Quality Management and Performance Improvement 2010 Jones

Скачать презентацию Quality Management and Performance Improvement 2010 Jones

7f74033cea2b193b40b0549c5dc15733.ppt

Количество слайдов: 101

Definitions • Adverse Event – The result of medical intervention in which the outcome was unforeseen and unexpected • Benchmarking – Performance comparison of one organization with that of a similar organization in that area • Error – An unintended act, either of omission or commission, or an act that does not achieve its intended outcome © 2010 Jones and Bartlett Publishers

Definitions (cont. ) • Compliance – Process of meeting a prescribed set of standards or regulations to maintain active accreditation, licensure or certification status • Accreditation – The act of granting approval to a healthcare organization • Licensure – The act of granting a healthcare organization or an individual healthcare practitioner permission to provide services of a defined scope in a limited geographical area • Certification – Grants approval for a healthcare organization to provide services to a specific group of beneficiaries © 2010 Jones and Bartlett Publishers

Definitions (cont. ) • Quality – Degree of excellence, superior in kind • Quality Improvements – Methods or activities designated for the purpose of increasing the quality of a service product • Quality Assessment – Process of measuring and evaluating service activities to determine the current level of quality • Quality Management – The process of coordinating all quality activities as necessary towards the accomplishment of desirable performance outcomes © 2010 Jones and Bartlett Publishers

Definitions (cont. ) • Quality Control – A group of activities designed to detect and recognize positive and negative variances with the existing performance and to ensure a predicted outcome • Total Quality Management – A mentality or philosophy based upon continuous quality improvement in the complete process of providing care • Performance Improvement – Production of the company’s product in the most efficient and effective means possible – In the health care industry, it is the key to helping people with challenged health return to healthier more productive lives by providing high quality health care © 2010 Jones and Bartlett Publishers

Definitions (cont. ) • Quality Indicators – A quantifiable measurement or standard to identify the point of acceptable from nonacceptable performance. – Performance measure that enables healthcare organizations to monitor a process to determine whether it is meeting process requirements – May be established and implemented internally, externally or generically – May be written as ratio such as – Number of admissions meeting criteria x 100 / number of admissions © 2010 Jones and Bartlett Publishers

Definitions (cont. ) • Sentinel Event – An unexpected occurrence involving death or serious physical or psychological injury to a patient • Root Cause Analysis – A process for identifying the basic or causative factor that underlines variation in performance • Safety – All health care facilities are required to report all suspected and identified patient safety occurrences related to care or lack of care, which resulted, or could have resulted to a patient. © 2010 Jones and Bartlett Publishers

The Joint Commission (TJC) 10 -step process • Assign responsibility • Delineate scope of care • Identify important aspects of care • Identify indicators • Establish thresholds © 2010 Jones and Bartlett Publishers

The Joint Commission (TJC) 10 -step process (cont. ) • Collect and organize data • Initiate evaluation • Take actions to improve care and services • Assess the effectiveness of actions and maintain the gain • Communicate results to affected individuals and groups © 2010 Jones and Bartlett Publishers

Avedis Donabedian Model for Assessing Healthcare Quality • Structure – Measures the ability of the organization to coordinate all its resources such as physical, manpower, facility, technology, policies and procedures, financial and other characteristics as needed to successfully support the delivery of health care services • Process – Measures the ability of the organization to foster and focus on positive interactions between the receiver of health care service and the provider of service through out the course of the care • Outcome – Measures and focus on the end result of the care provided and the overall satisfaction level of the patient with the care received © 2010 Jones and Bartlett Publishers

Historical Perspectives • Mid-1700 s, Pennsylvania Hospital becomes the model for the organization and development of hospitals • • 1760, New York State begins the practice of medical licensure • 1771, New Jersey begins the practice of medical licensure © 2010 Jones and Bartlett Publishers

Historical Perspectives (cont. ) • 1851, Massachusetts General Hospital establishes the first disease/procedure index by classifying patient disposition • 1854, Florence Nightingale introduced the following new protocols for nurses during the Crimean War: Nurses / patient care relationship, sanitations and ventilation systems • 1874, American Medical Association encourages the creation of independent state licensing boards © 2010 Jones and Bartlett Publishers

