Medical Staff Standards Focus: Performance Review

1. Medical Staff StandardsFocus: Performance Review Stephen M. Dorman, M.D. www.redandgold.com

2. 2009 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. 2009 Scoring/Accreditation Decision Model -Summary Elements of Performance (EP) will be categorized by common scoring characteristics (e.g., Category A-yes/no, Category C - multiple observations of non-compliance). The use of Category B EPs (qualitative and quantitative components) will be discontinued.

6. 2009 Scoring/Accreditation Decision Model -Summary The frequency of bulleted EPs will be reduced. 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. 2009 Scoring/Accreditation Decision Model -Summary • DIRECT impact • INDIRECT impact

8. 2009 Scoring/Accreditation Decision Model -Summary All partially compliant and insufficiently compliant EPs must be addressed via the Evidence of Standards Compliance (ESC) submission process – No “Supplemental” findings. Potentially multiple submission deadlines based on the “immediacy” of risk. Direct Impact Requirements: ESC due within 45 days. Indirect Impact Requirements: ESC due within 60 days.

9. 2009 Scoring/Accreditation Decision Model -Summary If partial compliance or insufficient compliance is not resolved, a progressively more adverse accreditation decision may result: Provisional, Conditional, Preliminary Denial of Accreditation.

10. 2009 Scoring/Accreditation Decision Model -Summary • Levels of Standards: • Immediate threat to life: no a single standard, but condition • Situational Decision Rule: immediate recommendation of Denial of Accreditation or Conditional accreditation alone. • eg: unlicensed provider • Onsite validation

11. 2009 Scoring/Accreditation Decision Model -Summary • DIRECT impact standard: Sedation • INDIRECT impact standard: Policies • New labels on standards: • (D): Documentation required • (2): Situational Decision Rule • (3): Direct Impact Requirements • (blank): Indirect Impact Requirements

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

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) B. Management and Coordination of Care (revised MS.03.01.03)

14. MS Chapter Outline IV. Medical Staff Role in Graduate Education Programs (revised MS.04.01.01) V. Medical Staff Role in Performance Improvement A. Role in Performance Improvement Activities (revised MS.05.01.01) B. Participation in Performance Improvement Activities (revised MS.05.01.03)

15. MS Chapter Outline VI. Credentialing and Privileging A. Determining Resource Availability (revised MS.06.01.01) B. Collecting Information (revised MS.06.01.03) C. Decision Process (revised MS.06.01.05) D. Reviewing Information (revised MS.06.01.07) E. Communicating Decision (revised MS.06.01.09) F. Expedited Process (revised MS.06.01.11) G. Temporary Privileges (revised MS.06.01.13)

16. MS Chapter Outline VII. Appointment to Medical Staff A. Recommending Appointment (revised MS.07.01.01) B. Peer Recommendations (revised MS.07.01.03)

17. MS Chapter Outline VIII. Evaluation of Practitioners A. Monitoring Performance (revised MS.08.01.01) B. Use of Monitoring Information (revised MS.08.01.03)

18. MS Chapter Outline IX. Acting on Reported Concerns About a Practitioner (revised MS.09.01.01) X. Fair Hearing and Appeal Process (revised MS.10.01.01) XI. Licensed Independent Practitioner Health (revised MS.11.01.01)

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

20. MOVED STANDARDS • MS.1.10 -> LD.01.05.01 • Standard LD.01.05.01 The organization has a medical staff that is accountable to the governing body.

21. LD.01.05.01 • 1: Single organized medical staff • 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

22. MS.01.01.01 • MS.1.20 (controversial) • All elements RETAINED (at least for now). • No new concepts pending rewriting this standard

23. MS.03.01.01 • Medical staff oversees quality of care, treatments, or services provided by practitioners privileged through the medical staff process • 1: LIPs designated to perform oversight • ! 2: Practitioners practices within scope of privileges • 3: LIPs perform oversight

24. MS.03.01.01 • 4: Leadership in patient safety • 5: Oversight of process of analyzing and improving patient satisfaction • D 6: Minimal content of H&Ps defined • 7: MS monitors quality of H&Ps • 8: Privileged provider performs H&Ps • 9: Others as allowed by laws may perform H&Ps, under a specified physician

25. MS.03.01.01 • D 10: Define when H&P must be validated or countersigned • D 11: Defines scope of H&P when required for non-inpatient services

26. MS.03.01.03 • The management and coordination of each patient’s care, treatment, or services is the responsibility of a practitioner with appropriate privileges • 1: LIP with privileges manage and coordinate patient’s care, treatment and services • 2: Hospital educates all LIPs on assessing and managing pain (NEW)

27. MS.03.01.03 • 3: Patient’s general medical condition managed by a physician. • 4: Circumstances warranting consultation • 5: Consultations obtained when warranted • 6: Coordination of care among practitioners

28. MS.05.01.01 The organized medical staff has a leadership role in organization performance improvement activities to improve quality of care, treatment, and services and [patient] safety. Practitioner specific performance data.

