COMPARATIVE DIFFERENCES: COMPARATIVE DIFFERENCES: TJC, CMS & NCQA MEDICAL TJC, CMS & NCQA MEDICAL STAFF and CREDENTIALING STAFF and CREDENTIALING STANDARDS STANDARDS Debra R. Green, MPA, CPMSM, CPCS Debra R. Green, MPA, CPMSM, CPCS Director, Medical Staff Services and Pediatric Director, Medical Staff Services and Pediatric Residency Program Residency Program Stanford University Medical Center Stanford University Medical Center • Stanford Hospital & Clinics Stanford Hospital & Clinics • Lucile Packard Children’s Hospital Lucile Packard Children’s Hospital
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COMPARATIVE DIFFERENCES: COMPARATIVE DIFFERENCES: TJC, CMS & NCQA MEDICAL TJC, CMS & NCQA MEDICAL STAFF and CREDENTIALING STAFF and CREDENTIALING
STANDARDSSTANDARDS
Debra R. Green, MPA, CPMSM, CPCSDebra R. Green, MPA, CPMSM, CPCSDirector, Medical Staff Services and Pediatric Residency ProgramDirector, Medical Staff Services and Pediatric Residency Program
Stanford University Medical CenterStanford University Medical Center•Stanford Hospital & ClinicsStanford Hospital & Clinics
• Overview of the 3 main regulatory bodiesOverview of the 3 main regulatory bodies– Who they are? Who they are? – What they do? What they do? – Why they exist?Why they exist?
• Overview of Credentialing Standards Overview of Credentialing Standards – RequirementsRequirements– ComplianceCompliance
• Survey Process Survey Process
The Joint Commission (TJC)The Joint Commission (TJC)
• Who are they?Who are they?– Private OrganizationPrivate Organization
• Why do they exist?Why do they exist?– To ensure patient care and qualityTo ensure patient care and quality
Center for Medicare/Medicaid Center for Medicare/Medicaid (CMS)(CMS)
• Who are they?Who are they?– Government OrganizationGovernment Organization– Surveyors are typically State DOH employeesSurveyors are typically State DOH employees– Gives deeming authority to TJC, HFAP and DNVGives deeming authority to TJC, HFAP and DNV
• What do they do?What do they do?– Validate TJCValidate TJC– Can Survey For CauseCan Survey For Cause
• Why do they exist?Why do they exist?– To ensure patient care and qualityTo ensure patient care and quality
Authorities Deemed by CMSAuthorities Deemed by CMS
• Healthcare Healthcare Facilities Facilities Accreditation Accreditation Program (HFAP)Program (HFAP)– Over 200 hospital Over 200 hospital
and 200 other HC and 200 other HC facilities and labsfacilities and labs
– Existed for 60 yrsExisted for 60 yrs
• Det Norske Veritas Det Norske Veritas Healthcare, Inc Healthcare, Inc (DNV)(DNV)– Certifies other Certifies other
companies in companies in additional to additional to healthcarehealthcare
– Existed since 1884 Existed since 1884 (began in Norway)(began in Norway)
– World wide World wide reputation for quality reputation for quality and integrityand integrity
National Committee for Quality National Committee for Quality Assurance (NCQA)Assurance (NCQA)
• Who are they?Who are they?– Private OrganizationPrivate Organization
• What do they do?What do they do?– Accredits: MCO’s, MBHO’s, PPO’s, NHP’s Accredits: MCO’s, MBHO’s, PPO’s, NHP’s
etc.etc.– Certifies: CVO’sCertifies: CVO’s
• Delegated Credentialing AgreementsDelegated Credentialing Agreements– Hospital does the work for MCOHospital does the work for MCO
Overview of StandardsOverview of Standards
• Joint Commission Joint Commission – 13 total MS Standards 13 total MS Standards – Several Elements of Performance (EP’s)Several Elements of Performance (EP’s)– Several changes to MS Standard – 2007, eff Several changes to MS Standard – 2007, eff
1/20081/2008• CMS Conditions of Participation (CoP’s)CMS Conditions of Participation (CoP’s)
– 5 MS Standards5 MS Standards– Evidence of ComplianceEvidence of Compliance
• NCQANCQA– 12 Standards (Credentialing)12 Standards (Credentialing)– Elements of Performance for each StandardElements of Performance for each Standard
MEDICAL EDUCATIONMEDICAL EDUCATION
• TJC RequirementTJC Requirement
• (I) Primary Source (I) Primary Source verification from verification from Medical SchoolMedical School
• Peer must be within same Peer must be within same professional discipline professional discipline (advisable to utilize peer (advisable to utilize peer in same specialty)in same specialty)
