Hot Topics - NAMSS · Web viewKathy Matzka, CPMSM, CPCS is a speaker, consultant, and writer...

Joint Commission Standards for the

Hospital Medical StaffResources

Kathy Matzka, CPMSM, CPCSConsultant/Speaker

1304 Scott Troy RoadLebanon, IL 62254

[email protected]: www.kathymatzka.com

Phone (618) 624-8124

BIOGRAPHICAL SKETCH, KATHY MATZKA, CPMSM, CPCS

Kathy Matzka, CPMSM, CPCS is a speaker, consultant, and writer with over 25 years of experience in credentialing, privileging, and medical staff services. She holds certification by the National Association Medical Staff Services (NAMSS) in both Medical Staff Management and Provider Credentialing. Ms. Matzka worked for 13 years as a hospital medical staff coordinator before venturing out on her own as a consultant, writer, and speaker.

Ms. Matzka has authored a number of books related to medical staff services including Medical Staff Standards Crosswalk: A Quick Reference Guide to The Joint Commission, CMS, HFAP, and DVN Standards, Chapter Leader’s Guide to Medical Staff: Practical Insight on Joint Commission Standards, Compliance Guide to Joint Commission Medical Staff Standards, and The Medical Staff Meeting Companion Tools and Techniques for Effective Presentations. For eight years, she was the contributing editor for The Credentials Verification Desk Reference and its companion website The Credentialing and Privileging Desktop Reference.

She has performed extensive work with NAMSS’ Library Team developing and editing educational materials related to the field including CPCS and CPMSM Certification Exam Preparatory Courses, CPMSM and CPCS Professional Development Workshops, and NAMSS Core Curriculum. These programs are essential educational tools for both new and seasoned medical services professionals. She also serves as instructor for NAMSS.

Ms. Matzka shares her expertise by serving on the editorial advisory boards for two publications - Briefings on Credentialing and Credentialing & Peer Review Legal Insider.

Ms. Matzka is a highly-regarded industry speaker, and in this role has developed and presented numerous programs for professional associations, hospitals, and hospital associations on a wide range of topics including provider credentialing and privileging, medical staff meeting management, peer review, negligent credentialing, provider competency, and accreditation standards. In her spare time, Ms. Matzka takes pleasure in spending time with her family, listening to music, traveling, hiking, fishing, and other outdoor activities.

Table of Contents

Documenting Recommendations.......................................................................................................1Recommendation and Approval Form for Medical Staff Appointment and Clinical Privileges...........2Sample Policy and Procedure for Verification of Identity...................................................................3Sample Letter for Verification of Training...........................................................................................4Training Program Director’s Evaluation and Recommendation.........................................................5Sample Letter: Facility Privileges and Competency Validation..........................................................7CONFIDENTIAL Evaluation of Privileges and Competency Validation..............................................8Work Sheet for Consideration of New Privilege.................................................................................9Sample Peer Recommendation Form..............................................................................................11Credentials File Audit [Name] Hospital of TJC Requirements for MS.06.01.03 through MS.06.01.07......................................................................................................................................................... 13Application Flow Chart.....................................................................................................................15Notification of Internal and External Parties Regarding Practitioner Privileges................................16Sample Medical Staff Expedited Credentialing Policy and Procedure.............................................18Temporary Privilege Form................................................................................................................20Sample Bylaws Language for Temporary Privileges........................................................................21Sample Bylaws Language for Telemedicine....................................................................................23Sample Disaster Privileges Policy and Procedure...........................................................................25Crosswalk Medical Staff and Governing Bylaws, Rules, Regulations, Policies, and Procedures....30Chart For Review Of Bylaws For Compliance With Joint Commission Standards Required Documentation.................................................................................................................................31Sample Clinical Consultation Form..................................................................................................34Sample Medical Staff Peer Review Policy.......................................................................................35Sample Indicators............................................................................................................................ 41Sample Medical Staff Peer Review Process Form...........................................................................45Sample Peer Review Form..............................................................................................................46Focused Professional Practice Evaluation Plan...............................................................................48Sample Proctorship Form................................................................................................................50Proctoring Summary Report.............................................................................................................51Sample Indicators for LIP APRNs and PAs.....................................................................................52Focused Professional Practice Evaluation (FPPE) Report..............................................................53Ongoing Professional Practice Evaluation (OPPE) Report..............................................................54College American Pathologists Recommendations for Tissue to be Submitted to Pathology..........55

Documenting Recommendations

Sample language for medical staff minutes:

“Committee members reviewed the applications, the supporting documentation, the Department Chairmen’s recommendations, and information received during the credentialing and privileging processes [or insert OPPE/FPPE etc., as appropriate]. Based on this review, it is the committee’s opinion that the following applicants meet the requirements for Medical Staff appointment and have documented appropriate education, training, experience, current competency, clinical judgment, professionalism, and health status to perform the privileges requested. It was moved, seconded, and carried to recommend to the [fill in Credentials Committee or MEC as appropriate] approval of the following appointments and clinical privileges [or insert cessation of FPPE, etc]:”

Sample language for Board minutes:

“Board members reviewed the applications, the supporting documentation, the Department Chairmen’s recommendations, Medical Executive Committee’s recommendations, and information received during the credentialing and privileging processes [insert OPPE/FPPE etc., as appropriate]. Based on this review, it is the Board’s opinion that the following applicants meet the requirements for Medical Staff appointment and clinical privileges [insert cessation of FPPE etc., as appropriate] as recommended and it was moved, seconded, and carried to approve of the following appointments and clinical privileges [insert cessation of FPPE, etc]:”

1 | P a g e

Recommendation and Approval Form for Medical Staff Appointment and Clinical PrivilegesPractitioner Name:____________________________________________________________________

Staff Status:__________________ Department: __________________Specialty:_________________________

Departmental RecommendationBased on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant the following recommendations are made:

Privileges be granted/renewed Medical staff membership be granted/renewed Additional privileges requested be granted Privileges be modified as follows: ___________________________________________________________________________________________________ Privileges not be granted/renewed Medical staff membership not be granted/renewed (comment below) Additional privileges requested be denied (comment below)

Comments:

Department Chairman Date

Credentials Committee RecommendationBased on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant and on the evaluations and recommendations of the Department Chairman the following recommendations are made:

Concur with recommendation(s) of the Department Chairman and forward these recommendations to the Medical Executive Committee Do not concur with the recommendations of the Department Chairman, and instead make the following recommendations ___________________________________________________________________________________________________ Credentials Committee Representative Date

Medical Staff Executive Committee RecommendationBased on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant, and on the evaluations and recommendations of the Department Chairman and Credentials Committee, the following recommendations are made:

Concur with recommendation(s) of the Department Chairman and Credentials Committee and forward these recommendations to the governing body for consideration. Do not agree with the recommendations of the Department Chairman, and Credentials Committee and instead make the following recommendations: ______________________________________________________________________

Medical Staff Executive Committee Representative Date

Governing Body Approvals/Action TakenBased on the evaluation of the education, training, current competence, health status, skill, character, and judgment data and information, and on the recommendations of the Medical Staff, the following action is taken:

Concur with and approve the recommendation(s) of the Medical Staff. Do not concur with the recommendations of the Medical Staff. Action taken is documented in Board minutes of ________________.

(date)

2 | P a g eKathy Matzka, CPMSM, CPCS

Board of Trustees Representative Date


Sample Policy and Procedure for Verification of Identity

Policy:

It is the policy of ___________ Hospital to verify the identity of all licensed independent practitioners (LIPs) who apply for medical staff appointment and privileges prior to the practitioner providing any patient care, treatment, or services. This is done to determine that these practitioners are the same practitioners identified in the credentialing documents.

Verification of identity can be accomplished by viewing any of the following:

Military ID, State ID, Customs Passport, State Driver’s License

Procedure:

Verification can be done during any of the following processes:

During provider orientation During the process of obtaining hospital picture ID Any time the practitioner presents in person

After presentation of a valid Military ID, state driver’s license/ID, or customs passport that includes a picture, the person verifying completes the Verification of Identity Documentation Form (Attachment A). The completed form is forwarded to the Medical Staff Office for inclusion in the practitioner’s credentials file.

Reference: Joint Commission Hospital Standard MS.06.01.03

Attachment AVerification of Identity Documentation Form

Practitioner Name: ____________________________________________________

I have reviewed the following identification for the above-named practitioner:

Military ID

Passport

State Driver’s license or ID ______________________________________ [List issuing state]

_______________________________ ____________________Signature of person verifying Date

_______________________________Printed name of person verifying


Sample Letter for Verification of Training

[Date]

Re: [Applicant’s full name, Title]Training: [Residency/fellowship]Specialty: [Specialty]Dates: [From/to]

Dear [Program Director name]:

We have received an application from the above-named provider for medical staff appointment and/or privileges. A copy of the privileges requested is attached. The applicant noted that the above-specified training took place at your institution. In order to process the application we require verification of completion of training and documentation of experience, ability, and current competence on the six areas of “General Competencies” adopted from the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) joint initiative.

Our policies require completion of the enclosed form. Failure to receive this form will delay consideration of the applicant’s request for privileges. Also, our policies require the physician to document competency in performing specific procedures by allowing our organization to obtain a copy of his/her procedure list from your program and the outcomes for those procedures (if outcomes are available). The applicant has authorized you to provide this information to our organization via signature on the attached Authorization and Release Form.

Enclosed is a copy of a release and immunity statement signed by the applicant consenting to this inquiry and your response. The immunity statement releases from liability any individual who provides the requested information.

Thank you for your assistance. We look forward to hearing from you.

Sincerely,

Director

Enclosures


Training Program Director’s Evaluation and Recommendation Page 1

Re: [Applicant’s full name]Training: [Residency/fellowship]Specialty: [Specialty]Dates: [From/to]

Area of EvaluationPlease use comment section below to provide additional information noting

question number for which information is provided.

