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 Did You
Know?...
Did you know ... vendors, observers and volunteers may be within your
facility with direct or indirect patient contact without benefit of
credentialing?
Conducting an annual provider and
patient care area survey (and periodic audit visits) may net you personnel that
may not have been properly credentialed (as applicable), oriented and or
supervised. This exercise can be done in tandem with Human Resources personnel
to precisely identify who are caring for your patients.
Did you know ... Teleradiology (now known as "Teleinterpretive Services)
and Telemedicine standards have changed per JCAHO?
Read
Bricker & Eckler bulletin, "Update on Rules for Telemedicine Privileges".
Did you know ... JCAHO MS.01.01.01 will take effect March
2011?
Read
Bricker & Eckler bulletin, "The Joint Commission Approves Revised Medical Staff
Standard MS.01.01.01".
Did you know ... a physician code of conduct is a JCAHO standard
requirement?
Leadership standard LD.03.01.01
requires a code of conduct for physicians and hospital administrators. Element
of Performance 4. stipulates that the code defines acceptable, disruptive and
inappropriate behaviors. Such targeted inappropriate behaviors may include:
active behaviors such as yelling or threatening, and or passive behaviors such
as sabotaging, refusing assignments, being uncooperative, abrasive attitude,
condescending language, ignoring questions, pages or inquiries; and impatience
with questions. Review your bylaws or policy today for compliance with this
important requirement.
Did you know ... that medical staff
privileges must be created, pre-approved and supportable by your facility to be
offered to a privilegable appliant?
Oftentimes the "new privilege" is brought to the attention of physician leaders
(Credentials Committee and or Medical Executive Committee) when an applicant
asks for a new (and or special request) privilege. The governing board has the
ultimate authority and responsibility to parameter clinical privileges to match
the facility support capabilities.
Here is an example: let’s say an orthopaedic surgeon applies for general
orthopaedic surgery privileges, and writes in the special request privilege of
total joint replacement. Your facility does not offer total joint replacement
surgery, as support services (such as in-facility physical therapy or equipment
(operative and patient care) or nursing expertise) are not in-place. The
facility can simply ask the applicant to withdraw the special request as the
facility does not offer the privilege for the reasons above. Such withdrawal of
a privilege request does not trigger reporting to the National Practitioner
Data Bank (NPDB). Any concern by physician or administrative leaders on NPDB
notification potential should be discussed with counsel familiar with the
legislation.
Did you know ... your credentialing tasks
for the operating room vendors don’t need to be as challenging as you might
think!
Inventory those who are coming into patient care areas (who are not on staff nor
employed). Next, find out who invited and who is monitoring said individual.
See if the entity the individual is representing has credentialing information
and as for it. Remember – the hospital’s governing body has the right and
obligation to limit who is providing and / or directing patient care in their
facility. Remember that other requirements – such as confidentiality assurances
– will also need consideration.
Did you know ... that you have options for
accreditation at your hospital?
Absolutely! Here they are:
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Centers for Medicare and Medicaid Services (CMS) – conducted by your state’s
health department personnel.
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The Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
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The American Osteopathic Association (AOA)
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The National Integrated Accreditation for Healthcare Organizations (NIAHO)
Did you know ... there is a distinct
difference between a “provisional medical staff appointment” period and a
“focused practitioner performance evaluation” (FPPE)?
A “provisional appointment” refers to the category of membership on a medical
staff and specifications of what rights and membership-based privileges /
obligations are associated with it. A provisional appointment has less rights
and privileges than an active staff appointment. An “FPPE” period is a medical
staff competency assessment policy-driven period of focused evaluation on
privilege exercise for all newly privileged practitioners, or a practitioner
who has been identified as having potential competency and /or patient safety
concerns.
Did you know ... there is a new requirement
for dispute resolution from JCAHO?
If your VP of Medical Affairs and your President of Medical Staff disagree on a
policy or process, don’t wait and let this fall off of your radar screen. Ask
physician leaders for an expected date of resolution on the matter. If it does
not appear to be forthcoming, let them know you will place the matter on the
agenda for the Medical Executive Committee to review and/or assist with
resolving. Work up your chain of command to help get a satisfactory resolution
– the sooner, the better.
Did you know ... JCAHO’s website has very
helpful information posted and they update content fairly often?
Pay particular attention to the FAQ section (http://www.jcaho.org)
for Hospitals and Standards. There’s a great core privileges vs. clinical
privilege options post!
Did you know ... your medical staff bylaws
and related peer review policy stipulate than an external peer review process
MUST be in place?