Historical Perspectives (cont. ) • 1910, Flexner Report indicates unacceptable variation in medical school curricula • 1917, American College of Surgeons (ACS) establishes the Hospital Standardization Program (minimum standard of care) • 1920, Most medical colleges meet rigorous academic standards and are approved by the American Association of Medical Colleges • 1946, Hill-Burton Act establishes funding to build new hospitals. • 1952, The Joint Commission on Accreditation of Hospitals (JCAH) was formed now referred to as The Joint Commission (TJC) © 2010 Jones and Bartlett Publishers

Historical Perspectives (cont. ) • 1953, The Joint Commission on Accreditation of Hospitals (JCAH) published its first set of standards for hospitals • 1965, The Congress passed the Social Security Amendment which establishes Medicare and Medicaid coverage for citizens 65 years of age or older (PL 89 -97) • 1972, Professional Standard Review Organizations (PSROs) are formed (PL 92 -603) now referred to as Quality Improvement Organizations (QIOs) • 1976, Condition of Participation was developed • 1980, The JCAH introduced accreditation standards © 2010 Jones and Bartlett Publishers

Historical Perspectives (cont. ) • 1982, Tax Equity and Fiscal Responsibility Act (TEFRA). Reimbursement structure changed from retrospective determined cost-based payment to prospectively established fixed price determined by patients’ final principal diagnosis thus creating the Prospective Payment System (PPS) • 1982, Prospective payment system is created (TEFRA) • 1982, Peer Review Organizations (PRO) were created now referred to as Quality Improvement Organizations (QIOs) • 1982, State and regional peer review organizations contract with HCFA (Centers for Medicare and Medicaid – CMS) • 1983, Prospective Payment for Medicare was established (PL 98 -21) © 2010 Jones and Bartlett Publishers

Historical Perspectives (cont. ) • 1986, Health Care Quality Improvement Act (HCQIA) Public Law 99 -660. Established the National Practitioner Data Bank (NPDB) a clearinghouse to collect and release information to eligible parties for the purpose of identifying problematic incompetent health care practitioners • 1985, JCAH developed a ten-step model for monitoring and evaluating effectiveness of a QA efforts • 1986, JCAH developed the project called “Agenda for Change” • 1989, Agency for Health Care Policy & Research was created (PL 101 -239) © 2010 Jones and Bartlett Publishers

Historical Perspectives (cont. ) • 1996, Health Insurance Portability and Accountability Act (HIPAA) was launched (PL 104 -191) • 1997, The ORYX initiative program began, to incorporate outcome measures and monitoring into healthcare accreditation processes • • 1990, Deming’s total quality management philosophy begins to spread in U. S. healthcare • 1990, TJC integrates quality improvement into the accreditation process • Health Care Quality Improvement Program (1993) redirected PROs focus toward improving quality © 2010 Jones and Bartlett Publishers

Historical Perspectives (cont. ) • 2001, Ambulatory payment classification system is initiated • 2002, HCFA becomes the Centers for Medicare and Medicaid Services (CMS) • 2002, Peer Review Organizations (PROs) were renamed Quality Improvement Organizations (QIOs) © 2010 Jones and Bartlett Publishers

Historical Perspectives (cont. ) • April 14, 2001, The Standard for Privacy of Individually Identified Health Information (the Privacy rule) took effect • April 14, 2003, covered entity must comply • January 2004, TJC begins unannounced tracer methodology for healthcare accreditation review process • 2000 s TJC places emphasis on patient safety © 2010 Jones and Bartlett Publishers

Healthcare Accrediting and Licensing Agencies ABBREVIATION AAAHC AGENCY AREAS OF RESPONSIBILITY Accreditation Association for Specialized in assisting ambulatory healthcare Ambulatory Health Care organizations to improve quality of their services ACS American College of Surgeons Initiated standard review in health care practice CARF Commission on Accreditation of Responsible for evaluating quality of care in organizations Rehabilitation Facilities providing rehabilitative treatment Health Plan Employer Data & Responsible for collecting data on managed care plans HEDIS Information Set TJC (formerly The Joint Commission Refined ACS standards and assumed responsibility National Committee for Quality Certifying qualified healthcare professional in quality Assurance assurance National Association of Healthcare Certifying qualified healthcare professional in promoting Quality continuous QI efforts JCAHO) NCQA NAHQ © 2010 Jones and Bartlett Publishers

Accomplishments of QI Pioneers CROSBY DEMING JOINER JURAN Quality means Developed 14 Developed the JOINER Developed complete principles and conformance 7 deadly to standards diseases Triangle Trilogy process Quality Scientific Approach All One Team © 2010 Jones and Bartlett Publishers