YES NO Unable to

Evaluate

1 Were you the director of the program at the time of this applicant’s training?2 Was the applicant at your institution in the above program for the stated

period of time?3 Was the program fully accredited throughout the applicant’s participation in

it?4 Did the applicant successfully complete the program?5 Did the applicant receive satisfactory ratings for all aspects of his/her training

in the program?6 Was the applicant ever subject to or considered for disciplinary action?7 Did the applicant ever attempt procedures beyond his/her assigned training

protocols?8 Was the applicant’s status and/or authority to provide services ever revoked,

suspended, reduced, restricted, not renewed, or was he/she placed on probationary status or reprimanded at any time or were proceedings ever initiated that could have led to any of the actions?

9 Did the applicant ever voluntarily terminate his/her status in the program or restrict his/her activities in the program in lieu of formal action or to avoid an investigation?

10 In reviewing the attached request for privileges, do you feel that the applicant’s training and experience included these procedures?

11 In reviewing the attached request for privileges, do you feel that the applicant is currently competent to carry out these procedures?

12 Are you aware of any physical or mental condition that could affect this practitioner’s ability to exercise clinical privileges in his/her specialty area, or would require an accommodation to exercise those privileges safely and competently?

Comments:

Question Comment_______ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ __________________________________________________________


Training Program Director’s Evaluation and Recommendation Page 2

Re: [Applicant’s full name]Training: [Residency/fellowship]Specialty: [Specialty]Dates: [From/to]

Please rate the applicant in each of the following areas:

Excellent Good Fair Poor Unable toevaluate

Patient care/Procedural SkillsMedical knowledgePractice-based learning and improvementInterpersonal and communication skillsProfessionalismSystems-based practice

This evaluation is based upon:

Personal knowledge of the applicant.

Review of file.

Other _____________________________________________________________________________

Overall Recommendation (check ONE):

I recommend privileges as requested without reservation.

I recommend privileges as requested with the following reservation(s) (use back of form, if necessary________________________________________________________________________________________

________________________________________________________________________________________

I do not recommend this applicant for the following reason(s) ________________________________________________________________________________________________________________________________________________________________________________

_______________________________________ _____________________________ Signature Date

_______________________________________ _____________________________Name, Position/Title (Please Print) Phone Number

Please return this form within 2 weeks. Failure to receive the form will delay consideration of the applicant’s request for privileges.


Sample Letter: Facility Privileges and Competency Validation

Date

Facility NameFacility Address

Regarding applicant: John Doe, M.D.Specialty: General Surgery

Dear Medical Services Professional:

We have received an application from the above-named provider for medical staff appointment and privileges. A copy of the privileges requested is attached. The applicant noted that s/he currently, or has in the past, held privileges at your facility. In order to process the application we require documentation experience, ability, and current competence on the six areas of “General Competencies” adopted from the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) joint initiative. These competencies include assessment of patient care, interpersonal and communication skills, professionalism, medical knowledge, practice-based learning and improvement, and systems-based practice.

Our policies require completion of the enclosed form. Failure to receive this form will delay consideration of the applicant’s request for privileges. Also, our policies require the physician to document competency in performing specific procedures by allowing our organization to obtain a copy of his/her privilege form from your hospital as well as a list of the actual procedures performed in the past 12 months and the outcomes for those procedures. The applicant has authorized you to provide this information to our organization via signature on the attached Authorization and Release Form.

Sincerely,

Medical Staff Coordinator


CONFIDENTIAL Evaluation of Privileges and Competency ValidationName of Facility Providing Information:___________________________________________________________

Name of Practitioner for which Information is Provided:_______________________________________________

Dates on Staff: From ________________________________ To ____________________________________

Has the practitioner been subject to any disciplinary action, restrictions, modifications, or loss of Yes Noprivileges or medical staff appointment either voluntary or involuntary at your facility?

Are you aware of any restrictions, modifications, or loss of privileges or medical staff appointment, Yes Noeither voluntary or involuntary, at any another facility?

Are you aware of any physical or mental condition that could affect this practitioner’s Yes Noability to exercise clinical privileges as requested, or would require accommodation to perform privileges safely and competently?

If the answer to any of the above questions is “YES”, please explain: __________________________________________________________________________________________________________________________________________________

Evaluation: Please rate the practitioner in the following areas.

Patient Care is compassionate, appropriate, and effective for the treatment of health problems and promotion of health. Procedural skills reflect those expected of a practitioner who has completed an accredited residency.

Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care

Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals

Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.

Excellent Good Fair Poor Unable to

evaluatePatient care/Procedural skillsMedical knowledgePractice-based learning and improvementInterpersonal and communication skillsProfessionalismSystems-based practice

_______________________________________ _____________________________ Signature Date


Please return this form within 2 weeks along with a copy of the applicant’s privilege list for your hospital and a list of the actual procedures performed in the past 12 months and the outcomes for those procedures.


Work Sheet for Consideration of New Privilege

Name of procedure/privilege_________________________________________

Education required to request privilege (check all that apply)

MD - Medical Doctor DO - Osteopathic Physician) DDS - Oral and Maxillofacial Surgeon DMD - Dentist DPM - Podiatrist APN – Advance Practice Nurse (specify specialty)______________________________ PA – Physician Assistant (specify specialty) ___________________________________ DC – Chiropractic Other (specify) __________________________________________________________

Training Required:

Experience required

Additional Requirements:

CME Board Certification Manufacturer’s Training Course/Certificate Peer Recommendations

Is monitoring or proctoring required?

No Yes.

If yes, specify the following:

Number of procedures ___________ Length of time __________________ In order to complete proctorship/monitoring requirements, the applicant must perform

_______ (number) procedures within _____________(time frame).

What type of review or follow up will be conducted?


Sample Peer Recommendation LetterDate

Facility NameFacility Address

Regarding applicant: John Doe, M.D.Specialty: General Surgery

Dear ______________:

We have received an application from the above-named provider for medical staff appointment and privileges. A copy of the privileges requested is attached. The applicant has listed you as a peer who will be willing to provide a recommendation. In order to process the application we require your evaluation of the applicant’s experience, ability, and current competence in the areas of medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism.

Our policies require completion of the enclosed form. Failure to receive this form will delay consideration of the applicant’s request for privileges. You may supplement the form with additional information, if you so desire. The applicant has authorized you to provide this information to our organization via signature on the attached Authorization and Release Form.

Sincerely,

Medical Staff Coordinator


Sample Peer Recommendation FormCONFIDENTIAL Professional Peer Reference & Competency Validation

Page 1 of 2

Name of Applicant:________________________________________________________________________________

Name of Evaluator:____________________________________ Relationship to Applicant:________________________

How well do you know the applicant? not well casual personal acquaintance professional acquaintance very well

Do you refer your patients to the applicant? yes no. If no, list reason(s) why not ___________________________________

_________________________________________________________________________________________________________

PLEASE RATE THE PRACTITIONER IN THE FOLLOWING AREAS

Excellent Good Fair Poor Unable to

evaluateMedical knowledge - Practitioner should have a good knowledge of established and evolving biomedical, clinical, and cognate sciences, and how to apply this knowledge to patient care. This is evidenced by completion of educational and training requirements as well as on-the-job experience, inservice training, and continuing education.Technical and clinical skills - Skill involves the capacity to perform specific privileges/procedures. It is based on both knowledge and the ability to apply the knowledge.Clinical judgment - Clinical judgment refers to the observations, perceptions, impressions, recollections, intuitions, beliefs, feelings, inferences of providers. These clinical judgments are used to reach decisions, individually and/or collectively with other providers, about a patient’s diagnosis and treatment.Communication skills - The provider should create and sustain a therapeutic and ethically sound relationship with other care givers, patients, and their families. He/she should be able to communicate effectively and demonstrates caring, compassionate, and respectful behavior. This also includes effective listening skills, effective nonverbal communication, eliciting/providing information, and good writing skillsInterpersonal skills - Areas of evaluation include how the provider works effectively with other professional associates, including those from other disciplines, to provide patient-focused care as a member of a healthcare team.Professionalism - Professionalism is demonstrated by respect, compassion, and integrity. It means being responsive and accountable to the needs of the patient, society, and the profession. It means being committed to providing high-quality patient care and continuous professional development as well as being ethical in issues related to clinical care, patient confidentiality, informed consent, and business practices.


CONFIDENTIAL Professional Peer Reference & Competency ValidationPage 2 of 2

Name of Applicant:__________________________________________________________________________

Name of Evaluator:________________________________________________________________________________

Relevant training and experience – In reviewing the attached request for privileges, do you feel that the applicant’s training and experience are adequate to carry out these procedures?

No - If no, please provide an explanation_______________________________________________________________ Yes Unable to evaluate

Current competence – In reviewing the attached request for privileges, do you feel that the applicant is currently competent to carry out these procedures?

No - If no, please provide an explanation_______________________________________________________________ Yes Unable to evaluate

Health Status - Are you aware of any physical or mental condition that could affect this practitioner’s ability to exercise clinical privileges in his/her specialty area, or would require an accommodation to exercise those privileges safely and competently?

No Yes - If yes, please provide an explanation_______________________________________________________________ Unable to evaluate

_________________________________________________________________________________________________

Overall Recommendation (check ONE):

I recommend privileges as requested without reservation.

I recommend privileges as requested with the following reservation(s) (use back of form, if necessary_______________________________________________________________________________________________

_________________________________________________________________________________________________ I do not recommend this applicant for the following reason(s) ___________________________________________

_______________________________________________________________________________________________

_________________________________________________________________________________________________

_______________________________________ _____________________________ Signature Date


Please return this form within 2 weeks. Failure to receive the form will delay consideration of the applicant’s request for privileges.


