Comparison of The Joint Commission and DNV GL

Comparison of The Joint Commission and DNV- GL HC’s National Integrated Accreditation for Healthcare Organizations (NIAHO℠) MS Standards Kathy Matzka, CPMSM, CPCS 1

History TJC • 1952 began • Unique statutory hospital deeming authority 1965 Medicare statute • July 15, 2008, the Medicare Improvements for Patients and Providers Act of 2008 became law • 11/09 – CMS approval • 4, 546 Hospital and CAH in 2011 • 4, 429 Hospital and CAH in 2013 (90% of accredited hospitals) • 4, 032 Hospital and CAH in 2016 (88% of accredited hospitals) NIAHO • 12/19/07 Application to CMS • 09/08 CMS approval • 94 Hospital and CAH on 7/14/10 • 393 Hospital and CAH on 4/17/2016 2

Process TJC NIAHO • Three year survey • Annual Survey • Standards directly • Most MS standards related to the CMS as directly related to the well as self-defined CMS • ISO 9001 quality management 3

Scoring Process TJC NIAHO • Three-point scale: – 0 = insufficient compliance – 1 = partial compliance – 2 = satisfactory compliance • Icons – Documentation required – Situational decision rules apply – Direct impact requirements apply – Category A requirement – Category 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 scoring 4

Appointment Timeframe TJC • Two years NIAHO • Three years if state law does not address 5

Continuing Medical Education TJC NIAHO • LIPs and other practitioners • All with privileges participate in privileged through the medical CE that is at least in part staff process must participate related to their clinical in CE privileges • Participation must be • CME considered in decisions documented and considered in about reappointment or decisions about reappointment, renewal or revision of clinical renewal, or revision of privileges individual 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 verified 6

Current Competence TJC • 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 NIAHO • 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 strategies 7

Malpractice History TJC NIAHO • MS evaluates • Review of involvement in a any professional liability action at initial and action, including final reappointment 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 8

Peer Recommendations TJC 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 practice • List of appropriate sources • Two peer recommendations required at initial appointment 9

Clinical Privileges TJC NIAHO • PSV for current licensure or • All permitted by the certification organization and by law to • PSV of relevant training provide patient care services • Evidence of physical ability to independently have delineated perform the requested privilege clinical privileges • If available, data from • If available and/or required by professional practice review the MS, a review of individual from other organization where performance data variation the applicant currently has from criteria determined by the privileges medical staff to identify need • Recommendations from for training or proctoring that peers/faculty may be required • On renewal, review of the applicant’s performance within the hospital 10

Telemedicine TJC 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 site • Medical staff at both sites make recommendation for services to be provided via telemedicine • For non-deeming, can be via contract only if TJC accredited entity • 2 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 entity 11

Temporary Privileges TJC 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 recommendation of a MEC member, MS president or medical director (as defined by MS • Urgent patient care need • Complete application w/o negative or adverse information before action by the medical staff or governing body 12

Temporary Privileges TJC NIAHO • Patient care need verify – Current licensure – Current competence • New Applicant verify • • • Current 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 Exclusions 13

Allied Health Professionals TJC 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 appointment 14

Executive Committee TJC 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 vote 15

TJC Notifications NIAHO • The decision to grant, • A current roster listing deny, revise, or each practitioner’s revoke privilege(s) is specific surgical disseminated and privileges must be made available to all available in the appropriate internal surgical suite and external persons scheduling area or entities, as defined • Include surgeons with by the hospital and suspended surgical applicable law privileges or whose surgical privileges have been restricted 16

Surgical Privileges TJC 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 body • Privileges for general surgery and surgical subspecialties defined with established criteria approved by MS • Privileges correspond with established competencies of each practitioner 17

Automatic Suspension TJC 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 status 18

QA/PI Data TJC • FPPE • OPPE • Medical Assessment – Blood – Medication – Operative and other procedure(s) – Appropriateness of clinical practice patterns – Significant departures from established patterns of clinical practice – Use of criteria for autopsies – Sentinel event data – Patient safety data NIAHO • Practitioner specific performance data is required and must be ratebased 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 noninvasive procedures/interventions – Utilization data – Significant deviations from established standards of practice – Timely and legible completion of patients’ medical records • Variants analyzed for statistical significance 19

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 convictions • Leadership standards place additional responsibilities on MS • Residency program requirements 20

Addressed by NIAHO, not TJC • Receipt of database profile from OIG Medicare/Medicaid Exclusions initial/reappointment/temporary privileges 21

Resources • Standards: NIAHO® Standards, Interpretive Guidelines, or Accreditation Process www. dnvaccreditation. com • Jointcomission. org 22

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? 23

Questions 24