Deming’s 14 principles 1. Create constant consistency towards purpose of the product or service 2. Adopt new philosophy 3. Focus on quality process flow of the product rather than mass inspection 4. Price tag does not always indicate quality, end practice of rewarding bases on price tag, embrace long term relationship, trust, loyalty and honesty © 2010 Jones and Bartlett Publishers

Deming’s 14 principles (cont. ) 5. Constantly assess and improve all processes 6. Institute on the job training, job orientation, continued education, equipment training etc 7. Institute leadership, remove workmanship barriers, be realistic, understand all staff can not be above average 8. Drive out fear (no one perform its best under fear) 9. Breakdown barriers within the organization by improving communication © 2010 Jones and Bartlett Publishers

Deming’s 14 principles (cont. ) 10. Eliminate numerical quotas, quota causes loss, chaos, dissatisfaction, burnout, boredom, turnover, etc 11. Eliminate quick fix solution 12. Eliminate inconsistent slogans and exhortation 13. Create an open atmosphere of creativity, identify and uplift talented staff 14. Involve everybody within the organization to work towards the transformation or improvement of the organization © 2010 Jones and Bartlett Publishers

Deming’s 7 Deadly Diseases 1. Lack of vision, mission, plan, and purpose of the product or service 2. Laying emphasis on short-time profits 3. Inconsistent, unfair and un-measurable evaluation, and merit rating 4. Employee job dissatisfaction 5. Customer, vendor and community dissatisfaction 6. Excessive medical cost 7. Excessive cost of liability © 2010 Jones and Bartlett Publishers

Court Decisions on Quality of Healthcare Year Case Decision 1965 Darling Vs. Charleston Court ruled that the hospital must assume certain responsibilities Community Hospital for care of the patient. The courts ruled that a hospital was negligent for permitting a general practitioner to perform orthopedic surgery. The court ruled that the hospital had a duty to apply reasonable standards to the practice of its physicians, since it was responsible for the privileging of physicians on its staff. 1973 The court found the hospital negligent if it knew or had reason to Mercy Hospital 1981 Gonzales Vs. Nork & know or should have known of the surgeon’s incompetence. John Vs. Misericordia The court found that the hospital owes a duty to its patients in Hospital selecting medical staff members and granting privileged. © 2010 Jones and Bartlett Publishers

10 core elements of a Performance Improvement Plan 1. Statement of mission 6. Organizational Structure 2. Statement of vision 7. Performance Measure Objectives 3. Objectives 8. Methodology for improvement 4. Organizational Values & Culture 9. Annual Review Plan 5. Leadership 10. Communication models © 2010 Jones and Bartlett Publishers

Continuous Quality Improvement (CQI) • A never-ending cycle • Concept that came out of business industry • Rather than creating a culture of blame if things do not go well, the focus is on a team approach to improvement that rewards the group when things get better © 2010 Jones and Bartlett Publishers

Benefits of CQI • A continuously learning organization • Strategically aligned improvement projects knowledge of key customers and suppliers at every level of the hospital • An integrated, customer-focused business plan for all organization functions • Improved satisfaction among patients, physician, employees and payers • Reduced expenses as a result of removing waste, needless complexity and rework • Assistance with meeting accreditation standards © 2010 Jones and Bartlett Publishers

Methods to Improve Quality • Department of Health and Human Services (HHS) – Quality Initiative – Hospital Compare • Clinical Practice Guidelines – Systematically developed statements used to assist provider and patient decisions about appropriate health care for specific clinical circumstances – Developed with the goal of standardizing clinical decision-making – Meant to be flexible and do not necessarily apply in every case • Clinical Protocols – Treatment recommendations often based on guidelines – The step-by-step description of an accepted procedure recommended by an authoritative body © 2010 Jones and Bartlett Publishers

Tools for Implementing Clinical Guidelines and Protocols • Critical paths – Display goals for patients and provide the corresponding ideal sequence and timing of staff actions to achieve those goals with optimal efficiency • Clinical pathways – Structured plans of care • Care maps – Multidisciplinary standards that outline the processes of care and expected outcomes within predetermined timeframes © 2010 Jones and Bartlett Publishers

