HFAP 2018 MEDICAL STAFF STANDARDS Karen Beem MS

HFAP 2018 MEDICAL STAFF STANDARDS Karen Beem, MS, RN HFAP Standards Interpretation kbeem@hfap. org 312 -202 -8069

CHAPTER 3 MEDICAL STAFF 2018 What’s New? 12/1/2020 HFAP │ National Credentialing Forum 2

What’s New for 2018? ª No New Medical Staff Requirements 12/1/2020 HFAP │ National Credentialing Forum 3

CHAPTER 3 MEDICAL STAFF 2017 Top Cited Deficiencies 12/1/2020 HFAP │ National Credentialing Forum 4

Condition of Participation 03. 00 Medical Staff CMS Requires… § The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. § 482. 22 12/1/2020 HFAP │ National Credentialing Forum 5

Condition of Participation 03. 00 Medical Staff § 482. 22 § Condition-level Citations: ª One (1) GI Proceduralist lacked privileges for moderate sedation ª Four (4) Physician Assistants lacked privileges – facility allowed PAs to function under “State Scope of Practice” 12/1/2020 HFAP │ National Credentialing Forum 6

Standard-level Citation 03. 00. 06 Medical Staff Recommendations to Governance: § Standard-level Citations: ª Privileges exceed 24 months ª Lack evidence of Medical Staff recommendations to the Governing Body 12/1/2020 HFAP │ National Credentialing Forum 7

CHAPTER 3 MEDICAL STAFF 2017 Challenges 12/1/2020 HFAP │ National Credentialing Forum 8

03. 15. 01 OPPE § Standard-level Citations: ª OPPE not addressed in Bylaws ª OPPE data not considered with re-appointment ª Failure to identify OPPE performance indicators (non-physician practitioners): • • 12/1/2020 Nurse Practitioners Physician Assistants HFAP │ National Credentialing Forum 9

03. 15. 02 FPPE § Standard-level Citations: ª FPPE not addressed in Bylaws ª FPPE process not communicated to individual with initial appointment ª Failure to identify FPPE performance indicators (non-physician practitioners): • • 12/1/2020 Nurse Practitioners Physician Assistants HFAP │ National Credentialing Forum 10

CHAPTER 3 MEDICAL STAFF 2018 Retired Standards 12/1/2020 HFAP │ National Credentialing Forum 11

Retired Standards 03. 05. 01 – 03. 05. 03 Utilization of Osteopathic Methods & Concepts Committee 12/1/2020 HFAP │ National Credentialing Forum 12

THANK YOU Email: Office: 12/1/2020 kbeem@hfap. com 312 -202 -8069 HFAP │ National Credentialing Forum 13