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Healthcare Healthcare Facilities Facilities Accreditation Accreditation Program (HFAP)Program (HFAP)

2007 Medical Staff 2007 Medical Staff Credentialing Credentialing

StandardsStandards George A. ReutherGeorge A. Reuther

Director, HFAPDirector, HFAP312-202-8060312-202-8060

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The HFAP The HFAP Accreditation HistoryAccreditation History HFAP first began in 1945HFAP first began in 1945

Accrediting Hospitals and Other Health Care Accrediting Hospitals and Other Health Care Facilities for over Facilities for over 6060 years years

Accrediting Hospitals Under Medicare for Accrediting Hospitals Under Medicare for Over Over 4040 years years

Recognized by Managed Care Organizations Recognized by Managed Care Organizations and Insurance Companiesand Insurance Companies

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Current Areas of Current Areas of AccreditationAccreditation Hospitals Hospitals

Clinical LaboratoriesClinical Laboratories

Ambulatory Care / Surgical FacilitiesAmbulatory Care / Surgical Facilities

Mental Health & Substance Abuse FacilitiesMental Health & Substance Abuse Facilities

Physical Rehabilitation FacilitiesPhysical Rehabilitation Facilities

Critical Access Hospitals Critical Access Hospitals

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Government RecognitionGovernment Recognition

Deeming Authority from the Deeming Authority from the Centers for Medicare and Centers for Medicare and Medicaid Services (CMS): Medicaid Services (CMS):

Medicare Conditions of Participation for Medicare Conditions of Participation for Hospitals, CAHs, and ASCs.Hospitals, CAHs, and ASCs.

Clinical Laboratory Improvement Clinical Laboratory Improvement Amendments (CLIA)Amendments (CLIA)

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Accreditation Survey Accreditation Survey Related ActivitiesRelated Activities

Hospitals – Three (3) day survey Hospitals – Three (3) day survey

Three (3) member Survey Team Three (3) member Survey Team reviews hospital compliance with reviews hospital compliance with HFAP accreditation requirementsHFAP accreditation requirements

– Physician, RN, and AdministratorPhysician, RN, and Administrator

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Patient Safety Patient Safety InitiativesInitiatives

National Quality Forum (NQF) National Quality Forum (NQF) 30 Safe Practices (2003) 30 Safe Practices (2003)

HFAP adopted 28 of the 30 HFAP adopted 28 of the 30

Safe PracticesSafe Practices

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National Quality Forum National Quality Forum 30 Safe Practices 30 Safe Practices (2003)(2003)

For example:For example: #14 Operative Site Verification #14 Operative Site Verification

#18 Anti-Thrombotic Therapy #18 Anti-Thrombotic Therapy

#20 Prevent Central Venous Catheter #20 Prevent Central Venous Catheter InfectionsInfections

#21 Surgical Site Infections (SSI) #21 Surgical Site Infections (SSI)

#22 Contrast Media #22 Contrast Media

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“ “The Organized Medical The Organized Medical Staff”Staff”

The hospital must have an The hospital must have an organized organized medical staffmedical staff that operates under that operates under bylaws approved by the governing bylaws approved by the governing body and is responsible for the body and is responsible for the qualityquality of medical care provided to patients by of medical care provided to patients by the hospital. 482.22the hospital. 482.22

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Credentialing and Credentialing and Privileging Process Privileging Process HFAP standards for credentialing and HFAP standards for credentialing and

privileging provide for the periodic privileging provide for the periodic appraisals by the facility’s medical appraisals by the facility’s medical staff of its members. staff of its members.

The appraisal is to determine the The appraisal is to determine the suitability of individual members and suitability of individual members and all other credentialed providers for all other credentialed providers for membership/continued membership membership/continued membership on the medical staff, or on the medical staff, or

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Credentialing and Credentialing and Privileging Process Privileging Process (cont’d)(cont’d) credentialing / re-credentialing (for credentialing / re-credentialing (for

non-member credentialed providers), non-member credentialed providers), and toand to

determine if an individual determine if an individual practitioner’s clinical privileges should practitioner’s clinical privileges should be approved, continued, discontinued, be approved, continued, discontinued, revised or otherwise changed. (HFAP revised or otherwise changed. (HFAP hospital 03.00.04)hospital 03.00.04)

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Credentialing and Credentialing and Privileging Process Privileging Process (cont’d)(cont’d) The standards describe the The standards describe the

responsibilities of credentialed responsibilities of credentialed professionals to the facility in which professionals to the facility in which they work, to the patients which they they work, to the patients which they treat, and to the Governing Body of treat, and to the Governing Body of the facility. (HFAP hospital 03.00.05, the facility. (HFAP hospital 03.00.05, 03.00.06, and 03.00.07)03.00.06, and 03.00.07)

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Medical Staff Medical Staff MembershipMembership

The standards identify the selection The standards identify the selection criteria for membership on the medical criteria for membership on the medical staff. staff.

