Overview of the main regulatory bodies Who they are? What they do? - PDF document

Debra R. Gre bra R. Green, MPA, CPMSM, CP , MPA, CPMSM, CPCS CS Di Dire rect ctor, Me , Medica cal Sta Staff S ff Servi rvices a and Ge d Genera ral P Pedi diatri ric R c Residenc ncy Prog rogram St Stanf anford Univ Univer ersit sity Medic Medical C l Cent nter er • St Stanf anford H Hosp spit ital & al & Clin Clinic ics • Luci Lucile le P Packa ckard C d Chil ildr dren’s H Hospi spital Director of Medical Staff Services and Pediatric Residency • Program for Stanford University Medical Center which includes Stanford Hospital and Clinics and Lucile Packard Children’s hospital in Palo Alto, CA. Oversight of a combined medical staff of approximately 2000 • physicians, 300+ Advanced Practice Professionals and 78 General Pediatric Residents. CPMSM and CPCS in addition to a Masters of Public • Administration(MPA) degree with a concentration in Health Care Management and Policy 20+ years of healthcare administrative experience; primarily • academic. Held previous leadership positions in New Jersey and Michigan. • Served as an Expert Witness in negligent credentialing and • privileging legal cases NAMSS Director at Large on the NAMSS Board for 5 consecutive • years. � Overview of the main regulatory bodies ◦ Who they are? ◦ What they do? ◦ Why they exist? � Overview of Credentialing/Privileging Standards ◦ Requirements ◦ Compliance

� 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 � Who are they? ◦ Private Organization � What do they do? - Unannounced Surveys � - Tracer Methodology � - Can Survey “For Cause” � � Why do they exist? ◦ To ensure patient care and quality � Healthcare Facilities � Det Norske Veritas Accreditation Program Healthcare, Inc (DNV) (HFAP) ◦ Deemed status since 9/08 ◦ Deemed Authority since 1965 ◦ Certifies other companies in additional to healthcare ◦ Surveyors are experienced healthcare ◦ Existed since 1864 professionals (began in Norway) in US since 1898 ◦ Recognized by Fed Gov, State DOH, Ins Carriers ◦ World wide reputation for and Managed Care quality and integrity Organizations (MCO) ◦ Surveys are unannounced

� 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 or Health Plan � Who are they? ◦ Private Organization, non-profit � What do they do? - Accredit Ambulatory Healthcare � Organizations, Surgery Centers, Community Health Centers and Medical/Dental Group Practices - US Air Force and Coast Guard � � Why do they exist? ◦ To promote patient safety, quality and value for Ambulatory health care � Who are they? ◦ Private Organization, non-profit � What do they do? - Accredit Health Plans and Preferred � Provider Organizations (PPO) � Why do they exist? ◦ To promote healthcare quality through accreditation education and measurement programs

URAC/AAAHC TJC NCQA HFAP DNV/CMS (I) Primary (I) Primary source (I) Primary Source URAC – (I) PSV DNV (I) Primary Source verification verification of Verification of required Source from Medical (Highest Level of Medical Education Verification of School Credentials) History of Medical Education Must be significant education and to support request training Requirements for privileges included on must be outlined in app Bylaws Alternate sources: Alternate sources: AMA, AOA, AMA, AOA, Alternate sources: Can use the state CMS – Not ECFMG ECFMG (for AMA, AOA, lic Board as a specially addressed foreign grads after ECFMG (after PSV in standards AAPA for PA’s 1986), state 1986), state (doesn’t mean its licensing agency (if licensing agency not required) the state performs AAAHC – (I) PSV PSV) required FCVS for closed residency No alternative programs sources noted. URAC/AAAHC TJC NCQA HFAP DNV (I) PSV required (I) PSV Highest (I) PSV of URAC – (I) PSV DNV - Bylaws required only from primary level of Training include criteria if not board source or credentials (i.e. required for determining certified equivalent board privileges source certification) Documentation including, History of must support specific training Education requested Required on requirements app Privileges Alternate CMS – Not sources: Can use the state specifically AMA, AOA, lic board as a addressed in PSV state licensing Alternate standards agency, Sources: (doesn’t mean transcripts Alternate AMA, AOA, its not required) AAAHC – (I) PSV (sealed), FCVS sources: required for closed AMA, AOA programs No alternative sources noted. TJC NCQA HFAP URAC/AAAHC DNV and CMS (I) Required (I&R) Peer Review (I) Obtain at least URAC – No specific DNV- 2 Peer (R) Required if there through Credentials 1 peer with the requirement recommendations at is insufficient Committee with same professional (I). Nothing in the practitioner- representation from Credential standards assess Peer specific data similar types and References at (R) available degrees of expertise Assessment of CMS – Not specially Peer with knowledge physical and mental AAAHC – (I &R) addressed of applicant health in relation to Peer recommendation privileges requested. required Recommendations should address (R) Individual letters clinical not required, can be competence and obtained through ability to PR, Cred Com, perform Dept Chair or MEC privileges 6 General Competencies

� How many organizations perform Work/Affiliation History Verifications? URAC/AAAHC TJC NCQA HFAP DNV/CMS There is no specific (I) PSV not (I) PSV Required URAC – Not DNV – Not requirement for required. addressed in addressed in verification of Verification of standards standards. work history. The A minimum of five where the standards require, years of applicant CMS – Not at the time of relevant work previously had addressed in appointment to history must privileges with standards membership and be obtained confirmation of the initial granting of through the applicant’s AAAHC – (I) privileges, practitioner’s appointment and Reviewed for verification of application or privilege history, continuity and relevant training curriculum and any pending relevance. or experience must vitae. investigations of be obtained from disciplinary Document the primary source Gaps exceeding six actions, voluntary interruptions (s) whenever months must resignations, or in practice feasible. be reviewed relinquishments of and clarified membership/clinic either al privileges verbally or in writing. TJC NCQA HFAP URAC/AAAHC DNV/CMS Clearly No requirement Must be consistent URAC – Privileges DNV documented for privileges with demonstrated must be Criteria Based process for competency included in granting the Practice within Criteria based application scope Evidence of Surgical privileges AAAHC – CMS Physical Ability to must be delineated Criteria based All patients must perform requested based on be under the privileges individual Reviewed and care of a competency approved by practitioner Grant or Deny the governing with privileges must be objective body and evidence based Privileges can only be granted by the hospitals Must be criteria governing based body Assess ability to perform