Presented byLynn L. Buchanan, CPMSM, CPCS

President, Buchanan & Assoc. Consultingfor

Alaska Assn. Medical Staff Services June 2010

©Edge-U-Cate LLC, 2010. Do not reproduce without written consent.

A specific scope and content of patient care services◦ Authorization granted by a healthcare

organization◦ Based on pre-determined criteria and consistently

applied◦ Based on evaluation of the individual’s credentials

and performance/competence◦ Organization-specific◦ Specifically delineated

Healthcare experts agree that an organization’s privilege delineation system is the foundation of quality patient care

Licensed Independent Practitioners (LIPs) – all individuals who are permitted ◦ All individuals permitted by law and by hospital

to provide patient care services independently in the hospital

PAs and APRNs (TJC – HR.01.02.05, EP10-15)

NOTE: Do not have to be medical staff members in order to have delineated clinical privileges

Acute care hospitals, critical access hospitals Behavioral Healthcare hospitals Ambulatory Care Centers (SurgiCenter, GI

Lab, etc.) Some Acute Long Term Care facilities (as may

be required by regulations and standards0

Privileges are not granted by Managed Care Organizations

The Medical Staff is responsible for planning and implementing a privileging process:◦ Developing and approving procedure list / criteria◦ Processing the application (defined procedure)◦ Evaluating applicant-specific information (objective,

evidence-based process)◦ Submitting applicant-specific privileging

recommendations to governing body◦ Notification of privileging decision◦ Monitoring the use of privileges and quality of care

◦ (ref. The Joint Commission – Intro to MS – HAS)

When a practitioner is providing direct patient care services within or on behalf of your organization

Time-limited (not to exceed 2 years)

Ensure that patients are receiving quality patient care by practitioners qualified to treat a specific illness or perform a specific procedure.*

• The Credentialing HandbookAspen Publishing 1998

TJC◦ Professional criteria for clinical privileges

designed to establish applicant’s background, competence, and physical and mental ability

◦ Criteria based privileges designed to help assure patients will receive quality care, treatment and services

CMS◦ All practitioners are individually evaluated to

assure that they possess current qualifications and demonstrate competencies for the privileges granted

CMS requires◦ Criteria for determining privileges◦ Procedure for applying criteria◦ List of specific privileges◦ Examine/assess each Practitioner’s ability to

perform each task/activity/privilege TJC requires

◦ Criteria for determining privileges◦ Evaluation process◦ Definition of privileges◦ Competency assessment (FPPE/OPPE)

Significant change – focus on determining an applicant’s competence (initial and renewal), not just qualifications

◦ Objective vs. Subjective

◦ Measurable criteria

◦ Evidence-based

◦ More comprehensive monitoring / data collection

◦ More comprehensive evaluation by MSO / MS

Concept of “hospital-specific” privileges◦ Generic templates used

Concept of “measurable criteria”◦ vague; not measurable; subjective

Concept of “core”◦ Laundry lists titled as core with no separation or added

criteria for special procedures◦ Non-definitive summary of core

Concept of “performance data”◦ “No issues identified”◦ Basic utilization data

Core (General) Privileges: Listing of those privileges that are commonly performed by residency-trained practitioners in a specific specialty and fall within general criteria◦ Must include listing of privileges included in core◦ Must include opportunity to “de-select”

Non-Core (Selected) Privileges: Defined privileges that require additional training/expertise and/or certain volume to obtain and maintain competence (defined by MS)

Separate criteria for membership from criteria for privileges◦ Admitting ◦ Board Certification◦ Availability◦ Other????

Review your Bylaws, Policies & Procedures

Need measurable criteria (“must have adequate training” is not measurable!!)

Must be uniformly applied throughout facility (regardless of who’s doing it and where)◦ e.g., multiple specialties doing same procedure

which may require defined “equivalent” criteria”

Must be defensible – if there is an adverse or perceived adverse outcome, can you stand behind your privileging P&Ps, the defined criteria, and the process used to privilege?

Avoid “exceptions” to criteria whenever possible – consider defining “alternatives” instead

If applicant fails to meet established criteria, it is not reportable to NPDB as a “denial of privilege” – he/she simply isn’t eligible to apply for the privilege.

If applicant fails to meet eligibility requirements, does not invoke right to fair hearing.