• Recommendations should Recommendations should address training or address training or experience, clinical experience, clinical competence and ability to competence and ability to perform privileges perform privileges
• 6 General Competencies6 General Competencies
• NCQA RequirementsNCQA Requirements
• (I&R) Peer Review (I&R) Peer Review through Credentials through Credentials Committee with Committee with representation from representation from similar types and similar types and degrees of expertisedegrees of expertise
WORK HISTORYWORK HISTORY
• TJC RequirementTJC Requirement
• (I) Doctor must (I) Doctor must provide chronological provide chronological history of his history of his education, training education, training and experienceand experience
• Determination of Determination of “significant” clinical “significant” clinical performanceperformance
• NCQA RequirementNCQA Requirement
• (I) Doctor must provide (I) Doctor must provide five year work history five year work history on application or CV on application or CV
• No verification required No verification required but must explain gaps but must explain gaps of 6 months or moreof 6 months or more
HOSPITAL PRIVILEGESHOSPITAL PRIVILEGES
• TJC RequirementTJC Requirement• ““Ability to perform”Ability to perform”• Significant clinical Significant clinical
performanceperformance• Practice within scopePractice within scope• Grant or Deny must be Grant or Deny must be
objective and objective and evidence basedevidence based
• NCQA RequirementNCQA Requirement• Application must include Application must include
attestation statement attestation statement from applicant regarding from applicant regarding history of limitation or history of limitation or loss of clinical privileges loss of clinical privileges or other disciplinary or other disciplinary actionaction
• NOTE: NCQA does not NOTE: NCQA does not require doctors to have require doctors to have clinical privileges at an clinical privileges at an acute care facilityacute care facility
Performance MonitoringPerformance Monitoring
• Required only by TJCRequired only by TJC
• Focused Professional Practice Focused Professional Practice Evaluation (FPPE)Evaluation (FPPE)
– Proctoring – Chart Review or Proctoring – Chart Review or ObservationsObservations
• Ongoing Professional Practice Ongoing Professional Practice Evaluation (OPPE)Evaluation (OPPE)
– Ongoing data assessment for ALLOngoing data assessment for ALL
• (I & R) Doctor must (I & R) Doctor must provide information provide information regarding previously regarding previously successful or successful or currently pending currently pending challenges or challenges or relinquishment of relinquishment of registrationsregistrations
• NCQA RequirementNCQA Requirement
• (I & R) Verify (I & R) Verify through copy of through copy of certificates, NTIS, certificates, NTIS, AMAAMA
CONTINUING MEDICAL CONTINUING MEDICAL EDUCATIONEDUCATION
• TJC RequirementTJC Requirement
• (I & R) Participate in (I & R) Participate in Continuing EducationContinuing Education
• DocumentedDocumented
• Considered in Considered in Privilege processPrivilege process
• Should be relevant to Should be relevant to clinical privileges clinical privileges requestedrequested
• NCQA RequirementNCQA Requirement
• (I & R) Not Required(I & R) Not Required
MALPRACTICE INSURANCEMALPRACTICE INSURANCE
• TJC RequirementsTJC Requirements
• Primary source Primary source verification not verification not required unless required unless required by bylaws.required by bylaws.
• (I & R) MS must (I & R) MS must evaluate professional evaluate professional liability actionsliability actions
• NCQA RequirementNCQA Requirement
• Primary source Primary source verification not requiredverification not required
• (I & R) Attestation by (I & R) Attestation by doctor or copy of policy doctor or copy of policy showing dates and showing dates and amount of coverage or amount of coverage or Face SheetFace Sheet
MALPRACTICE HISTORYMALPRACTICE HISTORY
• TJC RequirementTJC Requirement
• (I & R) evaluate (I & R) evaluate evidence of evidence of “unusual” or “unusual” or “excessive” “excessive” number of actions number of actions resulting in a final resulting in a final judgment.judgment.