Credentials File Audit [Name] Hospital of TJC Requirements for MS.06.01.03 through MS.06.01.07

Scoring: 1 = Element is present and in compliance, 0 = Element is not present or is not in compliance, N/A = not applicable

Element of Review File 1 File 2 File 3 File 4 File 5 File 6 File 7 File 8 File 9 File 10 Ratio

(#/#

)

Practitioner Name

Application present, complete, signed

Peer References Received and appropriateDocumentation of applicant statement that no health problems exist that could affect his or her ability to perform the privileges requested and documentation of

ID verification present

NPDB Query

PSV Medical School

ECFMG verification (if applicable)

PSV of Fellowship present (if applicable)

PSV of Residency present

PSV of [your] state license

PSV of other state License(s)

PSV of state controlled substance license

PSV Board Certification

Current DEA Certificate present

PrivilegesPrivilege form present and appropriate to specialty

Form signed by applicant

Form completed correctly

Privileges evaluated and recommended by department

Privilege decision granted pursuant to bylaws including time frame for approval


Element of Review File 1 File 2 File 3 File 4 File 5 File 6 File 7 File 8 File 9 File 10 Ratio

(#/#

)

There is consistent application of credentialing criteria as specified in bylawsBefore recommending privileges, the organized medical staff also evaluates

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.

Information regarding the practitioner’s scope of privileges is updated as changes in clinical privileges for each practitioner are made

Privileges do not exceed two years

Date of Audit: __________________________________________________________ Audit Performed by: ___________________________________________


Application Flow Chart

Name of Applicant Department

Application Type

Date Returned

Date Completed*

Days to Complete*

Date Chair Review

Days to Complete

Chair Review

Date Credential Committee Recomme

ndation

Days to Complete Credential

Com. Recomme

ndation

Date MEC Recomme

ndation

Days to Complete

MEC Review

Date Board Action

Days to Complete

Board Review/Ac

tion

Total Days From

Comple-tion to Action

AVERAGES(highlighted columns only)

*A complete application is one in which the application itself is not only complete, but all primary source verification and information required by the medical staff bylaws is completed.


Notification of Internal and External Parties Regarding Practitioner Privileges

Policy:

Key external and internal persons and organizations must be notified whenever a change occurs in a practitioner’s privileges or when a new practitioner is granted privileges or appointment. Some internal sources require information regarding clinical privileges granted, while others require only a general notification.

Procedure:

Internal Sources:

General Notification of New Practitioner:

When a new practitioner is granted medical staff appointment or clinical privileges, a general notification should be distributed via email or memo to all hospital departments. The following information should be included:

Full name, credential, address, phone, fax, pager/paging service number, partners, alternates, effective date, picture, sponsoring physician (if AHP).

General Notification Practitioner Leaving Staff:

When a practitioner leaves the staff, a general notification should be distributed via email or memo to all hospital departments. The following information should be included:

Full name, credential, forwarding address (if applicable), and effective date.

Notification of Privileges

When new privileges are granted either to a new applicant or an existing medical staff member or allied health professional; or when there is a modification (addition, deletion, termination, proctorship, etc.) to current privileges; the following internal personnel should be notified via email or memo and a copy of the privileges (or modification to privileges) should be included with the notification. (Note: Will need to modify this language to reference privileges that are posted via intranet or other electronic means).[Name] Admitting Department[Name] Operating Room[Name] Nursing Administration (for distribution to all nursing units)[Name] Administration[Name] Emergency Department[Name] Outpatient/Ambulatory Clinic(s)[Name] Quality Management[Name] (Include others, as appropriate)

External Sources17 | P a g e

Kathy Matzka, CPMSM, CPCS

National Practitioner Data Bank and State Licensing Boards

The Health Care Quality Improvement Act of 1986 includes a requirement for reporting of certain adverse actions to the National Practitioner Data Bank.

Hospitals must report:

(1) a professional review action which adversely affects a physician’s or dentist’s clinical privileges for more than 30 days and is based upon the physician’s or dentist’s professional competence or professional conduct; and

(2) the voluntary surrender of clinical privileges by a physician or dentist who is under investigation relating to questions of professional competence or conduct, or in return for no investigation or professional review action being conducted.

A professional review action includes denying, reducing, restricting, revoking and suspending privileges, and also includes a decision not to renew clinical privileges if that action is based on the physician’s or dentist’s professional competence or conduct.

Hospitals must submit adverse action reports to the appropriate state licensing board within 15 days of final Board action in the case of an adverse action or within 15 days of the date the physician surrenders his or her clinical privileges. These reports must be submitted electronically to the National Practitioner Data Bank as an Adverse Action Report. Within 15 days, a printed copy of the electronic report must be forwarded to the state medical licensing board.

Revisions to previously reported adverse actions must also be reported. For example, if a physician’s clinical privileges are reinstated after a 45 day suspension, both the suspension and the reinstatement must be reported.

Note: All reports to state licensing boards and the NPDB should be coordinated with the Legal Department.


Sample Medical Staff Expedited Credentialing Policy and Procedure

PURPOSE:

This policy and procedure is made to provide a more efficient mechanism for review of requests for new or renewed applications for appointment and privileges without compromising the quality of the review. “Expedited Credentialing” provides an expedited review and approval process if specific, pre-defined, Board approved criteria are met.

Expedited Credentialing is neither a right nor a privilege, and no applicant is automatically entitled to this type of processing. Candidates who do not meet the criteria for Expedited Credentialing will be processed through the usual credentialing process as specified in the Medical Staff Bylaws.

PROCEDURE:

The Credentials Committee Chair, Department Chair, or their designee, will review each application and its associated documentation, and categorize the application according to the following criteria:

Category One - Expedited:

Category One applications must meet all of the following criteria:

1. The application is complete and accurate with all requested information returned.2. The application contains no unexplained or alarming gaps in time.3. No discrepancies in information or negative or questionable information received 4. Unremarkable medical staff/employment history - no frequent moves5. The applicant’s request for clinical privileges is consistent with his/her specialty, based on experience,

training, and current competency, and meets applicable criteria.6. Medical staff appointment, staff status and/or clinical privileges have never been involuntarily resigned,

denied, revoked, suspended, restricted, reduced, surrendered, or not renewed at any other health care facility.

7. The applicant has never withdrawn application for appointment, reappointment or clinical privileges or resigned from the medical staff before a decision was made by another health care facility's governing board.

8. The applicant possesses current, valid state license, professional liability insurance (in sufficient limits), and federal and/or state narcotics certificate(s), if applicable.

9. No license(s), DEA or other controlled substance authorizations, or membership in local, state or national professional societies, or board certification have ever been suspended, modified, terminated or voluntarily or involuntarily surrendered or are pending.

10. The applicant has never been named as a defendant in a criminal action and/or has never been convicted of a crime.

11. There are no significant adverse findings reported by the National Practitioner Data Bank, Healthcare Practitioner Data Bank, Federation of State Medical Boards, and/or the American Medical Association/American Osteopathic Association.

12. There are no past or pending malpractice actions, including claims, lawsuits, arbitrations, settlements, awards or judgments that show an unusual pattern of, or an excessive number of, professional liability actions resulting in a final judgment against the applicant.


MEDICAL STAFFEXPEDITED CREDENTIALING POLICY AND PROCEDURE - continued

13. There are no proposed or actual exclusions and/or any pending investigations of the applicant from any health care program funded in whole or in part by the federal government, including Medicare or Medicaid.

14. The applicant has indicated that he/she can safely and competently exercise the clinical privileges requested, with or without a reasonable accommodation.

15. The applicant’s history shows an ability to relate to others in a harmonious, collegial manner.16. At the time of renewal of privileges, documentation of activity in the hospital and/or verification from

outside healthcare entities and/or peers sufficiently verifies current competence.17. At the time of renewal of privileges, the results of peer review activities and the quality improvement

functions of the medical staff reveal no areas of concern.

Processing Category One Applications:

1. The Medical Staff Office receives and processes the application.2. The appropriate department chair and the Credentials Committee Chair, or designees, review the

completed and verified application.3. The Department and Credentials Committee Chair, or designees, forward a report with findings and a

recommendation to the Medical Executive Committee, which reviews the application at its next scheduled meeting.

4. The Chief of Staff forwards the Executive Committee’s recommendation to the Credentials Committee of the Governing Board, which reviews and evaluates the qualifications and competence of the practitioner applying for appointment, reappointment, or renewal or modification of clinical privileges and renders its decision. A positive decision by the committee results in the appointment or privileges requested. If the Board Credentials Committee's decision is adverse to an applicant, the matter is referred back to the Medical Staff Executive Committee for further evaluation. The Board Credentials Committee reports its recommendation to the full Board.

5. The full Board considers and, if appropriate, ratifies all positive Board Credentials Committee decisions at its next regularly scheduled meeting (this step is not required by Joint Commission standards)

6. If, at any point, any reviewer feels the application does not meet Category One criteria, the file will be considered Category Two and the usual review process (Category Two) will be followed.

7. Expedited credentialing decisions will be reported to the Credentials Committee for informational purposes.

Category Two - Full Review:

Applications that do not meet ALL requirements as outlined under "Category One" above will be processed and transmitted through the full review process as outlined in the Medical Staff Bylaws.


Temporary Privilege Form[HOSPITAL NAME]

NAME OF APPLICANT_____________________________________________________

PRIVILEGES REQUESTED

LOCUM TENENS FROM ____________ TO _____________

NEW MEDICAL STAFF FROM ____________ TO _____________

NEW AHP FROM ____________ TO _____________

LIMITED PRIVILEGES FROM ____________ TO _____________

ADDITIONAL PRIVILEGES BY CURRENT MEDICAL STAFF APPOINTEE OR AHP PENDING MEDICAL EXECUTIVE COMMITTEE AND BOARD APPROVAL (LIST PRIVILEGES REQUESTED)

___________________________________________FROM ____________ TO _____________

If patient care need, document reason_______________________________________________

______________________________________________________________________________

______________________________________________________________________________

APPROVALS

HOSPITAL PRESIDENT OR DESIGNEE______________________________________

MEDICAL STAFF PRESIDENT OR DESIGNEE________________________________

COMMENTS OR RESTRICTIONS_________________________________________________

_____________________________________________________________________________


Sample Bylaws Language for Temporary Privileges

TEMPORARY CLINICAL PRIVILEGES HELD BY NON-MEDICAL STAFF MEMBERS

Temporary privileges may be granted by the hospital CEO or designee on recommendation of the Medical Staff President or designee in the following circumstances:

Patient Care Need

Temporary privileges may be granted when an important patient care, treatment, or service need must be filled. Prior to consideration of temporary privileges there must be completion of the appropriate application, consent, and release, proof of current licensure, DEA certificate, appropriate malpractice insurance, completion of the National Practitioner Data Bank query, and verification that there are no current or prior successful challenges to licensure or registration. In addition, the practitioner must not have been subject to involuntary termination of Medical Staff membership at another facility, and likewise has not been subject to involuntary limitation, reduction, denial, or loss of clinical privileges at another facility as confirmed by the National Practitioner Data Bank query.

