Template Presentation: - PowerPoint Presentation

Slide1

Template Presentation: Your Department Name Overview

Reporting Structure and Staffing

Interactions with Your Organizations Name At large

Scope of Services

Credential / Privileging Primer

Your Departments Structure

and Staffing

VP / CMO

Director, Medical Staff Services

CPCS /CPMSM

Medical Staff President

CMO/SVP Medical Affairs

Credentials/Privileging2.3 FTEs*2 CPCS staff

Enrollment2.4 FTEs

Information Specialist2.0 FTEs1 CPCS staff

Medical Education

.5 FTE

Always remember to note who is certified!

Your Department’s Organizational Interactions

Pharmacy

HIM (Outpatient Record Systems)

Clinical Care Areas

Nursing

Radiology

O.R.

Lab Services

Human Resources

Employed Credentialing

Payroll system

Education Systems

Marketing

Organization Website

Physician Finder

Physician Events

Provider Systems

Hospital System

Performance

Improvement

Occ Health

HIS

HIM systems

Billing Systems

Finances

Employed Practices

Practice Database

Legal / Risk Management

Medical Staff Services

Comment on certification knowledge needed in these areas

Your Department’s Functional Services

Medical Staff Services

Credentialing

Privileging

Enrollment

Medical Education

Information Services

Other

Department Scope of Services: Credentialing

/ Privileging

Credential / Privilege medical and allied health staff

# medical staff members, # allied health members

Avg. # new applicants/year; # reappointments/year Credential for Enrollment medical and allied health staff# medical staff members, # allied health members

# new applicants/year; # reappointments/yearCredential for PHO / PO membership

# members# new applicants/year; # reappointments/yearSelf-Insured Entities Professional Liability Enrollment

# members

Department Scope of Services:

Medical

Education

Describe the accreditations program and education programs offered, including volume

Comment on certification exam and related medical education questions

Discuss the relationship between ongoing competency, medical education and maintenance of board certification.

Department Scope of Services: Information Services

Manage Focused Professional Practice Evaluation Process

Create and Maintain the Ongoing Professional Practice Reports

Department and Specialty Specific OPPE reportsMedical Staff E-Learning CoordinationMandatory learning activitiesMSO System Maintenance

Report creation and distributionExpirable Process MaintenanceWeb crawlers, internet grabber creation and maintenanceApplication and Forms creation

Intranet Page

Department Scope of Services: Other

Medical / Allied Health Staff Orientation Program Management

Medical Staff Meeting Management

MEC, Medical Staff, Credentials Committee, Professional Conduct Committee, Medical Education Committee, Department / Specialty Meetings

Medical Staff Bylaws and Policies ManagementMedical Staff Leadership Support

Nominating Committee activities, Medical Staff Treasury supportMedical Staff Event Management

Relate knowledge needed in these areas to your certification

Key Activity: Ensure Regulatory & Accreditation Compliance

The Joint Commission (TJC) / Centers Medicare & Medicaid Services (CMS)

Medical Staff Standards Chapter

Leadership Chapter

National Committee for Quality Assurance (NCQA)Health Plan Accreditation Standards ACCME – Medical Education Accreditation

Board of Registration in Medicine Credentialing regulations, Reporting regulations, License Physicians and Acupuncturists

Department of Public Health (DPH) / State Licensing Authority

Division of Professional LicensureLicense APN, PA, Podiatrists, Dentists, RPA, Psychologists

Governing Body Responsibility

The Joint Commission:

Standard MS.01.06.07 EP 8

“The governing body or delegated governing body committee has final authority for granting, renewing, or denying privileges.”

CMS: Requirement 482.12 “There must be an effective governing body that is legally responsible for the conduct of the hospital.” 482.12 (a)(2) “The governing body must appoint members of the medical staff after considering the recommendations of the existing members of the medical staff.”