• NCQA RequirementNCQA Requirement
• (I&R) Doctor must (I&R) Doctor must provide provide malpractice history malpractice history for past five years.for past five years.
• Verified through Verified through carrier or NPDBcarrier or NPDB
NATIONAL PRACTITIONER NATIONAL PRACTITIONER DATA BANKDATA BANK
• TJC RequirementTJC Requirement
• (I&R) Must query at (I&R) Must query at granting of initial, granting of initial, renewal and when renewal and when aa new new privilege is privilege is requested.requested.
• NCQA RequirementNCQA Requirement
• (I&R) Query if you (I&R) Query if you can’t obtained last 5 can’t obtained last 5 years of claims from years of claims from Insurance carriers.Insurance carriers.
• Use as alternate Use as alternate source for sanctions source for sanctions or limitations on or limitations on licensurelicensure
HISTORY OF FELONY HISTORY OF FELONY CONVICTIONS/Drug UseCONVICTIONS/Drug Use
• TJC RequirementsTJC Requirements
• Terminology is not Terminology is not used in Medical used in Medical Staff StandardsStaff Standards
• Required under HR Required under HR StandardsStandards
• NCQA RequirementsNCQA Requirements
• (I&R) Application (I&R) Application must attest to must attest to his/her history of his/her history of loss of license and loss of license and felony conviction felony conviction and lack of illegal and lack of illegal drug use.drug use.
BOARD CERTIFICATIONBOARD CERTIFICATION
• TJC RequirementTJC Requirement
• (I) Verification not (I) Verification not required unless bylaws required unless bylaws require board require board certificationcertification
• Verify through ABMS, Verify through ABMS, AOA or specialty boardAOA or specialty board
• NCQA RequirementNCQA Requirement• (I) Not required, but verify (I) Not required, but verify
through ABMS, AMA, AOA, through ABMS, AMA, AOA, state licensing agency if state licensing agency if board certifiedboard certified
• (R) Verify only if (R) Verify only if certification has expired certification has expired (including lifetime)(including lifetime)
• Must document “lifetime” Must document “lifetime” in lieu of expiration datein lieu of expiration date
LICENSELICENSE
• TJC RequirementTJC Requirement• (I & R)Primary source (I & R)Primary source
verification required at verification required at initial appointment, initial appointment, reappointment, reappointment, revision of privileges revision of privileges and at time of and at time of expirationexpiration
• Current and ValidCurrent and Valid
• Verify through state Verify through state licensing boardlicensing board
• NCQA RequirementNCQA Requirement• (I & R) Primary source (I & R) Primary source
verification requiredverification required
• Must be current and Must be current and validvalid
• In effect at time of In effect at time of credentialing decisioncredentialing decision
• Verify through state Verify through state licensing boardlicensing board
LICENSE SANCTIONSLICENSE SANCTIONS
• TJC RequirementsTJC Requirements
• (I & R) The doctor (I & R) The doctor must provide must provide information information regarding challenges regarding challenges or relinquishment of or relinquishment of license (attestation license (attestation question)question)
• NCQA RequirementsNCQA Requirements
• (I & R) Primary (I & R) Primary source verificationsource verification
• Verify through state Verify through state license board, license board, NPDB, or FSMBNPDB, or FSMB
ATTESTATION STATEMENTATTESTATION STATEMENT
• TJC RequirementsTJC Requirements
• Terminology Not Terminology Not UsedUsed
• NCQA RequirementsNCQA Requirements
• Applicant must Applicant must provide a current, provide a current, signed attestation signed attestation statement regarding statement regarding the correctness and the correctness and completeness of completeness of applicationapplication
TIME FRAME FOR TIME FRAME FOR COMPLETIONCOMPLETION• TJC RequirementTJC Requirement
• Structured procedure Structured procedure must be defined in must be defined in bylaws bylaws
• Complete applications Complete applications must be acted upon must be acted upon within reasonable time within reasonable time frame as specified in frame as specified in bylawsbylaws
• NCQA RequirementNCQA Requirement
• Credentials Credentials information must information must be no more than be no more than 180 days old at the 180 days old at the time of time of credentialing credentialing committee’s committee’s decisiondecision
LENGTH OF APPOINTMENT LENGTH OF APPOINTMENT PERIODPERIOD
• TJC RequirementTJC Requirement
• May not exceed May not exceed two years two years
• NCQA RequirementNCQA Requirement
• Effective 7/1/01 Effective 7/1/01 credentialing credentialing period may be for period may be for 36 months36 months
NOW ABOUT CMS…..NOW ABOUT CMS…..
