The Ohio Hospital Association - 2015 Annual Meeting Hilton at Easton

June 8, 2015 8:30 – 9:30 a.m.

Kimberly S. Parks, Esq. Senior Attorney, Healthcare Department Bricker & Eckler, LLP 100 South Third Street Columbus, Ohio 43215 (614) 227-8801 kparks@bricker.com

Melinda Whitney, RN, BSN, BS, MS, CPHQ, CPMSM, FACHE Senior Consultant, Quality and Medical Staff Services The Quality Management Consulting Group, Ltd. 100 South Third Street Columbus, Ohio 43215 (614) 227-4849 mwhitney@qmcg.com

Definitions

Medical Staff Credentialing

Privileging/Clinical Privileges

Medical Staff Appointment

Foundation for Privilege Set Creation

Consistent with information contained within Medical Staff Bylaws.

Based upon CMS Medicare Hospital or Critical Access Hospital Conditions of Participation (CoPs).

Based upon applicable Hospital or Critical Access Hospital accreditation standards.

CMS Hospital CoPs

Hospital’s governing body is responsible for conduct of hospital.

• Medical staff is accountable to governing body for quality of care provided to patients at hospital.

[See 42 C.F.R. 482.12(a)(5) and 482.22(b) and corresponding interpretive guidelines]

CMS Hospital CoPs Hospital must have a privileging process in place that complies

with applicable CoPs, accreditation standards, and State law.

The medical staff bylaws must describe the privileging process to be used in the hospital and the process must be approved by the hospital’s governing body.

The process must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners.

[See 42 C.F.R. 482.12 (a)(6); 482.22(a)(2); 482.22(c)(4); 482.22(c)(6) and corresponding interpretive guidelines]

CMS Hospital CoPs The hospital’s governing body must determine the types of practitioners who are eligible for medical staff appointment and who are eligible for privileges.

Physicians (as defined by CMS): MD/DO; Dentists; Podiatrists, Optometrists, Chiropractors

Non-physician practitioners (as defined by CMS): physician assistant; advanced practice registered nurses (CNP, CNS, CRNA, CNM); clinical social worker; clinical psychologist; anesthesiologist’s assistant; registered dietitian or nutrition professional

Other types of licensed healthcare professionals

For purposes of this presentation, physicians and non-physician practitioners will be collectively referred to as practitioners.

[See 42 C.F.R. 482.12(a)(1); 482.22(a) and corresponding interpretive guidelines]

State Scope of Practice Privileges granted to individual practitioners must be consistent

with State scope of practice laws.

Examples:

Advanced Practice Registered Nurses

Physician Assistants

Podiatrists

Etc.

CMS Hospital CoPs Medical staff bylaws must state the duties and scope of privileges

each category of practitioner may be granted.

Specific privileges for each category must clearly and completely list the specific privileges or limitations for that category of practitioner.

Specific privileges must reflect the activities that the majority of practitioners in that category can do and that the hospital can support.

[See 42 C.F.R. 482.22(c)(2) and corresponding interpretive guidelines]

CMS Hospital CoPs

The individual practitioner’s ability to perform each privilege (task/activity) must be assessed and not assumed.

If a practitioner is not competent to perform one or more privileges, the list of privileges is modified for that practitioner.

[See 42 C.F.R. 482.22 (a)(2); 482.22(c)(2) and corresponding interpretive guidelines]

CMS Hospital CoPs

Privileges cannot be granted for tasks/procedures/activities that are not conducted within the hospital regardless of the individual practitioner’s ability to perform them.

[See 42 C.F.R 482.22(a)(1) and corresponding interpretive guidelines.]

CMS Hospital CoPs Any procedure/task/activity requested by a practitioner that

goes beyond the specified list of privileges for that particular category of practitioner requires an appraisal by the medical staff and approval of the governing body.

Appraisal must consider evidence of qualifications and

competencies specific to the nature of the request.

