and DNV GL HCs National Integrated Accreditation for Healthcare Organizations NIAHO MS Standards Kathy Matzka CPMSM CPCS 2 History TJC NIAHO 1952 began Unique statutory ID: 659239
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Comparison of The Joint Commission and DNV- GL HC’s National Integrated Accreditation for Healthcare Organizations (NIAHO℠) MS Standards
Kathy Matzka, CPMSM, CPCSSlide2
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History TJC NIAHO
1952 began
Unique statutory
hospital deeming authority 1965 Medicare statuteJuly 15, 2008, the Medicare Improvements for Patients and Providers Act of 2008 became law 11/09 – CMS approval 4,546 Hospital and CAH in 20114,429 Hospital and CAH in 2013 (90% of accredited hospitals)4,032 Hospital and CAH in 2016 (88% of accredited hospitals)
12/19/07 Application to CMS
09/08 CMS approval
94 Hospital and CAH on 7/14/10
393 Hospital and CAH on 4/17/2016Slide3
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ProcessTJC NIAHO
Three year survey
Standards directly related to the CMS as well as self-defined
Annual Survey
Most MS standards directly related to the CMSISO 9001 quality managementSlide4
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Scoring ProcessTJC NIAHO
Three-point scale:
0 = insufficient compliance
1 = partial compliance
2 = satisfactory compliance IconsDocumentation requiredSituational decision rules applyDirect impact requirements applyCategory A requirementCategory C requirement (based on # of times does not meet standard)Measurement of Success needed
Standards Scored as
Meets requirements
Nonconformity Category I Conditional level – Egregious non-compliance
Nonconformity Category I -Noncompliant
Nonconformity Category II – Occasional or isolated lapse in compliance
Immediate Jeopardy - Immediate threat to patient safety
No aggregate scoringSlide5
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Appointment Timeframe TJC NIAHO
Two years
Three years if state law does not addressSlide6
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Continuing Medical Education TJC NIAHO
LIPs and other practitioners privileged through the medical staff process must participate in CE
Participation must be documented and considered in decisions about reappointment, renewal, or revision of individual clinical privileges
All with privileges participate in CE that is at least in part related to their clinical privileges
CME considered in decisions about reappointment or renewal or revision of clinical privileges
Action on an individual’s application for appointment /reappointment or initial or subsequent clinical privileges is withheld until the information is available and verifiedSlide7
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Current CompetenceTJC NIAHO
The hospital verifies in writing and from the primary source, whenever feasible, or from a CVO, information concerning the current competence
Evaluate data from other organizations where the applicant currently has privileges, if available
Initial - MS qualifications include verification of current competence
Reap - Review of individual
performance
data for variation from
benchmark Variations to peer review for
determination of validity, written explanation of findings and, if appropriate, an action plan
to include
improvement strategiesSlide8
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Malpractice HistoryTJC NIAHO
MS evaluates involvement in a professional liability action, including final judgments and settlements involving a practitioner
Must evaluate any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant
Review of involvement in any professional liability action at initial and reappointment Slide9
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Peer RecommendationsTJC NIAHO
Required at initial, reap, consideration of termination, or revision/revocation of clinical privileges
Address the relevant training and experience, current competence, and any effects of health status on privileges being requested
Include evaluation of the applicant’s medical knowledge, technical and clinical skills, clinical judgment, communication skills, interpersonal skills, and professionalism
Obtained from a practitioner in the same professional discipline as the applicant with personal knowledge of the applicant’s ability to practiceList of appropriate sources
Two peer
recommenda-tions
required at initial appointmentSlide10
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Clinical PrivilegesTJC NIAHO
PSV for current licensure or certification
PSV of relevant training
Evidence of physical ability to perform the requested privilege
If available, data from professional practice review from other organization where the applicant currently has privilegesRecommendations from peers/facultyOn renewal, review of the applicant’s performance within the hospital
All
permitted
by the organization and by law to provide patient care services
independently have
delineated clinical privileges
If
available and/or required by the
MS, a
review
of individual
performance data variation from criteria determined by the medical staff to identify need for
training or
proctoring that may be requiredSlide11
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TelemedicineTJC NIAHO
3 choices
The originating site can fully privilege and credential the practitioner according to MS standards or
Use credentialing information from the distant site if the distant site is a Joint Commission-accredited organization or
Use credentialing and privileging decision from the Joint Commission-accredited distant siteMedical staff at both sites make recommendation for services to be provided via telemedicineFor non-deeming, can be via contract only if TJC accredited entity
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choices
The originating site can fully privilege and credential the practitioner according to
MS standards
or
Use credentialing and privileging decision
from telemedicine entity or distant
site
Medicare participating hospital
When
services
provided
by a contracted entity,
GB must
identify
criteria