One-Case Privileges

Upon receipt of a written request and documentation of important patient care, treatment, or service need, an appropriately licensed person who is not an applicant for membership may be granted temporary privileges for the care of one (1) patient. Such privileges are intended for isolated instances in which extension of such privileges are shown to be in an individual patient’s best interest, and no practitioner shall be granted one-case privileges on more than five (5) occasions in any given year. The letter approving such privileges shall include the name of the patient to be treated and the specific privileges granted. Practitioners granted one-case privileges shall attend the patient for whom privileges were granted within thirty (30) days of the request for one-case privileges. If a given practitioner exceeds the five (5) case limit, such person shall be required to apply for membership on the Medical Staff before being allowed to attend additional patients. Prior to any award of one-case privileges, the practitioner must submit a copy of current license, DEA certificate, proof of appropriate malpractice insurance and curriculum vitae and the CEO or his/her designee must obtain verification of the physician’s privileges at his/her primary hospital. In addition, the practitioner must not have been subject to involuntary termination of Medical Staff membership at another facility, and likewise has not been subject to involuntary limitation, reduction, denial, or loss of clinical privileges at another facility, and has had no current or prior successful challenges to licensure or registration as confirmed by the National Practitioner Data Bank query.

Locum Tenens

Upon receipt of a written request and documentation of important patient care, treatment, or service need an appropriately licensed person who is serving as locum tenens for a member of the Medical Staff or providing needed coverage in a hospital department may, without applying for membership on the staff, be granted temporary privileges for an initial period not to exceed thirty (30) days. Such privileges may be renewed for successive consecutive periods not to exceed thirty (30) days, but only upon the practitioner establishing his/her qualifications to the satisfaction of the and in no event to exceed one hundred and twenty (120) days of service as locum tenens within a calendar year. All physicians providing coverage through such locum tenens services must ensure that all legal requirements, including billing and reimbursement regulations, are met. The Data Bank query must be completed prior to any award of locum tenens privileges pursuant to this section. Further, prior to award of locum tenens privileges, the applicant must submit a completed application, a photograph, proof of appropriate malpractice insurance, the consent and release required by these bylaws, copies of the practitioner’s license to practice medicine, DEA certificate and telephone confirmation of


privileges at the practitioner’s primary hospital. The letter approving locum tenens privileges shall identify the specific privileges granted.

Members of the Medical Staff seeking to utilize the services of locum tenens physicians shall, where possible, advise the Hospital at least thirty (30) days in advance of the identity of the locum tenens and the dates during which the locum tenens services will be utilized in order to allow adequate time for appropriate verification to be completed. Failure to do so without good cause shall be grounds for corrective action and/or denial of these privileges.


Sample Bylaws Language for Telemedicine

TELEMEDICINE

Scope of Privileges

The Medical Staff shall make recommendations to the Board of Trustees regarding which clinical services are appropriately delivered through the medium of telemedicine, and the scope of such services. Clinical services offered through this means shall be provided consistent with commonly accepted quality standards.

Telemedicine Physicians

Any physician or practitioner who prescribes, renders a diagnosis, provides radiologic interpretation, or otherwise provides clinical treatment from a distance via electronic communications, must be credentialed and privileged through the Medical Staff pursuant to the credentialing and privileging procedures described in this section, as applicable.

(1) When the Hospital is not a party to a written agreement with a distant-site Medicare [Joint Commission] -participating hospital or distant-site entity containing all of the requirements of the CMS Hospital Conditions of Participation [and Joint Commission standards] related to distant-site telemedicine credentialing, the telemedicine physician must be credentialed and privileged through the Medical Staff pursuant to the general credentialing and privileging procedures described in these Medical Staff Bylaws. Recognizing that telemedicine physicians may be privileged at many healthcare facilities and entities, the Hospital shall conduct the primary verification procedures for an adequate number of hospitals, health care organizations and/or practice settings with whom the telemedicine physician is or has previously been affiliated in order to ensure current competency. In order to assist in this credentialing and privileging process, the Hospital may request information from the telemedicine physician’s primary practice site to assist in evaluation of current competency. The Hospital may also accept primary source verification of credentialing information from the physician’s primary practice site or the telemedicine entity to supplement its own primary source verification.

(2) When the Hospital is a party to a written agreement with a distant-site Medicare [Joint Commission] -participating hospital or distant-site entity containing all of the requirements of the CMS Hospital Conditions of Participation [and Joint Commission standards] related to telemedicine credentialing and privileging, the Board has the option to have the Medical Staff rely upon (i) the telemedicine physician’s credentialing and privileging information from a distant-site Medicare [Joint Commission] -participating hospital or distant-site entity and (ii) the credentialing and privileging decisions of a distant-site Medicare [Joint Commission] participating hospital or distant-site entity related to the telemedicine physician. However, the Hospital will remain responsible for


complying with applicable state regulations regarding the credentialing and privileging of practitioners; and performing the primary source verification of medical licensure, professional liability insurance, Medicare/Medicaid eligibility/exclusions, and query of the National Practitioner Data Bank.

For the purposes of this Section, the term “distant-site entity” shall mean an entity that: (1) provides telemedicine services; (2) is not a Medicare [Joint Commission] -participating hospital; and (3) provides contracted services in a manner that enables the hospital to meet all applicable CMS Hospital Conditions of Participation [and Joint Commission standards] related to the credentialing and privileging of physicians and contracted services. For the purposes of this Section, the term “distant-site hospital” shall mean a Medicare [Joint Commission] -participating hospital that provides telemedicine services.


Sample Disaster Privileges Policy and Procedure

POLICY STATEMENT:

Emergency privileges may be granted to health care professionals who volunteer their services when the hospital has activated its Emergency Operations Plan and requires additional health personnel to meet immediate patient needs and/or needs of the community.

During a disaster in which the Emergency Operations Plan has been activated, the Medical Director or designee has the option to grant, deny, suspend, modify, restrict or terminate emergency privileges. The Medical Director or designee is not required to grant privileges to any individual, and is expected to make such decisions on a case-by-case basis at her/his discretion.

PROCEDURE:

Initial Authorization

The Medical Director or designee may grant emergency privileges upon presentation of a valid government-issued photo ID any one of the following:

A current picture ID card from a healthcare organization that clearly identifies the volunteer’s professional designation

A current license to practice Primary source verification of licensure ID indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), the Medical

Reserve Corps (MRC), the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), or other recognized state or federal response hospital or group

ID indicating that the individual has been granted authority by a government entity to provide patient care, treatment, or services in disaster circumstances

Confirmation by an LIP currently privileged by the hospital or a staff member with personal knowledge of the volunteer practitioner’s ability to act as LIP during a disaster.

Scope of Clinical Activities and Monitoring

The practitioner will be assigned to provide services appropriate to her or his specialty. A current medical staff member will be designated to initially oversee the activities of the practitioner. Initial clinical activities may include assisting with initial triaging and stabilizing of patients and/or clinical activities for which they already hold privileges at another institution. The professional performance of the volunteer practitioner granted disaster privileges will be monitored be either direct observation, mentoring and/or clinical record review.

Identification

Practitioners granted privileges during a disaster will be given special identification so they will be easily recognized as an unaffiliated volunteer who is authorized to participate in response operations. An ID number will be assigned.

Messages identifying the names and clinical specialty of volunteer practitioners will be distributed to appropriate parties throughout the response organization.

Credentials Verification


Verification of the credentials and privileges of individuals who receive emergency privileges will be given high priority.

The timing for verification of credentials will be based on the judgment of the Medical Director or designee based on the demands of the emergency and the resources available. In severe or out-of-control emergencies, verification should begin when the immediate situation is under control. In less severe situations, verification should be done before the individual is assigned to provide patient care, treatment, or services.

Depending on the communications resources available during the emergency situation, the following will be verified as soon as possible:

Licensure in [state] verified by the licensure board NPDB query AMA profile

Should it be determined that the volunteer practitioner did not provide patient care, treatment, or services, no verifications will be necessary.

The hospital may have an arrangement with another hospital or healthcare facility to “share” medical personnel during a disaster. Should such an arrangement exist, the hospital can accept verification information provided by the contracted facility in lieu of obtaining these verifications directly from the source.

Emergency privileges may be terminated at any time during the verification process if areas of concern are identified. Emergency privileges will terminate when the service being provided by a volunteer is demobilized.