Must also consider whether activity/task/procedure is one that the hospital can support when it is conducted within the hospital.

[See 42 C.F.R. 482.22(a)(1) and corresponding interpretive guidelines.]

CMS Hospital CoPs Hospitals must assure that practitioners are competent to perform

all granted privileges.

Medical staff must periodically (defined as at least every 24 months in the absence of a State law that requires more frequent appraisals) conduct appraisals of individual current practitioners.

[See 42 C.F.R. 482.22(a)(1) and corresponding interpretive guidelines]

CMS Hospital CoPs

Medical staff appraisal procedures must evaluate each individual practitioner’s qualifications and demonstrated competencies to perform each task or activity for which he/she has been granted privileges.

[See 42 C.F.R. 482.22(a)(1) and corresponding interpretive guidelines]

CMS Hospital CoPs Components of practitioner qualifications and demonstrated

competencies would include at least: current work practice, special training, quality of specific work, patient outcomes, education, maintenance of continuing education, adherence to medical staff rules, certifications, appropriate licensure, and currency of compliance with licensure requirements.

[See 42 C.F.R. 482.22(a)(1) and corresponding interpretive guidelines]

TJC and HFAP require that the hospital have an FPPE/OPPE process.

Building Privilege Sets

• Privilege sets are the “work product” of compliance with law and requirements regulating hospital care delivery.

• Privilege sets are built to reflect uniqueness of each hospital (i.e. physical plant, equipment, support staff capability, and care setting).

• Privilege sets must reflect a scope of practice that can be safely performed for a defined population in a specific setting.

Building Privilege Sets

• Verify practitioner education, training, licensure, and current clinical competence to exercise a defined set of privileges in a given setting.

• Patient health, safety, and wellness first concern in decision-making with respect to clinical privileges.

Building Privilege Sets

Considerations for Privilege Set Scope

• Service line (“Maternal-Fetal Medicine” – may reflect OB, GYN, Family Medicine, Midwife, NICU, Pediatrics)

• Department (Surgery or Medicine)

• Division (Vascular Surgery within Department of Surgery)

• Specialty (Neurosurgery or other fellowship-based discipline)

Building Privilege Sets Elements of a Privilege Set

• Eligibility criteria (per the medical staff bylaws) • Additional “minimum threshold criteria” (specialty or sub-specialty training, etc.) • “Burden of proof” statement (with respect to satisfaction of qualification

requirements) • Location/setting(s) and patient populations

• Core privilege “statement” and “procedure list” (monitor “core” by aggregate patient

volumes/outcomes) • Special request privileges (additional training requirements; monitor each special

privilege by per case volume/outcome) • Performance volumes and quality monitoring (many initiatives)

Building Privilege Sets

Format Election

• Build a “master template” for privilege set format first.

• Provide format template to teams working on privilege set creation/revision.

• Review requirements for creation or amendment of privilege sets in medical staff bylaws.

Building Privilege Sets • Clinical process that requires practitioner involvement.

Utilize department chairs, credentials committee, or other suitable medical staff committees/leaders to assist, monitor, and review “draft” privilege sets.

Tenured and newer practitioner mix of participants/perspectives.

• Legal “access” needed for federal/state requirements

and legal questions (e.g., supervision, turf issues, eligibility, etc.).

Building Privilege Sets

• “Laundry list” (alphabetical list of procedures/skills)

• “Core” (statements of scope of practice)

• “Combination” (allows for election of a customized core and laundry list format to reflect individualized hospital parameters)

• Special Request privileges (additional privileges that are not included in the core/laundry list/combo)

Building Privilege Sets

• Consider hospital capabilities and limitations

• Build privileges to reflect current practices

• Do not project “future growth” of services

• Audit current patient populations/procedures to define the current scope of practice being exercised

Building Privilege Sets

• Formal education (medical school, internships, residency, and fellowships)