Project Management (cont. ) • Initiation – Determine gap between organization performance an expected outcomes – Project Teams • • • Identify improvement opportunity Research and define performance expectations Implement process education Measure performance Document and communicate findings Analyze and compare internal and external data • Planning – Expected impact on organization – Design • Development of alternative solutions • Gantt charts – Project management tool used to schedule important activities – Charts divide a horizontal scale into days, weeks or months an vertical scale into project activities or tasks • PERT Charts © 2010 Jones and Bartlett Publishers

Project Management (cont. ) • Execution – Once plan is completed, execution begins – Installation of equipment or construction begins – Training – Measure performance • Closure – Evaluation and control © 2010 Jones and Bartlett Publishers

Role of HIM staff in QI • HIM management must establish a service delivery and expectation standard for each services and products provided • It is important that the HIM staff knows the timeliness of specific service or product its department has to offer © 2010 Jones and Bartlett Publishers

Role of HIM staff in QI (cont. ) • Participate in QI planning • Interpret data • Identify deviations from norm • Display data • Identify areas needing improvement • Present data • Provide chart / information • Collect data • Analyze data • Benchmark collected data • Implement required changes • Monitor and evaluate changes • Communicate • Update / revise / or create supportive policy © 2010 Jones and Bartlett Publishers

Services & Products offered by HIM • Chart retrieval • Filing • Coding • Chart maintenance • Abstracting • Record Imaging & Indexing • Chart analysis • Transcription • Release of information • Hard copy & electronic storage • Disclosure tracking • Research processing • Record processing • Loose sheet processing • Chart tracking © 2010 Jones and Bartlett Publishers

Some Internal Customers of HIM • Other HIM staff within HIM department • Social workers and social service staff • Receptionists • Patient advocates, volunteers • Physicians • Eligibility counselor • Laboratory technicians • Risk management staff • Nurses and other medical assistants • Utilization review staff • Business services • Quality assurance staff • Radiology technician • Business associates • Pharmacists and Pharmacy staff • Students and researchers • Janitorial staff • Office of patient financial service • Physical therapist, respiratory therapist • Billing office © 2010 Jones and Bartlett Publishers

Some External Customers of HIM • Patient • Vendor • Physician • Licensing agencies • Accreditation agencies • Law enforcement agencies with needs to know • Medical Examiners • Patient advocates • Patient’s identified personal representatives • Local, state and federal agencies with needs to know © 2010 Jones and Bartlett Publishers

Data Collection • Primary source of clinical data • Medical record • Secondary sources of clinical data • • • Insurance data Registry data Reimbursement data Census data Other data © 2010 Jones and Bartlett Publishers

Pareto Chart • Type of bar graph which displays categories of data in descending order of frequency or significance 16 120. 00% 14 100. 00% 12 80. 00% 10 Frequency 60. 00% 8 Cumulative 6 40. 00% 4 20. 00% 2 0 0. 00% Dislike Neutral Very Good Excellent © 2010 Jones and Bartlett Publishers

Idea Generating Techniques • Brainstorming – Used to generate ideas to encourage creativity and a free flow of ideas. Example of a brainstorming topic can be customer satisfaction form design • Nominal group technique – Comparable to brainstorming, the group members generate the ideas, however, after ideas are generated they are objectively ranked or rated in the order of priority © 2010 Jones and Bartlett Publishers

Data Organization • Cause and effect diagrams – Also called “fishbone diagram” – Utilized to separate root causes for an effect or problem • Check sheet – Indicates how often an event occurs. Check sheets Contribute to data for the creation of histograms, Run charts, etc… • Decision matrix – Grid design to rank ideas and proposals. It also allows for scoring of each alternative. It helps to prioritize objectives • Flow chart – Pictorial illustration of sequenced steps to complete a process © 2010 Jones and Bartlett Publishers

Utilization Management • Method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients • Embodied in a hospital quality program • Goal is to review the facility’s efficiency in the provision of services and resources in the most cost effective manner • Under-utilization and over-utilization of services, resources, and facilities are outcomes are prevented © 2010 Jones and Bartlett Publishers

Utilization Management (cont. ) • Public Law 92 -603 of 1972, established Professional Standards Review Organizations (PSROs) – Comprised of licensed physicians whose goal is to determine if services provided were medically necessary and cost effective • TEFRA(1982) replaced PSROs with PROs – Now known as Quality Improvement Organizations (QIOs), are responsible for each state, territory and District of Columbia – Non-governmental agencies empowered to evaluate performance relative to quality and appropriateness of service and can recommend punitive action to CMS © 2010 Jones and Bartlett Publishers