Records

The hospital shall maintain records of volunteer healthcare providers that include: The starting and ending time for hours worked by each practitioner The type of service provided by each practitioner The location where these services were provided Documentation of ant evaluations of the care provided by the provider [Add any additional information required by for federal and State reimbursement]


EMERGENCY/DISASTER PRIVILEGES FOR LICENSED INDEPENDENT PRACTITIONERSAPPLICATION FORM

LAST NAME FIRST NAME MIDDLE NAME DEGREE

Other Name Used/Maiden Name __________________________________________________

Primary Specialty __________________________Sub-Specialty____________________________________________

GENERAL INFORMATIONSpecialty Subspecialty Social Security Number Date of birth Medicare UPIN

PRIMARY OFFICE ADDRESS:Street and Suite Number City State Zip

Telephone Number ( )

PRIMARY HOSPITAL AFFILIATIONName of Organization, Hospital, or Office Practice Address, City, State, Zip

From: To: Position

LICENSES AND REGISTRATION

State License Number Date Granted Expiration Date

State License Number Date Granted Expiration Date

Federal DEA Number Date Granted Expiration Date

SPECIALTY IN WHICH VOLUNTEER DISASTER PRIVILEGES ARE DESIRED

Anesthesiology Ophthalmology Psychiatry Dentistry/Oral Surgery Orthopedics Radiology Family Medicine Pathology Reproductive Medicine Medicine Pediatrics Surgery Neurosciences Podiatry Other


EMERGENCY/DISASTER PRIVILEGES FOR LICENSED INDEPENDENT PRACTITIONERSAPPLICATION FORM – Page 2

MEDICAL CENTER REFERENCE: Name of current hospital or medical staff member(s) who possesses personal knowledge regarding volunteer’s ability to act as a licensed independent practitioner during a disaster

NAME _____________________________________________ TELEPHONE # _________________

RELATIONSHIP _______________________________________________

PROFESSIONAL LIABILITY INSURANCE CARRIER(S):

NAME OF CARRIER _____________________________________

POLICY NUMBER __________________DATES OF COVERAGE __________________________

RELEASE OF INFORMATION CONSENT/ATTESTATION

I agree to defend, indemnify and hold harmless [HOSPITAL] for all acts and omissions. I understand that I shall not be granted the general privileges accorded to attending medical staff, but will adhere to the standards of patient care of the Medical Center and Medical Staff. I certify that I have not had a professional license that has been revoked or suspended in any State or possession of the United States.

_________________________ ______________________________________DATE: Signature

EMERGENCY/DISASTER PRIVILEGES FOR LICENSED INDEPENDENT PRACTITIONERSAPPLICATION FORM – Page 3

THIS SECTION TO BE COMPLETED BY MEDICAL STAFF ADMINISTRATION

PRACTITIONER TO BE SUPERVISED BY: _____________________________

PHYSICIAN IDENTIFICATION NUMBER: _____________________________

= = = = = = = = = = = = = = = = = = =VERIFICATIONS = = = = = = = = = = = = = = = = = = = = = =

1. HOSPITAL AFFILIATION VERIFICATION DATE: ___________GOOD STANDING: ____________

2. MEDICAL STAFF REFERENCE VERIFICATION DATE: __________________

3. LICENSE VERIFICATION DATE: ______________STATUS: _________________

5. DEA: DATE VERIFIED: ______________STATUS: __________________________

6. NPDB VERIFICATION DATE: __________________

7. OIG VERIFICATION DATE: ______________________ STATUS: ________________

8. AMA PROFILE DATE:____________________________________

DATE PRIVIELGES GRANTED:_____________________ Time Granted:____________

DATE PRIVILEGES TERMINATED: __________________ Time Terminated:____________


Crosswalk Medical Staff and Governing Bylaws, Rules, Regulations, Policies, and Procedures

[HOSPITAL NAME]

MEDICAL STAFF DOCUMENT

ISSUE ADDRESSED BOARD DOCUMENT

Article V, Section 1.3 Medical staff representation on governing body

Article II, Section 2.3


Chart For Review Of Bylaws For Compliance With Joint Commission Standards Required Documentation

TJC Standard Current Location in

Bylaws

Proposed Location In Bylaws and

CommentsMS.01.01.01 Medical staff bylaws must describeEP 12. The structure of the medical staffEP 13. Qualifications for appointment to the medical staffEP 14.The process for privileging and re-privileging licensed independent practitioners, which may include the process for privileging and re-privileging other practitionersEP 15. A statement of the duties and privileges related to each category of the medical staff (for example, active, courtesy).EP 16. The requirements for completing and documenting H&Ps. The medical history and physical examination are completed and documented by a physician, oralmaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.EP 17. A description of those members of the medical staff who are eligible to voteEP 18. The process, as determined by the organized medical staff and approved by the governing body, by which the organized medical staff selects and/or elects and removes the medical staff officersEP 19. A list of all the officer positions for the medical staffEP 20. The medical executive committee’s function, size, and composition, as determined by the organized medical staff and approved by the governing body; the authority delegated to the medical executive committee by the organized medical staff to act on the medical staff’s behalf; and how such authority is delegated or removed.EP 21. The process, as determined by the organized medical staff and approved by the governing body, for selecting and/or electing and removing the medical executive committee membersEP 22. That the medical executive committee includes physicians and may include other practitioners and any other individuals as determined by the organized medical staff.EP 23. That the medical executive committee acts on the behalf of the medical staff between meetings of the organized medical staff, within the scope of its responsibilities as defined by the organized medical staffEP 24. The process for adopting and amending the medical staff bylawsEP 25.The process for adopting and amending the medical staff rules and regulations, and policiesEP 26. The process for credentialing and re-credentialing licensed independent practitioners, which may include the process for credentialing and re-credentialing other practitionersEP 27. The process for appointment and re-appointment to membership on the medical staffEP 28. Indications for automatic suspension of a practitioner’s medical staff membership or clinical privileges

EP 29. Indications for summary suspension of a practitioner’s medical staff membership or clinical privilegesEP 30. Indications for recommending termination or suspension of medical staff membership, and/or termination, suspension, or reduction of clinical privilegesEP 31. The process for automatic suspension of a practitioner’s medical staff membership or clinical privilegesEP 32. The process for summary suspension of a practitioner’s medical staff membership or clinical privileges



Bylaws


CommentsEP 33. The process for recommending termination or suspension of medical staff membership and/or termination, suspension, or reduction of clinical privilegesEP 34 .The fair hearing and appeal process, which at a minimum shall include:• The process for scheduling hearings and appeals• The process for conducting hearings and appealsEP 35.The composition of the fair hearing committeeEP 36. When departments of the organized medical staff exist, the qualifications and roles and responsibilities of the department chair, including the following:

Qualifications: Certification by an appropriate specialty board or affirmatively established comparable competence through the credentialing processRoles and Responsibilities Clinically related activities of the department. Administratively related activities of the department, unless

otherwise provided by the hospital. Continuing surveillance of the professional performance of all

individuals in the department who have delineated clinical privileges.

Recommending to the medical staff the criteria for clinical privileges that are relevant to the care provided in the department.

Recommending clinical privileges for each member of the department.

Assessing and recommending to the relevant hospital authority off-site sources for needed patient care, treatment, and services not provided by the department or the organization.

Integration of the department or service into the primary functions of the organization.

Coordination and integration of interdepartmental and intradepartmental services.

Development and implementation of policies and procedures that guide and support the provision of care, treatment, and services.

Recommendations for a sufficient number of qualified and competent persons to provide care, treatment, and services.

Determination of the qualifications and competence of department or service personnel who are not licensed independent practitioners and who provide patient care, treatment, and services.

Continuous assessment and improvement of the quality of care, treatment, and services.

Maintenance of quality control programs, as appropriate. Orientation and continuing education of all persons in the

department or service.

MS.02.01.01 Medical Executive CommitteeEP 3 All members of the organized medical staff, of any discipline or specialty, are eligible for membership on the medical staff executive committee



Bylaws


CommentsEPs 8-12 The MEC makes recommendations as defined in the medical staff bylaws, directly to the governing body on, at least, all of the following: Medical staff membership; the organized medical staff's structure; the process used to review credentials and delineate privileges; the delineation of privileges for each practitioner privileged through the medical staff process, the executive committee's review of and actions on reports of medical staff committees; departments, and other assigned activity groupsMS. 06.01.03 CredentialingEP 4 The credentialing process is outlined in the medical staff bylawsEP 6. The credentialing process requires that the hospital verifies in writing from the primary source whenever feasible, or from a CVO, current licensure (at time of initial granting, renewal, an revision of privileges and on expiration), relevant training, and current competenceMS. 06.01.05 Privileging ProcessEP 2. The hospital, based on recommendations by the organized medical staff and approval by the governing body, establishes criteria that determine a practitioner’s ability to provide patient care, treatment, and services within the scope of the privilege(s) requested. Evaluation of all of the following are included in the criteria: 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 recommendationWhen renewing privileges, review of the practitioner’s performance within the hospitalMS.06.01.09 DecisionThe decision to grant, limit, or deny an initially requested privilege or an existing privilege petitioned for renewal is communicated tothe requesting practitioner within the time frame specified in the medical staff bylaws.Standard MS.09.01.01 - The organized medical staff, pursuant to the medical staff bylaws, evaluates and acts on reported concerns regarding a privileged practitioner’s clinical practice and/or competence.EM.02.02.13 Disaster PrivilegesThe organization may grant disaster privileges to volunteers eligible to be LIPs.EP 2. The medical staff identifies, in its bylaws, those individuals responsible for granting disaster privileges to volunteer licensed independent practitioners


Sample Clinical Consultation Form

Request for clinical consultation

Date of request _____________________________________________________

Date of initial patient visit by clinical consultant ___________________________

Attending (requesting) physician _______________________________________

Clinical consultant __________________________________________________

The following information is to be completed by the requesting physician

Reason(s) for requesting clinical consultation:

____Diagnosis obscure____Patient not responding to treatment as expected____Patient or family requests clinical consultation or a second opinion____Other ______________________________________________________________ _______________________________________________________________________ ________________________________________________________________________

Please:___Evaluate the patient and discuss findings and suggestions with me.___Evaluate the patient, discuss findings and suggestions with me, and follow up with me.___Assume care of the patient.

__________________________________Requesting physician’s signature

Note: Place this form in the patient’s medical record.


Sample Medical Staff Peer Review Policy

This Peer Review Policy is adopted in connection with the Medical Staff Bylaws and made a part thereof. The definitions and terminologies of the Bylaws also apply to the Peer Review Policy and procedures described herein.

I. PURPOSE

The primary purpose of this peer review policy is to ensure that patients receive quality services that meet professionally recognized standards of health care via ongoing objective, non-judgmental, consistent, and fair evaluation by the Medical Staff.

Peer review is properly conducted when based on evidence of objective trend measurement and/or quality concerns for clinical management, and evaluation of outcomes. A quality concern is a concern with a significant or potential for a significant, adverse effect on the patient’s wellbeing.

