COMPARATIVE DIFFERENCES: TJC, CMS & NCQA MEDICAL STAFF and CREDENTIALING STANDARDS

1. COMPARATIVE DIFFERENCES: TJC, CMS & NCQA MEDICAL STAFF and CREDENTIALING STANDARDS Debra R. Green, MPA, CPMSM, CPCS Director, Medical Staff Services and Pediatric Residency Program Stanford University Medical Center Stanford Hospital & Clinics Lucile Packard Children’s Hospital

2. Objectives • Overview of the 3 main regulatory bodies • Who they are? • What they do? • Why they exist? • Overview of Credentialing Standards • Requirements • Compliance • Survey Process

3. The Joint Commission (TJC) • Who are they? • Private Organization • What do they do? - Unannounced Surveys • Can Survey “For Cause” • Why do they exist? • To ensure patient care and quality

4. Center for Medicare/Medicaid (CMS) • Who are they? • Government Organization • Surveyors are typically State DOH employees • Gives deeming authority to TJC, HFAP and DNV • What do they do? • Validate TJC • Can Survey For Cause • Why do they exist? • To ensure patient care and quality

5. Healthcare Facilities Accreditation Program (HFAP) Over 200 hospital and 200 other HC facilities and labs Existed for 60 yrs Det Norske Veritas Healthcare, Inc (DNV) Certifies other companies in additional to healthcare Existed since 1884 (began in Norway) World wide reputation for quality and integrity Authorities Deemed by CMS

6. National Committee for Quality Assurance (NCQA) • Who are they? • Private Organization • What do they do? • Accredits: MCO’s, MBHO’s, PPO’s, NHP’s etc. • Certifies: CVO’s • Delegated Credentialing Agreements • Hospital does the work for MCO

7. Overview of Standards • Joint Commission • 13 total MS Standards • Several Elements of Performance (EP’s) • Several changes to MS Standard – 2007, eff 1/2008 • CMS Conditions of Participation (CoP’s) • 5 MS Standards • Evidence of Compliance • NCQA • 12 Standards (Credentialing) • Elements of Performance for each Standard

8. TJC Requirement (I) Primary Source verification from Medical School Alternate sources: AMA, AOA, ECFMG NCQA Requirement (I) Primary source verification from Medical School Not required if board certified or if residency has been verified Alternate sources: AMA, AOA, ECFMG (after 1986), state licensing agency MEDICAL EDUCATION

9. TJC Requirement (I) Primary source verification from training program Alternate sources: AMA, AOA NCQA Requirement (I) Primary source verification from training program Alternate sources: AMA, AOA, state licensing agency Not required if board certified (n/a for dentists) POST GRADUATE TRAINING

10. TJC Requirements (I&R) Required Peer must be within same professional discipline (advisable to utilize peer in same specialty) Recommendations should address training or experience, clinical competence and ability to perform privileges 6 General Competencies NCQA Requirements (I&R) Peer Review through Credentials Committee with representation from similar types and degrees of expertise PEER REFERENCES

11. TJC Requirement (I) Doctor must provide chronological history of his education, training and experience Determination of “significant” clinical performance NCQA Requirement (I) Doctor must provide five year work history on application or CV No verification required but must explain gaps of 6 months or more WORK HISTORY

12. TJC Requirement “Ability to perform” Significant clinical performance Practice within scope Grant or Deny must be objective and evidence based NCQA Requirement Application must include attestation statement from applicant regarding history of limitation or loss of clinical privileges or other disciplinary action NOTE: NCQA does not require doctors to have clinical privileges at an acute care facility HOSPITAL PRIVILEGES

13. Performance Monitoring • Required only by TJC • Focused Professional Practice Evaluation (FPPE) • Proctoring – Chart Review or Observations • Ongoing Professional Practice Evaluation (OPPE) • Ongoing data assessment for ALL

14. TJC Requirements Not addressed in standards NCQA Requirement (I & R) Current or previous sanctions must be verified Verify through NPDB, OIG, CMS, FSMB, state Medicaid agency MEDICARE/MEDICAID SANCTIONS

15. TJC Requirements Not addressed in standards NCQA Requirement P&P’s for the ongoing monitoring of sanctions 1) Medicare/Medicaid 2) License 3) Complaints Documentation is regularly obtained and reviewed Monitoring Adverse Events ONGOING MONITORING OF SANCTIONS

16. TJC Requirement (I & R) Doctor must provide information regarding previously successful or currently pending challenges or relinquishment of registrations NCQA Requirement (I & R) Verify through copy of certificates, NTIS, AMA DEA/CDS

17. TJC Requirement (I & R) Participate in Continuing Education Documented Considered in Privilege process Should be relevant to clinical privileges requested NCQA Requirement (I & R) Not Required CONTINUING MEDICAL EDUCATION

18. TJC Requirements Primary source verification not required unless required by bylaws. (I & R) MS must evaluate professional liability actions NCQA Requirement Primary source verification not required (I & R) Attestation by doctor or copy of policy showing dates and amount of coverage or Face Sheet MALPRACTICE INSURANCE

19. TJC Requirement (I & R) evaluate evidence of “unusual” or “excessive” number of actions resulting in a final judgment. NCQA Requirement (I&R) Doctor must provide malpractice history for past five years. Verified through carrier or NPDB MALPRACTICE HISTORY

20. TJC Requirement (I&R) Must query at granting of initial, renewal and when a new privilege is requested. NCQA Requirement (I&R) Query if you can’t obtained last 5 years of claims from Insurance carriers. Use as alternate source for sanctions or limitations on licensure NATIONAL PRACTITIONER DATA BANK