• Training (aggregate competencies and acquired skills necessary for privilege eligibility)

• Current clinical competence (within last two years, volumes of successful performance of patient management, procedures, surgery scope)

Building Privilege Sets

• Initial professional references for competency verification of

requested privileges

• Focused Professional Practice Evaluation (FPPE) process

• Ongoing Professional Practice evaluation (OPPE) process

• Performance volumes regarding case management/patient encounters for quality review purposes

• Approved in accordance with requirements set forth in medical staff bylaws (i.e. department chair, credentials committee, medical executive committee, and board)

Clinical Skills and Setting Parameters

Decision Tree:

1. Patient needs in a defined care setting

2. Setting capabilities / facility designations

3. Services to be offered (per governing body)

4. Current scope of management provided to target population

Clinical Skills and Setting Parameters

Example: An Orthopaedic Surgeon with Joint Replacement Training

• Community hospital vs. tertiary facility

• Core general orthopaedic surgery privileges

• Preoperative evaluations and surgical planning privileges

• Special request privileges (injections, post-operative evaluations)

• Privilege parameters for setting (note that no joint replacement privileges are included)

Clinical Skills and Setting Parameters

Specialists and Subspecialists

• What? Why? Where?

• Build a separate privilege set vs. adding special request privileges to an existing privilege set?

• Monitoring challenges for low volume, part-time practitioners (consider review options in and out of the hospital)

Special Request Privileges

Special request privileges may be applicable:

• “Non-core” privilege/procedure that requires additional, specialized education and training

• Think about unique procedures such as use of laser, (non-anesthesia provided) sedation, fellowship-based level of care/ procedures/management, etc.

Sample Privilege Set Review

See Handout

• Format election • Surgical privileges should be reviewed and updated at least every two (2)

years [See 42 C.F.R. 482.51(a)(4)]

• Eligibility (bylaws and additional requirements)

• Initial grant and regrant minimum patient encounter and/or procedural

volumes for purposes of competency assessment

• Core privilege statement and procedures list with minimum volumes for purposes of competency assessment

• Special request privileges – additional training with minimum volumes for

purposes of competency assessment

Additional Considerations

Provider-based locations Telemedicine

The scope of the privileges in the hospital must reflect the provision of services via a telecommunications system.

Example: Surgeon at distant-site hospital may provide telemedicine consultation services at a hospital under agreement but would not be able to perform surgery by this means and may not have surgical privileges in the hospital as part of his/her telemedicine services privileges.

If the surgeon also periodically performed surgery on-site at the hospital, then he/she would have to have privileges to do so granted in the traditional manner.

[See 42 C.F.R. 482.12(a)(8) and (9) and corresponding interpretive guidelines]

Additional Considerations Unified Medical Staff

When granting practitioners privileges to provide patient care, a hospital’s governing body must specify those hospitals in the system where the privileges apply.

Example: psychiatric hospitals do not offer surgical services, labor and

delivery, nuclear medicine, etc. so it would not be appropriate for practitioners practicing in those areas to hold privileges at a psychiatric hospital within a multi-hospital system using a unified medical staff.

Example: If a multi-hospital system covers a wide geographic area, many

practitioners may have no interest in practicing on-site at hospitals within the system that are distant from their usual practice location(s).

[See 42 C.F.R. 482.22(b)(4) and corresponding interpretive guidelines]

Questions and Answers

(With our thanks!)

Kimberly S. Parks, Esq. Senior Attorney, Healthcare Department Bricker & Eckler, LLP 100 South Third Street Columbus, Ohio 43215 (614) 227-8801 kparks@bricker.com

Melinda Whitney, RN, BSN, BS, MS, CPHQ, CPMSM, FACHE Senior Consultant, Quality and Medical Staff Services The Quality Management Consulting Group, Ltd. 100 South Third Street Columbus, Ohio 43215 (614) 227-4849 mwhitney@qmcg.com