The peer review in this facility will be conducted both where focus is on an individual practitioner arising from quality concerns, as well as the on-going surveillance of the professional performance of all physicians who have delineated clinical privileges. Peer review will also be conducted in order to evaluate the competence of each licensed independent practitioner’s performance, in accordance with the renewing of credentials.

In addition, the peer review participants in this Hospital shall establish triggers, subject to approval by the Board, for referring cases identified as variations of the quality indicators or quality screens. It is the intent of this policy to improve the efficiency of peer review by focusing on issues or individuals identified through objective data analysis using equivalent objective criteria.

II. DEFINITION OF PEER

For purposes of this policy, the term “Peer” refers to any practitioner who possesses the same or similar knowledge and/or training in a medical specialty as the practitioner whose care is the subject of review.

If a determination is reached that no physician on the staff is qualified to conduct the review, (ie., the hospital has only one physician in a particular specialty or with comparable privileges, or the pool of eligible reviewers is otherwise conflicted or unable to serve (see Part III, Paragraph B(2) below)), the MEC or the Board of Trustees may request external peer review consistent with the hospital’s External Peer Review Policy by a physician who is Board certified within the same specialty.

III. PEER REVIEW PROCESS AND ONGOING PROFESSIONAL PRACTICE REVIEW

These policies and procedures shall be applicable for all practitioners credentialed by {HOSPITAL}. The Medical Staff will conduct continuous, on-going review and focused review of the professional practice of departments, services, and members via aggregate collection of data and routing of Medical Staff Committee conclusions based upon Committee analysis of the data.

A. Ongoing Professional Practice Review


The Peer Review Process is coordinated by the Quality Department. Cases identified with quality of care issues are referred to the department for case review. Cases may be identified through member services, concurrent review, case management, risk management, audits, sentinel events, clinician referrals, allegations of substance abuse and other sources. Any quality issue regarding patient care will be initially reviewed by a nurse in the Quality Department with oversight of the Chief of the Department and/or Chief of Staff. If there are no quality of care issues identified following this quality management review, the case is closed, the findings are documented and trending is performed in the Quality Department. Results of peer review cases concerning medical care complaints are tracked for individual practitioners and incorporated into the physician's re-credentialing process.

Aggregate data regarding all practitioners will be reviewed and presented to the medical staff for pattern and trend analysis. Outliers identified by this analysis will be assigned for focused Peer Review by the committee chairperson if the analysis indicates an issue with an individual’s performance.

Incidences/complaints received which may require intervention to ensure quality patient care is delivered, will be forwarded for peer review and/or MEC review. The data collection is the comprehensive review done by non-physician reviewers, using objective and non-judgment dependent criteria.

Medical Staff approved indicators for screening purposes will be utilized by non-physician reviewers.

Findings are analyzed and trended for presentation to the appropriate medical staff committee. Conclusions of the data analysis will be routed as indicated in the table below.

Conclusion: Action:Related to an individual’s performance Refer for peer review / focused review by

appropriate Medical Staff CommitteeRelated to one medical or non-medical staff department’s performance

Refer to the appropriate medical staff department or hospital administrative representative

Related to more than one department’s performance

Refer to Quality Council for consideration of PI Team

Related to a process or system not working effectively

Refer to Quality Council for consideration of PI Team

B. Focused Review of a Practitioner’s Performance

Focused Professional Practice Evaluation (FPPE) is a time-limited period during which the medical staff evaluates a practitioner’s professional performance. A period of FPPE is implemented for all initially requested privileges and when there are concerns regarding a practitioner’s professional performance, as recognized through the peer review and Ongoing Professional Practice Evaluation (OPPE) process. The Department Chair or Service Chief or


designee shall be responsible for the oversight and development of the evaluation plan for all applicants or medical staff members assigned to their department.

(1) Existing Medical Staff/Privileges

Intensified (focused) review of an individual practitioner is triggered by the practitioner’s department, Quality Improvement Committee, Medical Executive Committee, member of Hospital Administration, or the Board, at anytime or during the course of the Peer Review Process as described above and/or otherwise upon any of the following occurrences:

Unexpected Patient Death; Emergency transfer following inpatient admission; “Sentinel Events” as defined by the Joint Commission; During the course of On-Going Professional Practice Evaluation a pattern or

trend is suspected regarding deviations from the standards of practice; A pattern or trend in issues regarding patient safety and/or negative patient

outcomes is identified during the course of On-Going Professional Practice Review;

The practitioner is cited for quality issues from an outside peer review or quality improvement organization requiring a plan for improvement;Minimal threshold criteria has not been met to maintain proficiency for a specific privilege or procedure as determined by the Department Chair/Service Chief;

Other occurrences which may affect the delivery of safe, quality patient care.

The Department or Committee Chair shall determine the individual physician(s) to perform the focused review and report back to the Committee. External peer review guidelines will be adhered to, as outlined above.

The Department or Committee Chair shall designate a deadline within which the individual physician reviewers shall complete the focused review. Should the focused review involve periods of evaluation and monitoring of the practitioner delivering patient care services, the time to complete the focused review may be extended by the Department Chair for an additional period of time.

(2) New Medical Staff Appointees and New Requests for Privileges

FPPE is utilized to establish a systematic process to evaluate whether there is sufficient information available to assess current competence of practitioners who initially request privileges.

The following guidelines should be used to determine the extent of FPPE to be performed:

(a). Initial Privilege Requestsi. Evaluation of peer recommendations from previous institutions ii.Ongoing monitoring of performance indicators and aggregate data within the

department iii. Input from colleagues, consultants, nursing personnel, and administration.iv. Procedure and clinical activity logs from previous institutions and/or training

programs. If current competency and adequate clinical activity is not well documented from previous institution, then a higher level of focused


evaluation may be assigned. Specifically, chart review or proctoring may occur to fully evaluate the ability to perform requested privileges.

v. At a minimum, the medical records of the first 5 patients will be reviewed by the Department Chair/Service Chief or his/her designee either prospectively (while patient is in house) or retrospectively (on patient discharge). Based on review of information received in the credentialing and privileging process, the Service Chief may require additional review, proctoring, or monitoring.

(b). Additional privilege request – The privilege(s) requested will be reviewed by the Department Chair/Service Chief. If the additional privilege(s) requested is significantly different from the requesting physician’s current practice and there is no transference of skill (as determined by the Department Chair/Service Chief), an FPPE plan will be established based on the guidelines in III.B(2)(a) above.

(c) A specific monitoring plan (see sample planning form) will be developed and will include the following as appropriate: Specific performance elements to be monitored Number of cases and/or length of time to complete the monitoring plan Practitioners assigned to perform monitoring or proctoring Description of how the results of monitoring and any recommendations will be

provided to the practitioner and to the appropriate monitoring body (Service Chief, Executive Committee, and/or Governing Board)

In instances where there may be a lack of expertise within the medical staff to provide monitoring, or in which the available monitors with appropriate expertise may have a conflict of interest, a plan for monitoring by an external source will be developed by the Executive Committee. The plan will contain the elements defined above.

If either during the process of, or after completion of the specific FPPE monitoring plan a recommendation is made that would result in restriction, decrease, or revocation of specific privileges, or in suspension or revocation of medical staff membership, the processes pursuant to the Medical Staff Bylaws will apply.

(C) MECHANISMS FOR REVIEW AND REPORTING

The Department or Committee Chair and/or individual physician reviewers shall exercise discretion in selecting the methods and means of evaluating the practitioner’s care which may include, but shall not be limited to: periodic internal or external chart reviews; direct observation of delivery of patient care services; monitoring (retrospectively or concurrently) diagnostic and treatment techniques and clinical practice patterns; proctoring; and/or discussion with others involved in patient care including consulting physicians, surgery assistants, nursing staff, members of Hospital Administration, and others. During the course of any focused review, the practitioner whose case is subject of review shall be offered the opportunity to address the individual physician reviewer(s) and respond to their questions, if any.

The individual physician reviewer(s) shall report written findings and recommendations to the Department or Medical Executive Committee at its next regularly scheduled meeting following the completion of the focused review period. The practitioner under review will be provided with a copy of these written findings and recommendations in advance of the Department/Committee meeting, and shall be offered the opportunity to address the Department or Committee and respond to the findings and conclusions.


The Department or Committee shall make a written report and recommendation to the MEC concerning the focused review.

1. Reviewer Selection & Duties

Reviews are completed by the designated Medical Staff Committee or Department.. However, in the case where a physician holds privileges in more than one specialty, any specific questions regarding the care involved will be forwarded to the appropriate medical staff for review.

Physician members of the department or service may be designated by the Committee or Department Chairperson to review medical records prior to the Committee meeting. The physician reviewer will present the results to the Committee. Patient and practitioner identities shall be redacted from the presentation and discussion.

The designated physician reviewer may not review a case where he/she participated in the care (including radiology and pathology). Members of the same physician groups cannot review the other members of the group (exception – contracted hospital services, such as radiology, pathology, emergency medicine, anesthesia, etc.)

2. Reviewer Disqualification & Replacement

If a reviewer does not feel he/she can adequately review a medical record due to a conflict of interest or believes he/she is not qualified to address a certain issue, the reviewer may discuss the issue with the Chairperson of the Department or Committee. If the Chair concurs, the Chair shall reassign the record(s) to another reviewer. If a member has reviewed a record that needs to be presented but is unable to attend the meeting, the member shall report to the Chair so that the presentation may be reassigned to another Committee member or presented by the Chairperson. If the chairperson is the practitioner subject to review, the record review will be assigned to another Active Staff member by the Chief of Staff. If the hospital has only one physician in a particular specialty, or the pool of eligible reviewers is otherwise conflicted or unable to serve, the MEC or the Board of Trustees may request external peer review consistent with the hospital’s External Peer Review Policy by a physician who is Board certified within the same specialty.