29. MS.05.01.01 • 1: The organized medical staff provides leadership for measuring, assessing, and improving processes that primarily depend on the activities of one or more licensed independent practitioners, and other practitioners credentialed and privileged through the medical staff process.

30. MS.05.01.01 • 2: Medical assessment and treatment of patients • 3: Use of information about adverse privileging decisions for any practitioner privileged through the medical staff process • 4: Use of medications

31. MS.05.01.01 • 5: Use of blood and blood components • 6: Operative and other procedure(s) • 7: Appropriateness of clinical practice patterns • 8: Significant departures from established patterns of clinical practice • 9: The use of developed criteria for autopsies.

32. MS.05.01.01 • 10: Sentinel event data • 11: Patient safety data

33. MS.05.01.03 • Practitioner specific data: citizenship • 1: Education of patients and families • 2: Coordination of care, treatment, and services with other practitioners and hospital personnel, as relevant to the care, treatment, and services of an individual patient.

34. MS.05.01.03 • 3: Accurate, timely, and legible completion of patient’s medical records • 4: Review of findings of the assessment process that are relevant to an individual’s performance. The organized medical staff is responsible for determining the use of this information in the ongoing evaluations of a practitioner’s competence.

35. MS.05.01.03 • 5: Communication of findings, conclusions, recommendations, and actions to improve performance to appropriate staff members and the governing body.

36. MS.06.01.01 • Prior to granting a privilege, the resources necessary to support the requested privilege are determined to be currently available, or available within a specified time frame.

37. MS.06.01.01 • 1: Process to determine sufficient: space, equipment, staffing, and financial resources are in place or time frame defined to support requested privilege • 2: The hospital consistently determines the resources needed for each requested privilege.

38. MS.06.01.03 • The [organization] collects information regarding each practitioner’s current license status, training, experience, competence, and ability to perform the requested privilege.

39. MS.06.01.03 • 1: Clearly defined process • 2: Process based on recommendations by medical staff • 3: Process approved by governing body • D 4: Outlined in bylaws • 5: Verify identify: hospital ID card, government issued ID (TO BE CHANGED)

40. MS.06.01.03 • D 6: Primary Source verification of: • The applicant’s current licensure at time of initial granting, renewal, and revision of privileges, and at the time of license expiration. • The applicant’s relevant training. • The applicant’s current competence.

41. MS.06.01.05 • The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidenced-based process.

42. MS.06.01.05 • ! 1: All licensed independent practitioners that provide care possess a current license, certification, or registration, as required by law and regulation. (SITUATIONAL DECISION)

43. MS.06.01.05 • D 2: Criteria based privileges include: • Current licensure and/or certification, as appropriate, verified with the primary source. • The applicant’s specific relevant training, verified with the primary source. • Evidence of physical ability to perform the requested privilege. • Data from professional practice review by an organization(s) that currently privileges the applicant (if available). • Peer and/or faculty recommendation. • When renewing privileges, review of the practitioner’s performance within the hospital.

44. MS.06.01.05 • 3: All of the criteria used are consistently evaluated for all practitioners holding that privilege • D 4: Process defined for granting, renewing, revising privileges • 5: Process is approved by medical staff

45. MS.06.01.05 • D 6: Applicant submits health statement. • 7: Hospital queries NPDB at initial privileges, renewal of privileges, and when new privileges requested.

46. MS.06.01.05 • D 8: Peer Recommendation includes: • Medical/Clinical knowledge. • Technical and clinical skills. • Clinical judgment. • Interpersonal skills. • Communication skills. • Professionalism.

47. MS.06.01.05 • 9: Before recommending privileges, the organized medical staff also evaluates the following: • Challenges to any licensure or registration. • Voluntary and involuntary relinquishment of any license or registration. • Voluntary and involuntary termination of medical staff membership. • Voluntary and involuntary limitation, reduction, or loss of clinical privileges. • Any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant. • Documentation as to the applicant’s health status. • Relevant practitioner-specific data as compared to aggregate data, when available. • Morbidity and mortality data, when available.

48. MS.06.01.05 • 10: The hospital has a process to determine whether there is sufficient clinical performance information to make a decision to grant, limit, or deny the requested privilege. (CMS) • C 11: Completed applications for privileges are acted on within the time period specified in the medical staff bylaws.

49. MS.06.01.05 • 12: Information regarding each practitioner’s scope of privileges is updated as changes in clinical privileges for each practitioner are made.

50. MS.06.01.07 • The organized medical staff reviews and analyzes all relevant information regarding each requesting practitioner’s current licensure status, training, experience, current competence, and ability to perform the requested privilege.