21. TJC Requirements Terminology is not used in Medical Staff Standards Required under HR Standards NCQA Requirements (I&R) Application must attest to his/her history of loss of license and felony conviction and lack of illegal drug use. HISTORY OF FELONY CONVICTIONS/Drug Use

22. TJC Requirement (I) Verification not required unless bylaws require board certification (R) Organization Specific Verify through ABMS, AOA or specialty board NCQA Requirement (I) Not required, but verify through ABMS, AMA, AOA, state licensing agency if board certified (R) Verify only if certification has expired (including lifetime) Must document “lifetime” in lieu of expiration date BOARD CERTIFICATION

23. TJC Requirement (I & R)Primary source verification required at initial appointment, reappointment, revision of privileges and at time of expiration Current and Valid Verify through state licensing board NCQA Requirement (I & R) Primary source verification required Must be current and valid In effect at time of credentialing decision Verify through state licensing board LICENSE

24. TJC Requirements (I & R) The doctor must provide information regarding challenges or relinquishment of license (attestation question) NCQA Requirements (I & R) Primary source verification Verify through state license board, NPDB, or FSMB LICENSE SANCTIONS

25. TJC Requirements Terminology Not Used NCQA Requirements Applicant must provide a current, signed attestation statement regarding the correctness and completeness of application ATTESTATION STATEMENT

26. TJC Requirement Structured procedure must be defined in bylaws Complete applications must be acted upon within reasonable time frame as specified in bylaws NCQA Requirement Credentials information must be no more than 180 days old at the time of credentialing committee’s decision TIME FRAME FOR COMPLETION

27. TJC Requirement May not exceed two years NCQA Requirement Effective 7/1/01 credentialing period may be for 36 months LENGTH OF APPOINTMENT PERIOD

28. NOW ABOUT CMS…..

29. Medical Staff Organization • Regulation: • Organized medical staff ; operates under bylaws that are approved by governing body; responsible for quality of care. • Compliance: • Bylaws, R&R’s, Cred files, Quality Reports, Meeting minutes

30. MS Composition (a) • Regulation: • MS composed of MD’s, DO’s according to state law; may also include others appointed by Governing Body. • Compliance: • MS Rosters, Cred Files, Minutes or approved Bylaws categories.

31. MS Composition (a)(1) • Regulation: • MS must conduct periodic appraisals • Compliance: • Cred Files, Profiles, Summary Reports of Credentialing activity, Board minutes documenting last 2 appraisals

32. MS Composition (a)(2) • Regulation: • MS must examine credentials of applicants for membership and make recommendation to Board. • Compliance: • Definition of Creds Review Process in the Bylaws; any MS or Dept minutes that document review and recommendations.

33. MS Organization & Accountability • Regulation: • MS must be well organized and accountable to Governing Body for quality of Medical Care provided. • Compliance: • MS Org Chart, Bylaws Description, Board Minutes, definition of MS Composition in Bylaws, Bylaws approval by Board

34. Medical Staff Bylaws • Requirement: • MS must adopt & enforce. • Must be approved by Board; include category descriptions, H&P requirement and criteria for privileges to be granted; describe MS Organization and applicant qualifications; • Compliance: • Bylaws, R&R, Minutes, Medical Records (H&Ps), Quality reports (H&P timelines data)

35. Autopsies • Requirement: • Secure in all cases of unusual deaths and for med/legal educational interests. • Compliance: • R&R, Autopsy Policy, QA or PI reports; Medical Record Review.

36. History & Physicals (H&P) • New Requirement as of 2007: • No more than 30 days before or 24 hrs after admission • Old Requirement: • No more than 7 days before and 48 hrs after

37. Success Tips for Compliance • Continuous Readiness • File Audits • Database Audits (Appendix A) • Increased Staff Knowledge (Appendix B) • Employee Motivators/Incentives

38. Appendix A

39. Fun Quiz • Temporary Privileges • (Answer Sheet) • 1. Under certain circumstances, temporary clinical privileges may be granted for a limited period of time. • TRUE • 2. When temporary privileges are granted to meet an important care need, the organized medical staff verifies only current licensure and current competence before the provider can begin seeing patients. • TRUE • 3. Temporary privileges for new applicants are granted for no more than 90 Bylaws/120 TJC days. • 4. All temporary privileges are granted by the chief executive officer or authorized designee. • TRUE • 5, Under which circumstances does the Joint Commission allow temporary privileges to be granted? • a. To fulfill an important patient care, treatment, and service need. • b. When a new applicant with a complete application that raises no concerns is awaiting review and approval of the medical staff executive committee and the governing body. • Bonus Question: • Temporary privileges for new applicants may be granted while awaiting review and approval by the organized medical staff upon verification of……? List 5 items • - Current licensure. • - Relevant training or experience. • - Current competence. • - Ability to perform the privileges requested. • - Other criteria required by the organized medical staff bylaws. • - A query and evaluation of the National Practitioner Data Bank (NPDB) information. • - A complete application. • - No current or previously successful challenge to licensure or registration. • - No subjection to involuntary termination of medical staff membership at another organization. • - No subjection to involuntary limitation, reduction, denial, or loss of clinical privileges. • All answers can be found in the Joint Commission Medical Staff Standards under MS.06.01.13 Educational and Motivational Tool Appendix B

40. Questions???? Contact information: Email: DeGreen@stanfordmed.org Phone: 650-497-8920