3. Review Form Summary

Reviewing physicians must fill out a designated Peer Review Form clearly and concisely. The reviewing physician must sign his/her name on the review form which shall grade the care and outcome based on the following schedule:

1. Some aspect of case fell outside screening indicators, but reviewer finds no evidence of any error in judgment or technique.

2. Clinical result not necessarily desirable but not totally unexpected.3. Clinical result or technique neither desirable nor expected.4. Clinical result neither desirable nor expected.

IV. DOCUMENTATION OF PEER REVIEW ACTIVITIES:


The written reports of Ongoing and Focused Professional Practice Evalution findings and recommendations shall be presented on a regular basis to the MEC. The MEC may adopt the recommendations of the Committee and/or make further recommendations, including recommendation for further investigation and/or Corrective Action in accord with the Medical Staff Bylaws.

All recommendations of the MEC other than for further investigation or Corrective Action shall be delivered to the Board. The Board shall make a final determination concerning any actions warranted based on the findings and recommendations of the MEC.

All reports, recommendations, and other information concerning the Focused ond Ongoing Review of Practitioner Performance shall be documented and maintained in the physician’s quality file. Outcomes are reviewed during the credentialing process at the time of reappointment. A brief summary of outcomes is documented in credentials file (see sample forms).

A physician may review his quality file by making an appointment with the Director of Quality Management and Regulatory Compliance (QMRC), and the Chief of Staff. No copies of the quality file may be made, nor may the physician remove any portion of the quality file from the Hospital. In the discretion of the CEO, in consultation with the Chief of Staff, personal information, such as the identity of external or internal peer reviewers, or the identity of patients or employees reporting quality issues, may be redacted before the physician may review the file.

Summaries of Peer Review, by category of Peer Review and by individual practitioner will be presented, at least semiannually, to the Quality Council, MEC and Board.

V. IMPLEMENTATION OF CHANGES TO IMPROVE PERFORMANCE

The Quality Council is responsible for the implemenation of changes to improve performance.

Reports will be forwarded to the MEC and Board at least quarterly.

Recommended by the Medical Executive Committee this ______day of ___________, ____.Approved by the Board this _____day of _______________, _____.

________________________Chief of Staff

________________________Chairperson of Board


Sample Indicators

1. ORYX Data (Core Measures)

2. QIO Reports

3. Data Advantage Reports

4. Surgery Review Indicators: Morbidity/Mortality Code Blue Review Autopsy Criteria Met If YES – chart contains documentation of discussion with family requesting autopsy Surgical Consent not obtained as per policy H&P not on chart prior to procedure Normal tissue Cases with no surgical specimen (specimen expected) Discrepancy pre-op and post-op Frozen / permanent section discrepancy Post-op infection Post-op complications related to surgery Excessive bleeding (> 400 cc blood loss) Intra-operative variances related to surgery: Injury to another organ during surgery Excessive bleeding (> 400 cc blood loss) Foreign body retained Intra-operative CPR / mortality Immediate Post-operative note not written Unplanned out-patient admission due to complication of surgery Unplanned return to OR Unplanned admission to ICU post-operatively related to surgery Unplanned transfer to a higher acuity level of care / facility post-operatively related to surgery Readmission < 30 days for surgical related problem Operative mortality related to surgery < 48 hours post-operatively Within 30 days post-operatively Patient Complaint

5. Anesthesia Indicators: No anesthesia consent Immediate pre-induction assessment not documented Reintubation / laryngospasm (Rx) Difficult airway / intubation Tooth damage Eye injury Hyperthermia > 101 degrees


Hypothermia < 94 degrees Surgery cancelled after induction Pulmonary edema (Intra / post op) Prolonged hypoxia (Sa02 > 10% of baseline) Codes in OR / PACU MI peri-op / post-op (within 24 hours) OB epidural problems / complications Post dura puncture (H/A requiring Rx Unplanned ICU admission Unplanned outpatient admission Unplanned readmission due to complication of anesthesia CVA within 24 hours related to anesthesia Neurological complications within 24 hours related to anesthesia Mortality within 24 hours related to anesthesia Unexplained change in patient condition in PACU Prolonged nausea / vomiting Prolonged PACU (> 2 hours) Aspiration Post operative infection related to anesthesia Pneumonia Patient Complaint

6. Department of Medicine: Morbidity/Mortality (MS.08.01.07) Code Blue Review Autopsy Criteria Met If YES – chart contains documentation of discussion AMI after non-cardiac admission Neurological deficit after non-neurological admission Nosocomial pneumonia / septicemia Non-Surgical Invasive Procedure Complication (central line, Swan Ganz, cut-down, chest tube,

etc.) Unplanned transfer to ICU Readmission within 7 days of hospital discharge related to previous admission Readmission within 31 days of hospital discharge related to previous admission Patient Complaint

7. Radiology: Procedure Correlation (High Volume, High risk, Problem Prone) Gall Bladder MRI CAT Scan (etc.) Unplanned admission following outpatient procedure Patient injury during procedure Neurological deficit due to procedure Seizure or convulsion Severe headache requiring Rx Pneumothorax secondary to lung biopsy


Arachnoiditis after myelogram Extra Arachnoid Tap necessary after mylegram Aspiration during procedure Allergic reaction to contrast dye Viscus Perforation Unplanned return to radiology for additional films

8. Pharmacy and Therapeutics: Medication errors with ‘serious’ score per medication variance report Patient received any of the drugs listed: Phenytoin / Digoxin / Theophylline / etc. If YES, then serum level measured Drug exceeds specified limit DUE results ADRs Drug ordered and not in formulary Over 3 antibiotics administered concurrently or over 5 antibiotics administered in same hospital

stay 3rd generation antibiotic administered

9. Blood Utilization: Transfusion criteria not met (PRBC, FFP, platelets) Patients with suspected / confirmed reactions C/T ratio – trend over time Single unit transfused

10.Pathology: Frozen Section / Histology Correlation (# of frozen / FNA’s with significant discrepancy with

final diagnosis. Goal < 5%) Number of frozen / FNA’s deferred (Goal < 5%) # of amended diagnoses (Goal < 1%) Cytology / Histology correlation Peer Congruence: External Consultations Internal / Blind Review

11.Emergency Medicine: Transfers to acute care facilities Unplanned return < 72 hours Arrests / deaths in ER LOS in ER > 3 hours X-Ray over-read discrepancy EKG over-read discrepancy No documentation of call back for positive culture

12. Infection Control: Nosocomial infections Wound infections post op Infections following insertion of a central line Pneumonia following surgical episode Death where nosocomial infections may have contributed


13.Utilization Review: Failure to meet admission criteria Re-admissions within 30 days Inappropriate transfers QIO Denial LOS > established norm for diagnosis

14.Medical Records: Clinical pertinence Legibility studies Delinquency in completions of medical records (H&P, immediate post-op note, verbal orders,

etc).15.Psychiatrist:

Admission criteria Patient transfer to acute care Readmission within 30 days of discharge Suicide or near miss Restraints Adverse outcome Psychotropic medications

16. Pediatrics Neonatal Mortality Pediatric Transfers

17. Obstetrics C/Section, Primary, Repeat Neonatal/Fetal Death Maternal Death Maternal Transfers Neonatal Transfers Maternal Complications/ICU/Blood product


Sample Medical Staff Peer Review Process FormANY HOSPITAL

Peer Review Form

Service or Department:_______________________________________________

Patient MR #:_____________________ Physician #:___________________

Admission date: ___________________ Discharge date:________________

Diagnosis / Procedure: _______________________________________________________________

Case Summary:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Physician Reviewer Findings (Circle): 1 2 3

4

Rationale for findings/additional comments

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

1. Some aspect of case fell outside screening indicators, but reviewer finds no evidence of any error in judgment or technique.

2. Clinical result not necessarily desirable but not totally unexpected.

3. Clinical result or technique neither desirable nor expected.

4. Clinical result neither desirable nor expected.

Reviewing Physician Signature: ________________________________ Date: _________________


Reviewing Physician Typed or Printed Name: ________________________________


Sample Peer Review FormWARNING - The information contained in this report is CONFIDENTIAL. Improper disclosure of the information contained herein may result in disciplinary action, as well as civil or criminal penalties.

ASSIGNED TO DOCTOR(S):________________________________________________________

COMMITTEE/DEPARTMENT REFERRED TO:__________________________________________

EVENT DATE:_____________________________________

PATIENT RECORD #:______________________________________________________________

ADMISSION DATE:_____________________DISCHARGE DATE:___________________________

PHYSICIAN(S) INVOLVED IN REVIEW _______________________________________________

REASON FOR REFERRAL: _________________________________________________________________________________________________________________________________________

SUMMARY:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

RESULTS OF PHYSICIAN REVIEW

CARE APPROPRIATE - NO FURTHER ACTION NECESSARY - Please provide documentation to reflect the bases for decision regarding the appropriateness of review of care/service. (Use back of page, if necessary.)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

FURTHER ACTION NECESSARY AS STATED BELOW (Use back of page if necessary) Documentation Only Counseling Disciplinary Action Refer to ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


PHYSICIAN REVIEWER SIGNATURE: _____________________________DATE______________


Focused Professional Practice Evaluation Plan Practitioner Name:_______________________________________________Medical Staff Department: _________________________________________Practitioner Specialty:_____________________________________________

Reason(s) for Review

Initially requested privilege(s) for current medical/professional staff (list privilege(s)) _____________________________________________________________________________________________________

Newly-credentialed practitioner new to staff Referred to peer review due to incident Low volume of clinical activity Trigger (list) _________________________________________________________________________ Other:______________________________________________________________________________

Duration (Complete for recommended timeframe and/or volume)

Time Specific: Start Date: ___________________ End Date:___________________

Volume Specific: Designated # of Cases: __________

Other (specify):_______________________________________________________________________

Method for Monitoring (Check all that apply)

Chart review o Retrospective (name of reviewer)___________________________________________________o Concurrent (name of reviewer)_____________________________________________________

Direct observation by (name of observer)___________________________________________________ Monitoring of diagnostic and treatment techniques and clinical practice patterns via QAPI program Proctoring by (name of proctor) ___________________________________________________________ External Review (list criteria met)__________________________________________________________ Discussions with other individuals, involved in the care of the patient, including consulting physicians,

assistants at surgery, nursing and administrative personnel Other (list) ___________________________________________________________________________

Additional Individual(s) Assigned for Review/Observation/Monitoring/Proctoring

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Additional Details/Specifics of Plan_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SIGNATURE:

___________________________________________ Date: ________________________Departmental Chair


___________________________________________Printed Name of Department Chair


Sample Proctorship Form

Verification of Proctored Procedure/Treatment

If a surgery or an invasive procedure is performed, the Proctor should evaluate the indication for the procedure, the technique for the procedure, how it is performed, and the preoperative, operative, and postoperative care of the patient. The Proctor may utilize the patient’s record, discussion with the physician, and actual observation as the basis for the review.