The means to stimulate external peer review is necessary per JCAHO. Utilization
of a “trusted resource” that offers actively practicing, board certified
physicians and other practitioners to render objective peer review opinions is
offered by professionals at The Quality Management Consulting Group, Ltd.
(QMCG). QMCG will provide you with a no-cost / no-obligation proposal and
curriculum vitae of a suggested consulting physician to meet your external peer
review needs.
Did you know ... a new Centers for Medicare
and Medicaid (CMS) deemed authority was named in late 2008?
Yes! Optional accreditation via the National Integrated Accreditation for
Healthcare Organizations (NIAHO) is now in place. The Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) has a competitor …
Did you know ... JCAHO’s six general
competencies for medical staff evaluation is suggested, not
required?
It’s true: medical staff competency evaluation is suggested, not required. Read
the introduction to the JCAHO Medical Staff chapter and see for yourself. Or,
visit them online to learn more: www.jhaco.org.
Did you know ... there is loads of valuable
information on credentialing, privileging, medical staff leadership,
performance improvement and policy information available online?
Visit www.NAMSS.org and/or
www.NAHQ.org – free and updated information about these hot topics
await you!
Did you know ... your attorneys usually
only focus in certain areas of practice?
Remember – it is imperative to have an attorney experienced in certain medical
staff/healthcare matters representing you and your interests. Some areas your
counsel should specialize in include: medical staff governance documents,
potential for adverse action, fair hearings, dealing with disruptive and/or
impaired practitioners, and HIPAA / privacy matters. For more information on
qualified counsel visit www.bricker.com.
Did you know ... medical staff information
is often readily available at your state chapter of the National Association
for Medical Staff Services (NAMSS)?
For example, Ohio’s chapter is called, “Ohio Association of Medical Staff
Services” (OAMSS). Visit www.OAMSS.org and
find a colleague to connect with!
Did you know ... Allied Health
Practitioners (according to JCAHO standards and some state laws) must be
afforded due process if they face an adverse recommendation?
First, look to your AHP manual and hospital policies to determine if such due
process is in place. If not, consult with your legal counsel to develop a
procedure compliant with the law.
Did you know ... the Ohio Department of Health is now accepting
certificate of need applications to relocate long-term care beds to a
contiguous county?
The application must meet the
following conditions: a) The beds proposed for relocation must be licensed
nursing home beds from an existing nursing home to another existing nursing
home located in a contiguous county; b) No more than 30 beds may be proposed
for relocation; c) After the proposed relocation, there will be existing
nursing home beds remaining in the source county; and d) the beds are proposed
to be licensed nursing home beds at the receiving facility. See
ORC 3702.594
Did you know ... the Ohio Department of Health will post the results of
the long-term care bed need formula in April, 2010?
The results of the formula will
identify those counties with too many long-term care beds and those counties
with too few beds. Applications for certificate of need to relocate beds from a
county with too many beds to a county with too few beds will be accepted from
July 1 through July 30, 2010 for a comparative review process.
Did you know ... the quality criteria for a certificate of need is now
less stringent and only applies to the nursing home operator and the applicant
entity for certificate of need?
Level G and J citations are no
longer considered and accommodation is made if the proposed operator operates
more than one nursing home in Ohio. See
ORC 3702.59
Did you know ... the certificate of need application form was revised,
effective October 16, 2009?
All certificate of need applications
submitted on or after this date must use the new form.
Did you know ... if you provide solid organ or bone marrow
transplantation, cardiac catheterization, adult open heart surgery, pediatric
cardiovascular surgery, or pediatric intensive care services, notice to the
Ohio Department of Health is required each time the service’s medical director
or provider’s authorized representative for the service is changed?
A revised attestation of compliance must be filed with
the Ohio Department of Health within 30 days of any change.
Did you know ... if you provide solid organ or bone marrow
transplantation, cardiac catheterization, adult open heart surgery, pediatric
cardiovascular surgery, or pediatric intensive care services, the Ohio
Department of Health will conduct an on-site inspection of your service every 3
years?
Our Regulatory Services line can
conduct an assessment of your service to identify compliance issues and means
for correction to ensure that your service is in compliance with
Department rules.
Did you know ... if your hospital is authorized to operate long-term care
beds, it is imperative that the beds be correctly registered on your Annual
Hospital Registration Report?
Failure to properly register the
beds may result in an inadvertent surrender of the beds or inability to avail
your facility to all options regarding relocation of the beds. Our Regulatory
Services line can review your Report to ensure accurate reporting. If the
report is not accurate, we can work with the Ohio Department of Health to make
the necessary corrections.
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