Laws Regulations Rules Policies Procedures Following them can

Laws – Regulations – Rules- Policies – Procedures Following them can be challenging! PRESENTED BY: CHRISTINA GILES, CPMSM, MS C. GILES & ASSOCIATES MAMSS 36 TH ANNUAL CONFERENCE THURSDAY, MAY 9, 2019

OBJECTIVES Recognize the differences between laws, regulations, rules, policies and procedures Analyze a recent law and discuss how to convert it to relevant policies and procedures for a medical staff Differentiate the need for rules vs. policies vs. procedures in the credentialing environment

Let’s Start with Some Definitions LAW a rule made by a government that states how people may and may not behave in society and in business, and that often orders particular punishments if they do not obey, or a system of such rules: civil/criminal law federal/state law LAW the principles and regulations established in a community by some authority and applicable to its people, whether in the form of legislation or of custom and policies recognized and enforced by judicial decision.

DEFINITIONS…. . REGULATION a rule or order issued by an executive authority or regulatory agency of a government and having the force of law Any standard statement which may include a policy statement or procedure of general applicability RULE A standard, statement or procedure, other than a policy or regulation, adopted by an authority to address matters within the operational authority of the unit

DEFINITIONS…. . POLICY A. definite course or method of action selected from among alternatives and in light of given conditions to guide and determine present and future decisions B. a high-level overall plan embracing the general goals and acceptable procedures especially of a governmental body any standard, statement or procedure of general applicability adopted by the governing board of an organization; may be pursuant to authority delegated by law. PROCEDURES a particular way of accomplishing something or of acting a series of steps followed in a regular definite order legal procedure a surgical procedure

What are you most familiar with? Hospital Medical Staff – • Medical Staff Bylaws, • Medical Staff Policies & Procedures, • Medical Staff Rules and Regulations Managed Care/Insurance Environment • Policies and Procedures Credentialing Verification Organizations • Policies and Procedures OTHER?

Deciding Factors…. When a new state law or accreditation standard occurs – what determines where the facility places the information? Which facility document will be used to “codify” the new requirement? Bylaws vs policy and procedure, rules/regulations Amendment process – How long will it take? Which group(s) need to vote on the revision? What education needs to take place What enforcement mechanism will be used? (Carrot or stick? )

Credentialing & Privileging requires written documents that will: Define any relevant laws Relate those laws to internal policies and procedures, rules and regulations BOTTOM LINE…. Formalize Medical Staff and Department operational policies and procedures Provide the structure that will assist the Medical Staff and the administrative staff to ensure compliance with the law and/or accreditation requirements

Remember the Pt. Care Assessment Regulations? Established in 1987 Massachusetts General Law (M. G. L. c. 112, § 5, and M. G. L. c. 111, § 203. 243 CMR(Code of Massachusetts Regulations): BOARD OF REGISTRATION IN MEDICINE , Sections 3. 01 – 3. 14

So Many Elements… Credentialing Malpractice Claims or Actions for Pending or Closed actions for previous ten years • At least every 2 years • Judgment & Clinical Skills • Policy number • Current license to practice; collect copy of most recent license application • Mental & Physical Status • Name, address and age of claimant/plaintiff • Compliance with CME requirements • Nature and substance of claim • Data dealing with utilization • Date and place at which claim arose • Adherence to facility and MS bylaws, policies & procedures • • Malpractice Claims Amounts paid if any and date and manner of disposition, judgment, settlement • • Information regarding any criminal proceedings Date and reason for final disposition or settlement • • Applicant provides listing & description of all malpractice claims & lawsuits pending or closed Facility must document and analyze: • Professional performance

Credentialing Requirements Cont’d. . . • Facility Must: Make reasonable inquiry to other health care facilities (I) every facility for previous ten (10) years (R) every facility for previous three (3) years • Reasonable means at least 3 times • Will require licensee to undergo a mental or physical examination if requested by MEC, Credentials or other supervisory body Licensee must: • Release name of any healthcare facility where he/she has been employed, practiced, associated for providing patient care or has/had privileges • Must release facility to share information with other facilities

Patient Care Assessment Program Internal Audits/Internal Incident Structure Facility shall establish a medical peer review committee to be known as Patient Care Assessment Committee Facility may have other peer review committees as it deems appropriate Pt Care Assessment Committee may consist of persons not only from the MS GB shall designate a Pt. Care Assessment Coordinator Reports Hospital & MS Bylaws contain provisions for reporting conduct of a provider that indicates incompetence or conduct inconsistent with or harmful to good pt. care & safety

WHERE ARE THEY? Do you know which documents at your facility contain the requirements from the Patient Care Assessment regulations?

Let’s Look at a New Law in California! Patient’s Right to Know Act - Effective July 1, 2019 First-in-the-nation law Senate Bill 1448 Requires doctors to notify their patients if placed on probation for sexual misconduct, drug or alcohol abuse, inappropriate prescriptive writing or criminal convictions that involve harm to a patient

What if we were in CALIFORNIA?

FURTHER INFORMATION When a physician is placed on probation, they are only legally required to notify their insurance company and the hospital or clinic with which they are affiliated. New law affects: Medical/Osteopathic Physicians Naturopathic Physicians Podiatrists Chiropractors Acupuncturists

PHYSICIANS WILL BE REQUIRED TO: Obtain a signed disclosure form from all patients before their next appointment. The written disclosure must include: Physician’s probation status Length of probation and end date Practice restrictions placed on the licensee An explanation of how the patient can find further information about the licensee’s probation on the licensee’s appropriate licensing website profile page.

What would be your first steps? How are patient complaints handled? Are the patient complaints summarized and integrated into the credentialing and privileging process? Are there any other departments that might have similar information that is not being tracked? Is there an available chaperone service/process for use with any physicians?

Which Documents do we use? Where does this new law need to be documented in our facility? What are the steps we should follow? Can the tracking become part of the OPPE process? Do we need an education plan? Do we need a communication plan? What else do you think is needed?

EDUCATION…. . Who Needs it? Governing Board Medical Staff Administration/HR Risk Management/Compliance Other Departments?

COMMUNICATION ….

CALIFORNIA UPDATE…. Senator Jerry Hill has proposed Senate Bill 425 to close reporting gaps to regulators. Hospitals, clinics and other health facilities would be required to report allegations of patient sexual abuse and other sexual misconduct by medical professionals to the appropriate state licensing authorities within 15 days. Besides medical & osteopathic physicians and surgeons, would also involve podiatrists, psychologists, dental hygienists, chiropractors, nurses, vocational nurses, psychiatric technicians, optometrists, veterinarians, PTs, pharmacists, speech-language therapists, audiologists, OTs, acupuncturists

IN SUMMARY…. Documentation is very important When choosing document placement you should consider: Ease of revision Awareness/Communication Type of enforcement

SUCCESS… Your Positive Action Combined with Positive Thinking Results in Success Shiv Khera

GOOD LUCK!! Chris Giles C. Giles & Associates Chriswg 46@gmail. com