Proctored Physician: _____________________________ Date: _________________________________

Proctor: ______________________________________________________________________________

Procedure/Treatment:____________________________________________________________________

Comments: _____________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Areas of in need of Improvement: ____________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________

Procedure Completed Successfully: _____ Yes _____ No

_________________________________________ ____________________Signature, Proctoring Physician Date

_________________________________________ ____________________Signature, Proctored Physician Date


Proctoring Summary Report

Proctored Physician: ________________________________ Date: ___________________

Proctor: ____________________________________________________________________

Number of Procedures/Treatment Episodes Proctored: _______________________________

Comments: _________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Areas in need of Improvement: _________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Proctoring Completed Successfully: _____ Yes _____ No

_________________________________________ ____________________Signature, Proctoring Physician Date

Department Chair Recommendation

The applicant appears to meet all of the qualifications for unsupervised practice in that department, has discharged all of the responsibilities of staff membership, and has not exceeded or abused the prerogative of the category to which the appointment was made, and that the member has satisfactorily demonstrated the ability to exercise the clinical privileges initially granted in those departments. It is recommended that proctoring cease.

It is recommended that proctoring continue for ______________________________________ (list number of procedures and/or time frame)

Comments________________________________________________________________________

________________________________________________________________________________

_________________________________________ ____________________Signature, Department Chairperson Date


Sample Indicators for LIP APRNs and PAs

Specialty FPPE OPPENurse Midwife Proctor for first 2 cases

vaginal delivery Review of charts for first 5

cases Discussion with nurse

manager of OB and NB nursery

3rd and 4th degree lacerations following vaginal delivery

Delivery unattended by provider

Significant birth trauma Medical records legibility

CRNA Anesthesiologist present in OR room to proctor first 2 major surgical procedures

Discussion with OR nurse manager/OR staff

ICU admission due to anesthesia management

Medical records legibility

Emergency Department PA ED physician closely monitor/proctor for (X) shifts

Visual monitoring of (X) procedures performed (i.e. suture of laceration, removal of foreign body, nasogastric intubation etc.)

Death in ED Unplanned returns within

48 hours for same complaint

Patients admitted to Med/Surg and moved to ICU within 4 hours of admission

APRN Need to customize pertaining to area of practice.

Refer to/consult with other health care professionals, as appropriate

Order appropriate diagnostic tests

Medication usage Medical records

documentation Any department-specific

indicators relevant to all LIPs

Focused Professional Practice Evaluation (FPPE) Report(To be included in Credentials File)

Practitioner Name:______________________________________________________

Department:___________________________________________________________

Time Period for Review: From:_____________________ To:__________________

The information from Focused Professional Practice Evaluation has been reviewed and based on this review:

The practitioner is performing well or within desired expectations and it is recommended that current privileges continue and FPPE cease.

Issue(s) exist or trigger(s) met requiring continuation of Focused Evaluation. The specific issue(s) is (are)_____________________________________________

________________________________________________________________

________________________________________________________________

Practitioner has not had sufficient patient volume or has not met assigned FPPE requirements. Continue FPPE for ______ months.

Other__________________________________________________________

_______________________________________________________________

__________________________________ _________________________ Signature, Department Chair Date

__________________________________ Name Department Chair


Ongoing Professional Practice Evaluation (OPPE) Report(To be included in Credentials File)

Practitioner Name:______________________________________________________

Department:___________________________________________________________

Time Period for Review: From:_____________________ To:__________________

The information from Ongoing Professional Practice Evaluation has been reviewed and based on this review:

The practitioner is performing well or within desired expectations and no further action is warranted. It is recommended that current privileges continue.

Issue(s) exist or trigger(s) met requiring a focused evaluation. The specific issue(s) is (are)___________________________________________________

________________________________________________________________

________________________________________________________________

Practitioner has had no patient contact for _____ months, notify practitioner and initiate focused review.

Other__________________________________________________________

_______________________________________________________________

__________________________________ _________________________ Signature, Department Chair Date

__________________________________ Name Department Chair


College American Pathologists Recommendations for Tissue to be Submitted to Pathology

The College of American Pathologists has developed the following recommendations to help in determining what surgical specimens should routinely be submitted to the pathology department for examination. These are intended only as suggestions and are not mandatory or a requirement for CAP accreditation.

Each institution, in conjunction with the pathologist and appropriate medical staff departments, should develop a written policy that addresses which specimens do not need to be submitted to the pathology department and which specimens may be exempt from a requirement for microscopic examination. This policy must be individualized for each institution and should take into account the diagnostic needs of the medical staff, the likelihood of significant findings in otherwise unremarkable specimens given the clinical situation, the reliability of procedures to ensure proper handling of specimens in surgery, and potential medicolegal implications. According to the Joint Commission Standards and CAP guidelines, this policy must be jointly determined by the pathologist and the institution's medical staff. The policy should clearly state that all specimens not specifically exempted must be submitted to the pathology department for examination. It should also state that a microscopic examination will be performed whenever there is a request by the attending physician, or when the pathologist determines a microscopic examination is indicated by the gross findings or clinical history. A pathology report should be generated for every specimen submitted to the pathology department for examination. Creating two lists may be useful. One list should designate those specimens (if any) that are exempt from routine submission to the pathology department. A second list should specify those specimens that are to be submitted to pathology for gross examination but which are exempt from mandatory microscopic examination, i.e., gross only examination. The following are examples of specimens that an institution may choose to exclude from routine or mandatory submission to the pathology department. There should be an alternative procedure for documenting the removal and disposition of any specimens or devices not submitted to pathology for examination. This is particularly important for any failed medical devices that may have contributed to patient injury, any failed device for which litigation is pending or likely, and for devices subject to tracking under the Safe Medical Devices Act of 1990 (see Appendix).

• Bone donated to the bone bank. Bone fragments removed as part of corrective or reconstructive orthopedic procedures (e.g., rotator

cuff repair, synostosis repair) excluding large specimens such as femoral heads, and knee, ankle, or elbow reconstructions.

• Cataracts removed by phacoemulsification. • Dental appliances. • Fat removed by liposuction. • Foreign bodies such as bullets or other medicolegal evidence given directly to law enforcement • personnel. • Foreskin from circumcisions of newborns. • Intrauterine contraceptive devices without attached soft tissue.


• Medical devices such as catheters, gastrostomy tubes, myringotomy tubes, stents, and sutures that have not contributed to patient illness, injury or death.

• Middle ear ossicles. • Orthopedic hardware and other radio-opaque mechanical devices provided there is an alternative

policy for documentation of their surgical removal. • Placentas from uncomplicated pregnancies that appear normal at time of delivery (do not meet

institutionally specified criteria for examination). • Rib segments or other tissues removed only for purposes of gaining surgical access, provided the

patient does not have a history of malignancy. • Saphenous vein segments harvested for coronary artery bypass. • Skin or other normal tissue removed during a cosmetic or reconstructive procedure (e.g.,

blepharoplasty, cleft palate repair, abdominoplasty, rhytidectomy, syndactyly repair), provided it is not contiguous with a lesion and the patient does not have a history of malignancy.

• Teeth when there is no attached soft tissue. • Therapuetic radioactive sources. • Normal toenails and fingernails that are incidentally removed.

It is recommended that the following specimens be submitted to the pathology department for examination.

These specimens may require only a gross examination, but exceptions are at the pathologist's discretion.

• Accessory digits. • Bunions and hammertoes. • Extraocular muscle from corrective surgical procedures (e.g., strabismus repair). • Inguinal hernia sacs in adults.* • Nasal bone and cartilage from rhinoplasty or septoplasty. • Prosthetic breast implants (2). • Prosthetic cardiac valves without attached tissue. • Tonsils and adenoids from children.* • Torn meniscus. • Umbilical hernia sacs in children.* • Varicose veins.

*Each institution should determine its own specific age requirements. Appendix The following is a complete list of devices required for tracking under the Safe Medical Devices Act of 1990 (Federal Register. May 29, 1992; 57:22966-22981) 1. Permanently implantable devices: - Vascular graft prostheses - Vascular bypass (assist) devices - Implantable pacemaker pulse generator - Cardiovascular permanent pacemaker electrode - Annuloplasty ring - Replacement heart valve


- Automatic implantable cardioverter/defibrillator - Tracheal prosthesis - Implanted cerebellar stimulator - Implanted diaphragmatic/phrenic nerve stimulator - Implantable infusion devices 2. Life-sustaining or life-supporting devices: - Breathing frequency monitors (apnea monitors) - Continuous ventilator - CD-defibrillator and paddles 3. FDA-designated devices: - Silicone inflatable breast prosthesis - Silicone gel-filled breast prosthesis - Silicone gel-filled testicular prosthesis - Silicone gel-filled chin prosthesis - Silicone gel-filled angel chik reflux valve - Electromechanical infusion pumps Revision history Adopted May 1996 Reaffirmed May 1999 Revised November 2007


Date post:	25-Mar-2018
Category:	Documents
Upload:	trinhcong
View:	217 times
Download:	2 times

Hot Topics - NAMSS · Web viewKathy Matzka, CPMSM, CPCS is a speaker, consultant, and writer...

Documents