Transcript Healthcare Facilities Accreditation Program (HFAP)

Healthcare
Facilities
Accreditation
Program (HFAP)
2007 Medical Staff
Credentialing
Standards
George A. Reuther
Director, HFAP
312-202-8060
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The HFAP
Accreditation History




HFAP first began in 1945
Accrediting Hospitals and Other Health Care
Facilities for over 60 years
Accrediting Hospitals Under Medicare for Over 40
years
Recognized by Managed Care Organizations and
Insurance Companies
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Current Areas of
Accreditation

Hospitals

Clinical Laboratories

Ambulatory Care / Surgical Facilities

Mental Health & Substance Abuse Facilities

Physical Rehabilitation Facilities

Critical Access Hospitals
3
Government Recognition
Deeming Authority from the Centers
for Medicare and Medicaid Services
(CMS):
 Medicare
Conditions of Participation for
Hospitals, CAHs, and ASCs.
 Clinical
Laboratory Improvement
Amendments (CLIA)
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Accreditation Survey
Related Activities


Hospitals – Three (3) day survey
Three (3) member Survey Team
reviews hospital compliance with HFAP
accreditation requirements
– Physician, RN, and Administrator
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Patient Safety
Initiatives
National Quality Forum (NQF)
30 Safe Practices (2003)
HFAP adopted 28 of the 30
Safe Practices
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National Quality Forum
30 Safe Practices (2003)
For example:
 #14 Operative Site Verification


#18 Anti-Thrombotic Therapy
#20 Prevent Central Venous Catheter
Infections

#21 Surgical Site Infections (SSI)
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#22 Contrast Media
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“The Organized Medical Staff”
The hospital must have an organized
medical staff that operates under bylaws
approved by the governing body and is
responsible for the quality of medical care
provided to patients by the hospital. 482.22
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Credentialing and
Privileging Process


HFAP standards for credentialing and
privileging provide for the periodic
appraisals by the facility’s medical staff of its
members.
The appraisal is to determine the suitability
of individual members and all other
credentialed providers for
membership/continued membership on the
medical staff, or
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Credentialing and
Privileging Process (cont’d)


credentialing / re-credentialing (for nonmember credentialed providers), and to
determine if an individual practitioner’s
clinical privileges should be approved,
continued, discontinued, revised or
otherwise changed. (HFAP hospital
03.00.04)
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Credentialing and
Privileging Process (cont’d)

The standards describe the responsibilities
of credentialed professionals to the facility in
which they work, to the patients which they
treat, and to the Governing Body of the
facility. (HFAP hospital 03.00.05, 03.00.06,
and 03.00.07)
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Medical Staff Membership

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The standards identify the selection criteria
for membership on the medical staff.
These criteria must include: licensure,
training / education, current competence,
health status, experience, character, and
judgment. (HFAP hospital 03.01.13)
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Required Application
Information


The standards identify the required
application/reapplication information to be
provided for review.
This information includes:
1. licensure history,
2. medical education and post
graduate training,
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Required Application
Information (cont’d)
3. malpractice insurance and history,
4. specialty board status,
5. sanctions or disciplinary actions,
6. criminal history,
7. healthcare employment history,
8. professional references, and
9. clinical activity.
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Required Application
Information (cont’d)
10. All information provided by the
applicant/re-applicant is to be
compared against verified
information.
(HFAP hospital 03.01.15)
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Quality Assessment and
Performance Improvement

The facility’s quality assessment and
performance improvement (QAPI) function
involve:
A. clinical assessments by Medical
Staff and other providers for all
service types of patients,
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QAPI (cont’d)

B. diagnostic procedures – including
invasive and non-invasive
procedures from clinical laboratory,
imaging, cardiorespiratory, physical
or behavioral medicine, etc., for
patients of all service types; and
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QAPI (cont’d)
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C. therapeutic interventions –
including those processes and
outcomes as appropriate to Medical
Staff functions.
(HFAP hospital 03.02.03)
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QAPI Information Used in
Review of Candidates

Information derived from the facility’s QAPI
functions is used in the review of candidates
for appointment and privileging and
addresses:
1. medication therapy,
2. infection control,
3. surgical / invasive and manipulative
procedures,
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QAPI Information Used in
Review of Candidates (cont’d)