Centers for Medicare / Medicaid Services (CMS) • Formerly Health Care Financing Agency • Oversee Quality Improvement Organizations (QIOs) • Scope of Work – Clinical quality outcomes – Payment error prevention © 2010 Jones and Bartlett Publishers

Some Medical Services Requiring Utilization Monitoring • Inpatient confinement • • • Surgical and non-surgical confinements Skilled nursing facility Rehabilitation facility Inpatient hospice Maternity confinements • Reconstructive procedures and procedures that may be considered cosmetic • Selected durable medical equipment • Medical injectables • Surgical procedures © 2010 Jones and Bartlett Publishers

Some Medical Services Requiring Utilization Monitoring (cont. ) • Elective (non-emergent) transportation by ambulance or medical van and all transfers via air ambulance • All home health care services • Requests for in-network level of benefits for nonparticipating physicians and providers for nonemergent services • Dental implants and oral appliances © 2010 Jones and Bartlett Publishers

Some Medical Services Requiring Utilization Monitoring (cont. ) • Services that may be considered investigational or experimental special programs – Mental health, substance abuse or behavioral health services – Maternity management programs, including genetic testing, antenatal testing, prenatal consultations and counseling – Infertility Program – Pharmacy pre-certification for certain pharmaceuticals – Major organ transplant evaluations and transplants including but not limited to kidney, liver, heart, lung, and pancreas and bone marrow replacement or stem cell transfer after high-dose chemotherapy – Outpatient imaging pre-certification for CTs, MRI/MRA, nuclear cardiology, PET scans © 2010 Jones and Bartlett Publishers

Case Management • Coordination, development and provision of patient care plans for the patients with complicated cases. The goal is to provide patient care plan in a cost effective manner to patients with complicated cases © 2010 Jones and Bartlett Publishers

Peer review • Crucial component of Medicare reimbursement process • Individual hospitals submit claims for payment of covered services to fiscal intermediary by way of a standardized billing form © 2010 Jones and Bartlett Publishers

Peer review (cont. ) • For Medicare claims, fiscal intermediary transmits duplicate of all claims for a review period to PRO to determine – Whether services are reasonable and medically necessary – Whether services could effectively be furnished on an outpatient basis as opposed to inpatient admission – Medical necessity, reasonableness and appropriate inpatient services – Inappropriate medical or other practices resulting in inappropriate admission or fraudulent billing for reimbursement – Validity of diagnostic and procedural information submitted to request reimbursement – Completeness and adequacy of care provided – Whether the quality of services meets professionally recognized standards of care © 2010 Jones and Bartlett Publishers

Goal of the Peer Review • For the PRO physician reviewer to identify three primary issues – Utilization concerns – Quality concerns – Diagnostic related group concerns © 2010 Jones and Bartlett Publishers

Utilization Review Process • Preadmission review (Prospective review) – Review prior to admission that determines if the procedure and reason for potential admission is appropriate and necessary – Consist of comparing patient’s medical condition with standard criteria that specify clinical indications for admission. • Criteria are Intensity of Service / Severity of Illness criteria (IS/ SI) • Admission review – Review at time of admission to determine medical necessity and appropriateness • Concurrent review – Review of medical necessity for tests and procedures ordered during an inpatient hospitalization © 2010 Jones and Bartlett Publishers

Utilization Review Process (cont. ) • Discharge review – Review at time of discharge that determines if the patients meet specific discharge screen criteria. It may involves arranging appropriate home health care services for the discharged patient • Retrospective review – Review conducted by the PRO for evaluation of quality issues, cost and outliers issues, and issues of utilization management and appropriateness of care. © 2010 Jones and Bartlett Publishers

Risk Management • The management of any event or situation that could potentially result in an injury to an individual or financial loss to the health care institution • Consists of policies, procedures and practices that reduce risk and liabilities for injuries that may occur © 2010 Jones and Bartlett Publishers

Risk Management Objectives • To create and maintain a safe, healthy environment and enhance quality care • To minimize risk of medical or accidental injuries and losses • Provide cost-effective techniques to insure against financial loss © 2010 Jones and Bartlett Publishers