These criteria must include: licensure, These criteria must include: licensure, training / education, current training / education, current competence, health status, competence, health status, experience, character, and judgment. experience, character, and judgment. (HFAP hospital 03.01.13)(HFAP hospital 03.01.13)

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Required Application Required Application InformationInformation

The standards identify the required The standards identify the required application/reapplication information application/reapplication information to be provided for review. to be provided for review.

This information includes:This information includes:

1. licensure history, 1. licensure history, 2. medical education and post2. medical education and post graduate training, graduate training,

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Required Application Required Application Information (cont’d)Information (cont’d)

3. malpractice insurance and history, 3. malpractice insurance and history, 4. specialty board status, 4. specialty board status, 5. sanctions or disciplinary actions, 5. sanctions or disciplinary actions, 6. criminal history, 6. criminal history, 7. healthcare employment history,7. healthcare employment history,8. professional references, and8. professional references, and9. clinical activity.9. clinical activity.

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Required Application Required Application Information (cont’d)Information (cont’d)

10. All information provided by the10. All information provided by the applicant/re-applicant is to be applicant/re-applicant is to be compared against verified compared against verified information. information. (HFAP hospital 03.01.15) (HFAP hospital 03.01.15)

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Quality Assessment and Quality Assessment and Performance Performance ImprovementImprovement The facility’s quality assessment and The facility’s quality assessment and

performance improvement (QAPI) performance improvement (QAPI) function involve: function involve:

A.A. clinical assessmentsclinical assessments by Medical by Medical Staff and other providers for all Staff and other providers for all service types of patients, service types of patients,

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QAPI (cont’d)QAPI (cont’d)

B.B. diagnostic proceduresdiagnostic procedures – including – including invasive and non-invasive invasive and non-invasive procedures from clinical laboratory, procedures from clinical laboratory, imaging, cardiorespiratory, physical imaging, cardiorespiratory, physical or behavioral medicine, etc., for or behavioral medicine, etc., for patients of all service types; and patients of all service types; and

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QAPI (cont’d)QAPI (cont’d)

C.C. therapeutic interventionstherapeutic interventions – – including those processes and including those processes and outcomes as appropriate to Medical outcomes as appropriate to Medical Staff functions. Staff functions. (HFAP hospital 03.02.03) (HFAP hospital 03.02.03)

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QAPI Information Used in QAPI Information Used in Review of CandidatesReview of Candidates Information derived from the facility’s Information derived from the facility’s

QAPI functions is used in the review of QAPI functions is used in the review of candidates for appointment and candidates for appointment and privileging and addresses:privileging and addresses:

1. medication therapy, 1. medication therapy, 2. infection control, 2. infection control, 3. surgical / invasive and manipulative3. surgical / invasive and manipulative procedures, procedures,

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QAPI Information Used in QAPI Information Used in Review of Candidates Review of Candidates (cont’d)(cont’d)

4. blood product usage, 4. blood product usage, 5. data management (with emphasis 5. data management (with emphasis on medical record pertinence and on medical record pertinence and timeliness), timeliness),6. discharge planning, 6. discharge planning, 7. utilization management, 7. utilization management,

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QAPI Information Used in QAPI Information Used in Review of Candidates Review of Candidates (cont’d)(cont’d)

8. complaints from patients and8. complaints from patients and families or from hospital staff, families or from hospital staff, 9. restraint / seclusion usage, and9. restraint / seclusion usage, and10. mortality review. 10. mortality review. (HFAP hospital 03.02.02) (HFAP hospital 03.02.02)

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Medical Staff Medical Staff AccountabilityAccountability

The Medical Staff is accountable to the The Medical Staff is accountable to the Governing Body for the quality of Governing Body for the quality of medical care provided to patients by medical care provided to patients by all credentialed practitioners and for all credentialed practitioners and for

aggregating their QAPI finding from aggregating their QAPI finding from the departments, services, committees the departments, services, committees or other structural components to:or other structural components to:

