Standards Update June 2010 Presented by Lynn L. Buchanan, President Buchanan & Associates Consulting For Alaska Assn. Medical Staff Services 1

Standards UpdateJune 2010

Presented byLynn L. Buchanan, President

Buchanan & Associates ConsultingFor

Alaska Assn. Medical Staff Services

1www.Edge-U-Cate.com

The Joint Commission

2010 – New Scoring Methodology

All EPs in Medical Staff Chapter are Category A requiring 100% compliance

(except 4 which are category C scored on occurrences of non-compliance – 90% or ESC)

www.Edge-U-Cate.com 2

Medical Staff Standards

POSSIBLE – Preliminary Denial of Accreditation

• MS.03.01.01 EP2: Practitioners practice only within the scope of their privileges as determined through mechanisms defined by the OMS (CONVERTED to Direct Impact as PDA)

• MS.06.01.05 EP1: Licensed independent practitioners possess a current license


TJC / CMS

• Several changes have been made in order to “sync” with CMS Conditions of Participation

• Separate Language for organizations that use TJC accreditation for deemed status

– Bylaws (MS.01.01.01)– MEC (MS.02.01.01)– Oversight of Quality of Care (MS.03.01.01)– Autopsies (MS.05.01.01)– Radiology Service Supervision


MS.01.01.01 – MS Bylaws• Task Force continues work to determine best

approach to review standard• Key Issues:– Relationship between OMS and MEC– What needs to appear in bylaws and how such

decisions are made– How to manage conflict between OMS and GB /

between OMS and MEC – regarding bylaws, R&R, policies

• Effective 3/31/2011 - 36 Elements of Perf.


MS.01.01.01 – MS Bylaws

• EP 3 – New– Associated details for EPs 12-36 may reside in

bylaws, R&R or policies• OMS adopts what constitutes associated details, where

they reside and whether adoption can be delegated

– If a process is required for EPs 12-36, bylaws must include the basic steps (as determined by the OMS and approved by GB)



• EP 8 – New– OMS has the ability to adopt MS bylaws, R&R,

policies and amendments thereto, and to propose them directly to the GB

• EP 9 – New– If voting members of OMS propose to adopt R&R,

policy or amendment, first communicate with MEC; If MEC proposes, must first communicate with MS (applies only if MEC has been delegated authority over R&R, policies by OMS & GB)



• EP 10 – New– OMS has process to manage conflict between MS

and MEC on issues, including but not limited to proposals to adopt R&R, policy or amendment

– Does not prohibit members of MS from communicating with GB. GB determines method of communication


MS.01.01.01 MS Bylaws

• EP 11 – New– When documented need for urgent amendment

to R&R/Policy to comply with law or regulation, MEC (if so delegated) may provisionally adopt and GB provisionally approve without prior notification• MS notified immediately• Opportunity for retrospective review/comment• If no conflict, amendment stands• If conflict, conflict resolution (EP10) is implemented

and any revision submitted to GB for action



• EP 15 (2010)– A statement of the duties and privileges related to

each category of the medical staff (ex: active, courtesy)

– NOTE: Solely for purposes of this EP, TJC defines “privileges” as the duties and prerogatives of each category of MS membership, and the clinical privileges to provide patient care, services & treatment



• EP 17 – New– Description of MS members eligible to vote

• EP 19 – New– List of all MS officer positions

• EP 24 & 25 – New– Process for adopting and amending MS bylaws,

R&R, policies



• Former EP 19 – related to medical staff governance documents that supplement the bylaws

Implementation date still suspended pending work of the Medical Staff Bylaws Task Force – continues to not be in effect


MS.03.01.03 Pain Mgmt

• (New, not CMS)• Hospital educates all LIPs on assessing and

managing pain– Philosophy – conservative vs aggressive– Assessment/reassessment components and time

frames– Pain Sclaes– Medication policies related to orders with multiple

pain medication choices, dose and frequency ranges, parameters for administration


Telemedicine (7/15/10) LD.04.03.09(9), MS.13.01.01(1)

• For hospitals using TJC for deemed status– All LIPs who are responsible for the patient’s care,

treatment and services via a telemedical link are credentialed and privileged to do so at the originating site

– can use CVO if it meets TJC 10 guidelines– If distant site is Medicare-participating hospital, may

use copy of distant site’s credentialing packet for privileging if packet includes list of all privileges granted, attestation that packet is complete, accurate and up to date


Telemedicine (7/15/10) LD.04.03.09(9), MS.13.01.01(1)

• For hospitals not using TJC for deemed status– Specify in the written agreement that the

contracted organization will ensure that all contracted services provided by LIPs will be within scope of their priv.


Telemedicine – MORE NEWS!

• CMS Reconsidering

• CMS has delayed effective date of TJC’s revised standards until March 2011


TJC Position - Core Privileges

• MS.06.01.07• Per John Herringer, 5/10 at FAMSS meeting:– Core Privileges – activities for which the majority

of practitioners who meet the defined criteria should be able to perform

– Core terminology must define the specific activities included and any limitations, e.g., those that are outside the core

– Cannot assume applicant can perform all core activities


MS.08.01.01 FPPE

• Focused professional practice evaluation is done for all initial privileges – effective January 1, 2008– Time of application– When additional privileges are requested– Predefined to ensure consistent implementation

• Criteria are developed for evaluating performance when issues affecting care are identified


MS.08.01.03 OPPE

• Ongoing continuous evaluation• Identify performance problems early and

resolve• Results in evidence-based privileging at time

of renewal• Process includes evaluation of each

practitioner’s professional practice• Good and the negative (outlier)


HR.01.02.05 PAs & APRNs

• EPs 10-15– Credentialed and privileged through MS process

(or equivalent)• Approved by governing body• Evaluates applicant’s credentials• Evaluates applicant’s competence• Includes peer recommendations• Input from individuals and committees incl. MEC• No inherent right to a fair hearing• CMS requires GB grant privileges


HR.01.02.05 – Other individuals brought in by an LIP

• EP 5 & 7 (Not applicable to PA/APRN)– Must be authorized prior to provision of care,

treatment or service– Organization determines that the qualifications

and competence are same required of like employees performing same or similar services

– Organization reviews qualifications, performance and competence at same periodic time frame as like employees


Industry / Manufacturers / Vendors

• No current standards, but FAQ posted 4/10 offers consultative advice– EC.02.01.01 – Identify who is entering organization

and what individuals are doing– RI.01.01.01 – ensure patient rights are respected– IC.02.01.02 – Infection control precautions and other

organization-specific P&Ps are followed– LD.04.01.05 (EP 1&3) – leaders oversee operations,

and administrative and clinical direction responsibilities are defined

– LD.04.04.05 (EP 1,3,4) – the development and implementation of a patient safety program


OTHER REGS

• CMS Anesthesia Guidelines Revised

• ABMS Implements Continuous Reporting of MOC Pilot (ABP)

• Changes to Ambulatory Center Surveys


QUESTIONS


Documents

Standards Update June 2010 Presented by Lynn L. Buchanan, President Buchanan & Associates Consulting For Alaska Assn. Medical Staff Services 1