for selection and procurement of
services
and
how to evaluate
the
entitySlide12
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Temporary PrivilegesTJC NIAHO
120 days for new applicant with complete file awaiting MEC approval
Time as specified in bylaws for patient care need
On recommendation of MS President or designee
No successful challenges to licensure or registration; involuntary termination of MS appointment; involuntary limitation, reduction, denial, or loss of clinical privileges
Not exceed 120 days
Locum
tenens
not
to exceed
6 months
On r
ecommendation
of a
MEC member, MS president or
medical director (as defined
by MS
U
rgent
patient care need
Complete application w/o negative
or
adverse information
before action by the medical staff or governing bodySlide13
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Temporary PrivilegesTJC NIAHO
Patient care need verify
Current licensure
Current competence
New Applicant verifyCurrent licensure Relevant training or experience Current competence
Ability to perform the privileges requested
Other criteria required by medical staff bylaws
NPDB
In all cases verify
education
(AMA/AOA
Profile OK
current competence
primary verification of State professional
licenses
professional
references (including current
competence)
Database
profiles from AMA, AOA, NPDB, and OIG Medicare/Medicaid ExclusionsSlide14
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Allied Health ProfessionalsTJC NIAHO
LIPs through MS process
Non-LIP APRNs and PAs HR or MS if not providing a medical level of care
If State law allows, MS may include DPM, OD, DC, PA, CRNA, NM, APRN, DMD, PHD or other designated professionals approved by MS and Board and eligible for appointmentSlide15
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Executive CommitteeTJC NIAHO
10 EPs outlining responsibilities, structure, function
If MS has an executive committee, a majority of the members of the committee shall be doctors of medicine or osteopathy
CEO and the nurse executive of the organization or designee shall attend each meeting on an ex-officio basis, with or without voteSlide16
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NotificationsTJC NIAHO
The decision to grant, deny, revise, or revoke privilege(s) is disseminated and made available to all appropriate internal and external persons or entities, as defined by the hospital and applicable law
A current roster listing each practitioner’s specific surgical privileges must be available in the surgical suite and scheduling area
Include surgeons with suspended surgical privileges or whose surgical privileges have been restrictedSlide17
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Surgical PrivilegesTJC NIAHO
Included in general category for privileges
All practitioners performing surgery
have
surgical privileges established by the department of surgery and medical staff and approved by the governing bodyPrivileges for general surgery and surgical subspecialties defined with established criteria approved by
MS
Privileges correspond with established
competencies of each
practitionerSlide18
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Automatic SuspensionTJC NIAHO
The medical staff bylaws include
description of indications for automatic suspension or summary suspension of a practitioner’s medical staff membership or clinical privileges
description of when automatic suspension or summary suspension procedures are implemented
The medical staff will define the criteria and have a mechanism for consideration of automatic suspension of clinical privileges of a practitioner at a minimum when:
revocation/restriction of professional
license
DEA certificate has been revoked, suspended or on probation
Failure to maintain the minimum specified amount of professional liability insurance
non-compliance with written medical record delinquency or deficiency
requirements
Mechanism for immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioner’s Medicare or Medicaid statusSlide19
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QA/PI DataTJC NIAHO
FPPE
OPPE
Medical Assessment
BloodMedicationOperative and other procedure(s)Appropriateness of clinical practice patternsSignificant departures from established patterns of clinical practiceUse of criteria for autopsiesSentinel event dataPatient safety data
Practitioner specific performance data is required and must be rate-based with comparative peer or national data available for comparison.
Blood use
Prescribing of medications
Surgical Case Review
Specific departmental indicators
Moderate Sedation Outcomes
Anesthesia events
Appropriateness of care for non-invasive procedures/interventions
Utilization data
Significant deviations from established standards of practice
Timely and legible completion of patients’ medical records
Variants analyzed for statistical significanceSlide20
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Addressed by TJC, Not NIAHO
Verification of applicant identity
Use of CVO (DNV does allow – is addressed under telemedicine)
Health status (DNV only under surgical privileges)Applicant required to provide info re: previously successful or currently pending challenges to licensure or voluntary relinquishment, felony convictionsLeadership standards place additional responsibilities on MSResidency program requirementsSlide21
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Addressed by NIAHO, not TJC
Receipt
of database
profile from OIG - Medicare/Medicaid Exclusions initial/reappointment/temporary privilegesSlide22
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Resources
Standards: NIAHO
®
Standards
, Interpretive Guidelines, or Accreditation Process www.dnvaccreditation.comJointcomission.orgSlide23
Questions to Consider…Will our reputation in the community suffer if we change? (Are minimal standards sufficient in today’s healthcare climate?)Contracts with insurers may require certain accreditation and may need renegotiation Will there be a saving in direct and indirect accreditation costs?23Slide24
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Questions