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Medical Staff Medical Staff Accountability (cont’d)Accountability (cont’d)

A. develop plans for continuing theA. develop plans for continuing the education of its members and all education of its members and all credentialed staff; credentialed staff;

B. provide annual evaluations of B. provide annual evaluations of improvements in the clinical care improvements in the clinical care provided; provided;

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Medical Staff Medical Staff Accountability (cont’d)Accountability (cont’d)

C. utilize as information in the C. utilize as information in the process of evaluating Medical Staff process of evaluating Medical Staff for all membership categories for all membership categories includingincluding associate (provisional), active, associate (provisional), active, consulting, and hospital-based consulting, and hospital-based membership categories; membership categories;

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Medical Staff Medical Staff Accountability (cont’d)Accountability (cont’d)

D. utilize as information in the process D. utilize as information in the process of evaluating and acting upon of evaluating and acting upon reappointment and reprivileging reappointment and reprivileging requests from its members and all requests from its members and all other credentialed staff; and other credentialed staff; and

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Medical Staff Medical Staff Accountability (cont’d)Accountability (cont’d)

E. E. utilize as information in an utilize as information in an ongoing process of evaluating ongoing process of evaluating the members of the medical the members of the medical staff. staff. (HFAP hospital 03.02.04) (HFAP hospital 03.02.04)

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03.00.04 Demonstrated 03.00.04 Demonstrated CompetenciesCompetencies

To includeTo include::1.1. Current work / practiceCurrent work / practice2.2. Special trainingSpecial training3.3. Quality of specific workQuality of specific work4.4. Patient outcomesPatient outcomes5.5. EducationEducation6.6. Maintenance of CME (continued)Maintenance of CME (continued)

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03.00.04 Demonstrated 03.00.04 Demonstrated Competencies (cont’d)Competencies (cont’d)

7.7. Adherence to Medical Staff Adherence to Medical Staff guidelinesguidelines

8.8. CertificationsCertifications9.9. Appropriate licensureAppropriate licensure10.10. Currency of compliance with Currency of compliance with

licensure requirements licensure requirements to to perform each task, activity, perform each task, activity, privilege requested for the privilege requested for the category of practitionercategory of practitioner. .

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03.00.0403.00.04

If the practitioner is If the practitioner is not competentnot competent

to perform one or more task/ to perform one or more task/ activity/activity/

privilege…privilege…

……the list of privileges is the list of privileges is modifiedmodified for that practitioner.for that practitioner.

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03.01.04 Bylaws – 03.01.04 Bylaws – Categories of Medical Categories of Medical StaffStaff Include a statement of the duties, Include a statement of the duties,

responsibilities, and privileges for responsibilities, and privileges for each category of medical staff.each category of medical staff.

Categories Categories mustmust include all include all practitioners who provide a practitioners who provide a ““medical-relatedmedical-related” level of care, ” level of care, such as…such as…

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03.01.04 Bylaws – 03.01.04 Bylaws – Categories of Medical Categories of Medical StaffStaff Physicians Physicians DentistsDentists Allied Health Practitioners, e.g., Allied Health Practitioners, e.g.,

– RN First Assistants, RN First Assistants, – Surgical Assistants, Surgical Assistants, – Anesthesia Assistants, Anesthesia Assistants, – CRNAs, CRNAs, – MidwivesMidwives

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03.01.15 Re-application03.01.15 Re-application

H.H. References – Re-applicantsReferences – Re-applicants

MustMust have Clinical Competence Review have Clinical Competence Review

MustMust have peer review reports, e.g., have peer review reports, e.g., Clinical peer review, Clinical peer review, Medical record review, Medical record review, Credentials Committee/Function , and / Credentials Committee/Function , and /

or or Medical Executive Committee reviewMedical Executive Committee review

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03.01.15 Re-application 03.01.15 Re-application

I.I. Clinical Activity – Application & Re-applicationsClinical Activity – Application & Re-applications

Must have QAPI clinical / objective data with Must have QAPI clinical / objective data with signature of department chairpersonsignature of department chairperson

# Cardiac Stents# Cardiac Stents # Complications# Complications

Must have recommendation from department in Must have recommendation from department in which privileges are soughtwhich privileges are sought

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03.01.15 Re-application 03.01.15 Re-application

I.I. Clinical Activity – Re-applicantsClinical Activity – Re-applicants

Examples of QAPI clinical / objective data Examples of QAPI clinical / objective data

Timeliness of H&PTimeliness of H&P Content of Discharge Summary Content of Discharge Summary # Patient Complaints# Patient Complaints # Surgical Complications# Surgical Complications # Re-intubations# Re-intubations

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03.01.17 Emergency Privileges 03.01.17 Emergency Privileges

Medical Staff Bylaws provide granting of Medical Staff Bylaws provide granting of

emergency privileges.emergency privileges.

