspending the privilege, which suspends the data collection, and notifying the practitioner that if they wish to reactivate it they must request a reactivation determining that the zero performance should trigger a focused review (MS.4.30 EP 5) whenever the practitioner actually performs the privilege determining that the privilege should be continued because the organization's mission is to be able to provide the privilege to its patients

49. 2009 Medical Staff Update HR.01.02.05 EP 10 – 15 – PAs and Non-LIP APRNs All PAs and Non-LIP APRNs EP10. An equivalent process EP11. Approved by the governing body EP12. Evaluates applicant’s credentials EP13. Evaluates applicant’s competence

50. 2009 Medical Staff Update HR.01.02.05 EP 10 – 15 – PAs and Non-LIP APRNs EP14. Includes peer recommendations EP15. Input from individuals and committees including the MEC to make informed decisions No inherent right to a fair hearing unless organization policy CMS requires Governing Body Grant Privileges

51. 2009 Medical Staff Update HR.01.02.05 EP 7- Other individuals brought in by an LIP NOT Applicable to PAs and APRNs under EP 10 Prior to the provision of care, treatment or services For non-employee individuals brought into the organization by a licensed independent practitioner to provide care, treatment or services Organization determines that the qualifications and competence are the same qualifications and competence required of employed individuals performing the same or similar services.

52. 2009 Medical Staff Update HR.01.07.01 - EP 5- NOT Applicable to PAs and APRNs under EP 10 – 15 The organization reviews: qualifications, performance and competence of each non-employee individual brought into the organization by an LIP to provide care, treatment or services at the same periodic time frame identified by the organization for individuals employed by the organization. e.g., annually

53. 2009 Medical Staff Update Industry/Manufacturers/Vendor Representatives No current standard FAQ May be developed Consultative advice – consider treating them as a contract employee, i.e., Verification of competence, limited orientation, performance evaluation

54. 2009 Medical Staff Update LD.03.01.01 – Culture of Safety and Quality—Effective January 1, 2009 EP 4 – Code of conduct defines acceptable, disruptive, and inappropriate behaviors EP 5 – Leaders create and implement a process for managing disruptive and inappropriate behavior No additional moratorium approved as requested by the AMA

55. 2009 Medical Staff Update Department of Standards Interpretation Call Board – 630-792-5900 option 6 Online submission form: www.jointcommisison.org, select Standards, then select Online Question Form

56. 2009 Medical Staff Update Questions?