Criteria should be developed for◦ Obtaining privilege◦ Maintaining privilege

Criteria may also include◦ Age groups (Example: “At ABC Hospital, Internal

Medicine privileges are generally limited to patients 16 years or older”

Basic Criteria(applicable to the core/general privileges in a specialty)

Education / training / board cert (be specific) Licensure and/or certification Experience (yrs in practice, volume, etc) Other requirements: evidence of physical

ability to perform requested privilege, peer recommendations, data from professional practice review, other

Privilege-Specific (Selected) Privileges

Assumes basic criteria has been met, PLUS:

For each selected privilege:◦ Training criteria, regardless of specialty (can be

“equivalent”) Formal program, subspecialty board, CME, proctored

◦ Experience (optional) – example: volume requirements to maintain proficiency in procedure)

Good criteria – where do you find it???◦ Specialty boards◦ Commercial products

White Papers (HC Pro) E Privileges (Morrisey, Cactus, MedKinetics)

◦ Networking with colleagues◦ Consultants◦ Internet!!!! (you’d be amazed!)◦ Your medical staff

Dealing with that “new” privilege a practitioner may want to begin doing

in your organization

Cannot apply for privilege you don’t offer! Have a Policy & Procedure

◦ Medical Staff & Administration must determine if new privilege is feasible (based on patient population, community need, capital expenditure, support staff, space, etc)

◦ If it is determined that new privilege would be in best interest, must first develop criteria and have it approved

Only then can practitioner apply for privilege

OLD WAY: (usually a laundry list)

1. Make sure applicant fills out request2. Check for signature3. At reappointment, compare for changes4. Have Department Chair review, check

off and sign

NEW WAY: (Core / Select)

1. Make sure applicant fills out request2. Check for signature3. **Review specific criteria for each privilege and

determine if appropriate evidence is attached 4. **Arrange for FPPE – based on specific

privileges5. At reappointment, compare for changes6. **Review specific criteria for renewal of

privileges and determine if appropriate evidence is either attached, included in Profile, or obtained from another facility

7. Have Department Chair review, check off and sign

IN A NUTSHELL

Credentialing/verification for criteria-based privileges – Does practitioner look good on paper?

FPPE #1 – Focused review of privileges granted for first time: Organization wants to see for themselves that s/he really is good at doing what they say they can do – prove it!

OPPE – Ongoing performance review: Does s/he continue to perform the privilege well?

FPPE #2 – Focused review when there is question about performance: Oops, need to look at this case (procedure) a little closer!

Focused Professional Practice Evaluation:

Process whereby organization evaluates the privilege-specific competence of practitioner who doesn’t have documented evidence of competently performing the privilege at the organization (we call this FPPE #1)

New applicant or newly requested privilege (Replaces “provisional period”) Can include data on patient care, medical/clinical

knowledge, technical and clinical skills, interpersonal and communication skills, professionalism

FPPE #1 – develop review criteria for:◦ A group of privileges (core)◦ Single privileges (selected)

Criteria, method and length of evaluation are flexible, and can vary from privilege to privilege◦ Chart review◦ Monitoring clinical practice patterns◦ Simulation◦ Proctoring◦ External peer review◦ Discussion with others involved with care

FPPE: Process also used when question arises re: currently privileged practitioner’s ability to provide safe, high quality patient care (we call this FPPE #2)

◦ Requires medical staff evaluation

◦ MS.08.01.01 Intro – Effective January 2008

Ongoing Professional Practice Evaluation (OPPE)

Process that allows the organization to identify professional practice trends impacting quality patient care and safety (in between reappointment periods). Examples:◦ Review of operative procedures◦ Blood and pharmacy use◦ Test and procedure requests◦ Morbidity and mortality data◦ Use of consultants◦ Other criteria determined by medical staff

Evidence based privileging : Information from these evaluations must be part of the decision-making process

Joint Commission◦ Decision to grant, deny, renew privilege(s) is

objective and evidence based ◦ Ongoing professional practice evaluation

information is factored into the privileging decision

CMS◦ All practitioners are individually evaluated to assure

that they possess current qualifications and demonstrated competencies for the privileges granted

Evidence based privileging Joint Commission

◦ Decision to grant, deny, renew privilege(s) is objective and evidence based

◦ Ongoing professional practice evaluation information is factored into the privileging decision

CMS◦ All practitioners are individually evaluated to

assure that they possess current qualifications and demonstrated competencies for the privileges granted