Risk Management Program • Elements – Risk identification • Identifying areas of existing or potential loss. The incident report is the essential tool that is used in identifying risk. – Risk control • Prevention and control of risks and minimizing of occurrences for which the facility may be held liable – Risk Financing • Plan to financially cover losses. Types of funds to be considered include self insurance, insurance pools, and commercial insurance © 2010 Jones and Bartlett Publishers

Risk Management Program (cont. ) • Methodology – Occurrence screening • Adverse patient occurrences • Potential compensable events – Incident report • Reportable incidents are written and investigated • Root cause analysis is done to determine underlying factors of a sentinel event – Patient advocacy © 2010 Jones and Bartlett Publishers

Risk Management Program (cont. ) • Use of Risk Management information – Improve system processes – Increase patient and employee satisfaction – Improve clinical outcomes – Decrease risk factors © 2010 Jones and Bartlett Publishers

Reportable Adverse Events • Unauthorized Medication • Omission • I. V. Infiltration • Wrong dose • Wrong Patient • Wrong Medication • Wrong Site • Wrong Route • Wrong dosage • Wrong Time • Wrong Technique • Wrong Drug Preparation • Wrong Rate • Drug Interaction • Drug allergy • Food & Drug Interaction • Deteriorated Drug © 2010 Jones and Bartlett Publishers

Other Types of Reportable Events Patient abuse Patient neglect Medically unstable at discharge Returning to intensive care unit within 24 hours of being transferred out • Unplanned return to surgery for same condition • Patient Fall • • © 2010 Jones and Bartlett Publishers

Other Types of Reportable Events (cont. ) • • Missed diagnosis Delayed diagnosis Blood transfusion error Complication with anesthesia Unanticipated death Suicide / Unsuccessful Suicide Attempt Prenatal death Inappropriate use of restraints © 2010 Jones and Bartlett Publishers

Other Types of Reportable Events (cont. ) • Operative injury or complications • Unexpected admission, readmission, or return to Emergency Center following inpatient or outpatient care for same condition • Equipment failure • Infant abduction • Blood Transfusion reaction • Unauthorized inpatient departure • Patient injury while in restraints © 2010 Jones and Bartlett Publishers

Sentinel Events • Surgery on wrong body part • Unanticipated death • Infant abduction • Suicide • Permanent loss of major function associated with medication or surgical error © 2010 Jones and Bartlett Publishers

Credentialing • The reviewing, verifying, validating, and evaluating of key factors that determines an individual practitioner’s ability to carry out certain patient care activities and granting of professional privileges • TJC states, “authorization granted by the governing board to a practitioner to provide specific patient care services in the hospital within defined limits, based on an individual practitioner’s license, education, training, experience, competence, health status, and judgment” © 2010 Jones and Bartlett Publishers

Credentialing • Crucial role in maintaining high quality professional care to the patients • Hospital has obligation to carefully select its staff and to grant them privileges as appropriate to ensure the staff highly educated, trained, experienced, qualified and competent to deliver needed services © 2010 Jones and Bartlett Publishers

Purpose of Credentialing • Ensure medical staff members only perform procedures and services they are qualified and competent to perform through training and experience • Key aspects • • Initial appointments to the medical staff Initial delineation and granting of clinical privileges Periodic reappointment to the medical staff Periodic renewal or revision of clinical privileges © 2010 Jones and Bartlett Publishers

Medical Staff Functions • Adopts medical staff by-laws • Provides patient care and carry out other professional responsibilities • Actively participate and exercise professional leadership in measuring, assessing, and improving the performance of the organizations within which they practice © 2010 Jones and Bartlett Publishers

Medical Staff Functions (cont. ) • Continually improve the quality of healthcare services delivered • Provides patient care within their professional competence • Provides patient care as reflected in the scope of their clinical privileges • Participating in ongoing measurement, assessment, and improvement of both clinical and non-clinical processes © 2010 Jones and Bartlett Publishers

Characteristics of Medical Staff • Clinical privileges subject to medical staff and departmental bylaws, rules and regulations, and policies and subject to review as part of the organization's performance improvement activities • Fully licensed staff • Staff permitted by law and by the hospital to provide patient care services independently in the hospital © 2010 Jones and Bartlett Publishers

Characteristics of Medical Staff (cont. ) • Delineated clinical privileges that define the scope of patient care services they may provide independently in the hospital © 2010 Jones and Bartlett Publishers