4. blood product usage,
5. data management (with emphasis
on medical record pertinence and
timeliness),
6. discharge planning,
7. utilization management,
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QAPI Information Used in
Review of Candidates (cont’d)

8. complaints from patients and
families or from hospital staff,
9. restraint / seclusion usage, and
10. mortality review.
(HFAP hospital 03.02.02)
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Medical Staff Accountability
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
The Medical Staff is accountable to the
Governing Body for the quality of medical
care provided to patients by all credentialed
practitioners and for
aggregating their QAPI finding from the
departments, services, committees or other
structural components to:
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Medical Staff Accountability
(cont’d)

A. develop plans for continuing the
education of its members and all
credentialed staff;
B. provide annual evaluations of
improvements in the clinical care
provided;
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Medical Staff Accountability
(cont’d)

C. utilize as information in the
process of evaluating Medical Staff
for all membership categories including
associate (provisional), active,
consulting, and hospital-based
membership categories;
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Medical Staff Accountability
(cont’d)

D. utilize as information in the process
of evaluating and acting upon
reappointment and reprivileging
requests from its members and all
other credentialed staff; and
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Medical Staff Accountability
(cont’d)

E. utilize as information in an
ongoing process of evaluating
the members of the medical
staff. (HFAP hospital 03.02.04)
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03.00.04 Demonstrated
Competencies
To include:
1. Current work / practice
2. Special training
3. Quality of specific work
4. Patient outcomes
5. Education
6. Maintenance of CME (continued)
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03.00.04 Demonstrated
Competencies (cont’d)
7.
8.
9.
10.
Adherence to Medical Staff guidelines
Certifications
Appropriate licensure
Currency of compliance with
licensure requirements to perform
each task, activity, privilege
requested for the category of
practitioner.
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03.00.04
If the practitioner is not competent
to perform one or more task/ activity/
privilege…
…the list of privileges is modified for
that practitioner.
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03.01.04 Bylaws –
Categories of Medical Staff


Include a statement of the duties,
responsibilities, and privileges for each
category of medical staff.
Categories must include all
practitioners who provide a “medicalrelated” level of care, such as…
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03.01.04 Bylaws –
Categories of Medical Staff



Physicians
Dentists
Allied Health Practitioners, e.g.,
– RN First Assistants,
– Surgical Assistants,
– Anesthesia Assistants,
– CRNAs,
– Midwives
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03.01.15 Re-application
H.
References – Re-applicants

Must have Clinical Competence Review

Must have peer review reports, e.g.,
 Clinical peer review,
 Medical record review,
 Credentials Committee/Function , and / or
 Medical Executive Committee review
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03.01.15 Re-application
I.
Clinical Activity – Application & Re-applications

Must have QAPI clinical / objective data with
signature of department chairperson



# Cardiac Stents
# Complications
Must have recommendation from department in
which privileges are sought
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03.01.15 Re-application
I.
Clinical Activity – Re-applicants
Examples of QAPI clinical / objective data

Timeliness of H&P
Content of Discharge Summary
# Patient Complaints
# Surgical Complications
# Re-intubations




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03.01.17 Emergency Privileges
Medical Staff Bylaws provide granting of
emergency privileges.

Within scope of license

For life saving procedures

During times that a staff member who is a
credentialed practitioner with appropriate
privileges is not available.
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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
Disaster – Clinical Volunteers:
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
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A plan is in place for clinical volunteers
The plan provides for primary source
identification from the volunteer’s hospital, e.g., a
documented telephone call
Volunteers function within their scope of license /
certification
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Chapter 2 – Allied Health
Professionals
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
Professionals
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
Professionals
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 Professionals Employed by Hospital
02.00.02 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 Credentialing
Organizations (PCO)
Definition:

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“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 Credentialing
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 Credentialing
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 Participation
Final Rules (2006)
Final Rule –
November 27, 2006:
– H & P within 30
days / 24 hours of
admission (before
surgery)
Final Rule –
December 8, 2006:
– Restraint or
Seclusion
– Verbal Orders:
Authenticate and
time order within 48
hours
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The Healthcare Facilities
Accreditation Program (HFAP)
George A. Reuther,
Director
142 East Ontario Street
Chicago, IL 60611-2864
312-202-8060
[email protected]
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