Your States Rules and Regulations for Advance Practice Nurses / Physician Assistants

Showcase your accreditation knowledge to Leadership

Credentialing Checklist

Verify Practitioner - Notarized government issued identification, candidates interviewed, Criminal background status, OIG status

Review Application / Privilege Request

Verify Education, Residency, Fellowship, “primary source” schooling, training programs

Confirm Board Certification StatusVerify MA license, CSR, DEA

Verify Professional Liability Coverage - Claims history NPDB query

Confirm Work History Obtain and Verify References (including Program Director, Dept. Chair)

Red Flags

Obvious

Loss of licensure or narcotics registration

Multiple liability judgments or settlements, NPDB alerts“yes” answer on application for membership or licensureNegative response from references

Disciplinary Actions reportedSubtle> 4 years in medical school with single degreeUnexplained gap in work history or trainingNumerous moves (>3 in 5 years)Paperwork delays, numerous requests for references

Information on application/CV differs from responsesUrgency on the part of employer

Privileging Checklist

Privilege form complete & accurate

Appropriate professional liability coverage for request

Privileges appropriate for the specialty

Confirm documentation to support eligibility Training documentation

Certificates References

Review Recent Privileging Cases

Malpractice Claims At Alamogordo Hospital Settled (2008)

About 80 malpractice claims that forced an Alamogordo hospital to seek bankruptcy court protection last summer have been settled for more than $33 million

Dr. Christian Schlicht

, an anesthesiologist and pain management specialist, is accused of using fraudulent credentials to operate on patients even though he wasn’t a surgeon and injected the cement into patients’ spines in a procedure that turned out to be neither safe nor effective.Schlicht had told him in late 2008 that some of Schlicht’s neurosurgery training was falsifiedWilliam Hamman, a Pilot, passed himself off as a NY Cardiologist (2010)

Hamman is a licensed pilot who worked for United Airlines until the airline grounded him when his lies came to light. In addition to the real credentials he possessed, he also had ones he made up, including M.D. and Ph.D. degrees, as well as 15 years of clinical experience as a cardiologist. In reality, he did attend medical school for a few years, but never graduated.

"We need to be vigilant that the credentials of physicians are real, current and that the doctor is board certified and participating in their board's lifelong learning program," said Dr. Richard J. Shemin, chief of the Division of Cardiothoracic Surgery

at the Ronald Reagan UCLA Medical Center in Los Angeles.

15

What is Negligent Credentialing?

(Topics you need to be aware of for certification)

A widely adopted civil tort theory of liability.

A type of corporate negligence.

The failure to perform “diligent inquiry” into a practitioner’s credentials to ensure that only qualified and competent professionals are selected and retained to treat patients.

Inquiry performed at the time of Medical Staff appointment, reappointment, and privileging.

Includes the on-going requirement to supervise, monitor, and continuously reassess the practitioner’s performance.

What is the Basis of Liability?

The entities and persons who credential and privilege practitioners owe a duty of care to patients to exercise reasonable care in the selection, retention, supervision, monitoring and assessment of the practitioners who treat them.

When that duty is breached and the patient is injured by an incompetent or unqualified practitioner, the patient has the right to sue those entities and persons who were responsible for the proper credentialing and privileging of that practitioner.

What “Diligent Inquiry” Is Expected?

Obvious sources:

Extent of practitioner’s training and experience in performing procedures; malpractice case payments from the National Practitioner Databank (NPDB); results of disciplinary investigations and actions by Boards of Registration; prior practice and employment references.

Less obvious sources:

history of 3 + malpractice cases (regardless of results); number and results of peer review cases; Ongoing Professional Practice Evaluations (OPPE); Focused Professional Practice Evaluations (FPPE); patient safety event reports; complaints by nurses of substandard care; patient complaints; professional conduct events.

Negligent Credentialing Case Law: Examples

Darling v. Charleston Community Memorial Hospital (Illinois, 1965):

First case. Hospital liable ($110K) to teenage athlete who suffered permanent injury because the Hospital granted surgical privileges to a general family practitioner who negligently set the patient’s broken leg.

Johnson v.

Misericordia (Wisconsin, 1980): Hospital liable for damages to patient who suffered permanent paralysis when his femoral nerves/artery were damaged during a procedure by an orthopedic surgeon who failed to disclose pending malpractice cases and was untruthful about prior hospital privileging. Frigo v. Silver Cross Hospital (Illinois, 2007): Hospital liable (~$8 million) to patient who suffered an amputated foot where the podiatrist, who did not have the advanced training required for surgical privileges, negligently performed a

bunionectomy. Kadlec Medical Center v. Lakeview Medical Center, Anesthesia Assoc. (Louisiana, 2008): Hospital found partially liable (~$8 million) to patient who suffered extensive brain damage during tubal ligation where Hospital credentialed locum anesthesiologist fired by his prior Hospital/practice group (excellent references provided) for diverting and ingesting

demerol while working.