Within scope of licenseWithin scope of license

For life saving proceduresFor life saving procedures

During times that a staff member who is a During times that a staff member who is a credentialed practitioner with appropriate credentialed practitioner with appropriate privileges is not available.privileges is not available.

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03.01.18 Temporary Privileges 03.01.18 Temporary Privileges

1. Bylaws provide for the granting of temporary

privileges while a file is waiting to go to MEC and Board for final approval.

2. Application must be complete.

3. Credentialing Committee has reviewed file.

4. Applicable for: For specific patients For locum tenens For times of emergency and / or disaster

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03.01.18 Temporary Privileges 03.01.18 Temporary Privileges

Disaster – Clinical VolunteersDisaster – Clinical Volunteers: :

A plan is in place for clinical volunteersA plan is in place for clinical volunteers

The plan provides for primary source The plan provides for primary source identification from the volunteer’s hospital, identification from the volunteer’s hospital, e.g., a documented telephone calle.g., a documented telephone call

Volunteers function within their scope of Volunteers function within their scope of license / certificationlicense / certification

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Chapter 2 – Allied Health Chapter 2 – Allied Health ProfessionalsProfessionals

02.00.01 Allied Healthcare Practitioner (AHP) Categories

The governing body with the medical staff will determine which allied health

practitioner disciplines will function under each category.

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Chapter 2 – Allied Health Chapter 2 – Allied Health ProfessionalsProfessionals

02.00.02 Credentialing Procedures Appointed using privilege lists or a

defined scope of practice.

Privileges that require physician supervision are identified.

Privileges that require direct or indirect supervision are identified.

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Practitioners that provide a Medical – Related Level of Care…

or Conduct Surgical Procedures:

Must be individually credentialed based on their own individual qualifications.

• Regardless if care is provided directly or

under supervision,

• Whether employed by the hospital, a physician

or other entity, or a contracted provider

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Chapter 2 – Allied Health Chapter 2 – Allied Health ProfessionalsProfessionals

02.00.02 Credentialing Procedures

The privileging process for AHP is the same process as used for the Medical Staff

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Allied Health Allied Health Professionals - Professionals - Employed by HospitalEmployed by Hospital02.00.02 Credentialing Procedures

If the AHP functions in an education or leadership role,

This individual would not usually be privileged by the medical staff.

Files would be maintained in the HR department or as defined by hospital.

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Professional Professional Credentialing Credentialing Organizations (PCO)Organizations (PCO)Definition:

“An independent contractor who has no clinical or financial affiliation with the people on whom data is being collected. There can be no evidence of any relationship that could raise the question of a conflict of interest.”

Facilities may use PCOs to assist in data collection for the credentialing and re-credentialing process, but the responsibility for granting privileges always remains with the facility.

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Professional Professional Credentialing Credentialing Organizations (PCO)Organizations (PCO)The PCO may perform:

Personal reference checks

Verification of privileges at all facilities where the candidate maintains privileges

Verification of education and certification, etc.

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Professional Professional Credentialing Credentialing Organizations (PCO)Organizations (PCO)

Minimally, the facility granting privileges MUST :

Verify State licensure

Query the National Practitioner Data Bank, and

Perform verification immediately prior to appointment.

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CMS Conditions of CMS Conditions of Participation Final Rules Participation Final Rules (2006) (2006) Final Rule –November 27, 2006:

– H & P within 30 days / 24 hours of admission (before surgery)

– Verbal Orders: Authenticate and time order within 48 hours

Final Rule – December 8, 2006:

– Restraint or Seclusion

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The Healthcare Facilities The Healthcare Facilities Accreditation Program Accreditation Program

(HFAP)(HFAP)

George A. Reuther,George A. Reuther,

DirectorDirector

142 East Ontario Street142 East Ontario Street

Chicago, IL 60611-2864Chicago, IL 60611-2864

312-202-8060312-202-8060

greuther@hfap.orggreuther@hfap.org