Medical Staff Record Maintenance • A separate record is maintained for each individual requesting medical staff membership or clinical privileges • Complete applications are acted on within a reasonable period of time, as specified in the medical staff bylaws • Each file is consistent with applicant’s consents for inspection of records and documents pertinent to his or her licensure, specific training, experience, current competence, and ability to perform the privileges requested, and, if requested, appears for an interview © 2010 Jones and Bartlett Publishers

Medical Staff Record Maintenance (cont. ) • Each file is consistent with applicant’s consents for inspection of records and documents pertinent to his or her licensure, specific training, experience, current competence, and ability to perform the privileges requested, and, if requested, appears for an interview • Applicant pledges to provide for continuous care for his or her patients © 2010 Jones and Bartlett Publishers

Medical Staff Record Maintenance (cont. ) • Bylaws, rules and regulations, and policies of the medical staff indicate applicant for reappointment or renewal of clinical privileges is required to submit any reasonable evidence of current ability to perform privileges that may be requested • Signed acknowledgement for release and immunity from civil liability © 2010 Jones and Bartlett Publishers

Purpose of Clinical Privileges • Delineates the types of procedures that can be performed by each provider of care • Delineates the types of care and treatment that can be carried out by each provider of care • Delineates the types of patients the health care provider will be allowed to have access to © 2010 Jones and Bartlett Publishers

Credentialing Application Process • The medical staff bylaws and the medical staff rules and regulations delineate what needs to be collected and reviewed during the credentialing phase. It also delineates the processes and responsibilities for approval and denial of medical staff clinical privileges and membership © 2010 Jones and Bartlett Publishers

Categories of Applicants • Type One – Physicians – Dentist – Podiatrist • Type Two – Physician Assistant – Advanced Nurse Practitioner – Allied health providers – All other licensed and certified staff © 2010 Jones and Bartlett Publishers

Application Information • Applicant’s demographic and identifying information • Education • State Licensure Number • State Licensure Expiration Date • Previous Employer • Prior Malpractice Claims • Denial of Medical Privileges with other institutions • Narcotics number • Third Party Payment Program Involvements • Name of References / letter • Acknowledgement of Medicare / Medicaid fraud • Revocation of Medical Privileges with other Institution • Suspension of Medical Privileges with other Institution • Voluntary relinquishment of licensure • Involuntary relinquishment of licensure © 2010 Jones and Bartlett Publishers

Credentialing Department Chair • Responsible for coordinating, reviewing, evaluating, and validating timeliness and appropriateness of submitted application • With satisfactory application, the Departmental Chair request for privilege verification • Maintains documentation • Forwards the application and the request for clinical privileges to Credentialing Committee for further review © 2010 Jones and Bartlett Publishers

Credentialing Committee • Functions in advisory capacity and is not empowered to make appointment • Peer review of applicant is conducted • Makes recommendation for appointment and privileges to executive committee – Executive committee makes recommendation to governing board – Governing board approves or denies membership © 2010 Jones and Bartlett Publishers

Re-appointment • Practitioner profile – Mechanism to integrate information compiled from quality management activities into credentialing process to determine reappointment – Re-appointment criteria may be different from initial appoint criteria © 2010 Jones and Bartlett Publishers

Continued Education • All individuals with clinical privileges participate in an ongoing continuing education activities related to their granted privilege • Continued education must be documented and must be made available and become a part of indicator for qualifying for reappointment or renewal or revision of individual clinical privileges • The educational activities must be related to the type of care performed by the particular medical staff and in part, care offered by the hospital • Continued education must be considered in re-appointment, revision or renewal of medical staff clinical privileges © 2010 Jones and Bartlett Publishers

Example Data Collection Tool For Credentialing Application ITEMS YES NO COMMENT Application is completed Requested privileges specified Attestation to correctness and completeness of information submitted Authorization to request, disclose and or share information is signed Special consent was signed as needed Names of three professional recommendations was submitted © 2010 Jones and Bartlett Publishers

Example Status Check Sheet Credentialing ITEMS RECEIVED PENDING SENT CONTACT DATE PERSON DATE Proof of professional liability verification Three professional recommendations Verification of past and or pending professional disciplinary actions Verification of voluntary and involuntary limitations, loss of clinical privileges, or reduction of privileges Confirmation from National Practitioner Data Bank (NPDB) Confirmation from American Medical Association (AMA) Confirmation from Drug Enforcement Agency (DEA) Verification of educational background © 2010 Jones and Bartlett Publishers