Medical Staff OrganizationMedical Staff Organization
• Regulation:Regulation:– Organized medical staff ; operates under Organized medical staff ; operates under
bylaws that are approved by governing bylaws that are approved by governing body; responsible for quality of care.body; responsible for quality of care.
• Regulation:Regulation: – MS must conduct periodic appraisalsMS must conduct periodic appraisals
• Compliance:Compliance:– Cred Files, Profiles, Summary Reports of Cred Files, Profiles, Summary Reports of
Credentialing activity, Board minutes Credentialing activity, Board minutes documenting last 2 appraisalsdocumenting last 2 appraisals
MS Composition (a)(2)MS Composition (a)(2)
• Regulation:Regulation:– MS must examine credentials of MS must examine credentials of
applicants for applicants for membershipmembership and make and make recommendation to Board.recommendation to Board.
• Compliance:Compliance:– Definition of Creds Review Process in the Definition of Creds Review Process in the
Bylaws; any MS or Dept minutes that Bylaws; any MS or Dept minutes that document review and recommendations.document review and recommendations.
MS Organization & MS Organization & AccountabilityAccountability
• Regulation:Regulation:– MS must be well organized and MS must be well organized and
accountable to Governing Body for accountable to Governing Body for quality of Medical Care provided.quality of Medical Care provided.
• Compliance:Compliance:– MS Org Chart, Bylaws Description, Board MS Org Chart, Bylaws Description, Board
Minutes, definition of MS Composition in Minutes, definition of MS Composition in Bylaws, Bylaws approval by BoardBylaws, Bylaws approval by Board
Medical Staff BylawsMedical Staff Bylaws
• RequirementRequirement::– MS must adopt & enforce. MS must adopt & enforce. – Must be approved by Board; include Must be approved by Board; include
category descriptions, H&P requirement and category descriptions, H&P requirement and criteria for privileges to be granted; criteria for privileges to be granted; describe MS Organization and applicant describe MS Organization and applicant qualifications; qualifications;
• Compliance:Compliance:– Bylaws, R&R, Minutes, Medical Records Bylaws, R&R, Minutes, Medical Records
1. Under certain circumstances, temporary clinical privileges may be granted for a limited period of time.TRUE
2. When temporary privileges are granted to meet an important care need, the organized medical staff verifies only current licensure and current competence before the provider can begin seeing patients.TRUE
3. Temporary privileges for new applicants are granted for no more than 90 Bylaws/120 TJC days.4. All temporary privileges are granted by the chief executive officer or authorized designee.
TRUE 5, Under which circumstances does the Joint Commission allow temporary privileges to be granted?
a. To fulfill an important patient care, treatment, and service need.b. When a new applicant with a complete application that raises no concerns
is awaiting review and approval of the medical staff executive committee and the governing body.
Bonus Question:Temporary privileges for new applicants may be granted while awaiting review and approval by the organized medical staff upon verification of……? List 5 items- Current licensure.- Relevant training or experience.- Current competence.- Ability to perform the privileges requested.- Other criteria required by the organized medical staff bylaws.- A query and evaluation of the National Practitioner Data Bank (NPDB) information.- A complete application.- No current or previously successful challenge to licensure or registration.- No subjection to involuntary termination of medical staff membership at another organization.- No subjection to involuntary limitation, reduction, denial, or loss of clinical privileges.
All answers can be found in the Joint Commission Medical Staff Standards under MS.06.01.13
