The TJC Medical Staff Standards Update 2018 Joint

The TJC Medical Staff Standards Update 2018 © Joint Commission Resources Laurie Mc. Court, MD, ABFM, CJCP JCR Consultant

Joint Commission Resources Disclaimer § These slides are current as of April 1, 2018. Joint Commission Resources reserves the right to change the content of the information, as appropriate. § These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or Joint Commission Resources. © Joint Commission Resources § These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.

Objectives © Joint Commission Resources § Review the top scored standards in the medical staff chapter and their related Co. Ps from 2017 § Review of processes that have been used as solutions to the top scored standards § Review what is new from TJC in 2018 § Review proposed changes in MS chapter

© Joint Commission Resources Project REFRESH

Project REFRESH: What is it? © Joint Commission Resources § A series of enhancements to the entire survey process which are the result of data collected from a variety of sources, most importantly, YOU, our customers. These enhancements are to be phased in over 2016, 2017, and 2018.

Project REFRESH: What is it? § Real-time information gathering between – surveyors and Standards Interpretation Group – during survey § Enhanced mobile technology § Fewer standards: No changes in MS Chapter as yet § Revised criticality models § Easier & less complex decision process § Higher consistency in interpretation of standards © Joint Commission Resources § Streamlined post-survey process

The Review § An effort to modernize and streamline – Phase 1: 225 EP deletions effective July 1, 2016 and January 1, 2017. – Phase 2: An additional 51 EPs deletions effective January 1, 2017 – Phase 3: Non-hospital program deletions effective July 1, 2017 – Phase 4: Consolidations of EPs across programs throughout 2018 © Joint Commission Resources Joint Commission requirements

Project REFRESH in the Accreditation Process The Review, Pre-Survey Document Review Onsite-Survey: Mobile Survey Technology, SIG Onsite Support, CITe, SAFER Matrix Post-Survey: Report, Clarifications © Joint Commission Resources Pre-Survey:

© Joint Commission Resources

Pre-Survey Document Review § Surveyors spend hours during survey reviewing documents § Started in 2017: Allow customers ability to upload key documents prior to survey for Joint Commission review: Could include Bylaws, Rules, Regulations © Joint Commission Resources § This cuts into valuable survey time that would be better spent doing tracers, environmental tours, etc. where surveyors could identify more relevant patient and environmental safety risks

© Joint Commission Resources

Changes to Surveys § “A” and “C” designations were removed: MS chapter was mostly “A”s § “Direct” vs. “Indirect” designations removed § Continued review of manual with EP revision and removal § Surveyors documenting real time on tablets § Involvement of organizations on SIG phone calls § New scoring process 12 © Joint Commission Resources January 2017 :

© Joint Commission Resources Survey Analysis for Evaluating Risk™ (SAFER™) Matrix

§ A transformative approach for identifying and communicating risk levels associated with deficiencies cited during surveys § Helps organizations prioritize and focus corrective actions § Provides one, comprehensive visual representation of survey findings § Replaces current scoring methodology § Implementation: January 2017 – Was implemented June 6 th, 2016 for deemed Psychiatric Hospitals only © Joint Commission Resources Survey Analysis for Evaluating Risk (SAFER)

A New SAFER Model Immediate Threat to Life (follows current ITL processes) Likelihood to Harm a Patient/Visitor/Staff HIGH LOW LIMITED PATTERN Scope WIDESPREAD © Joint Commission Resources MODERATE

§ High: Could directly lead to harm without need for other significant circumstances or failures. – Likely § Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures. – Possible § Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm. – Rare © Joint Commission Resources Likelihood to Harm

Scope § Widespread: issue is “pervasive at the organization” – Process failure/systemic failure – Majority of patients are/could be impacted § Pattern: issue has potential to “impact more than a limited number of patients impacted” – Process variation – Outlier – Not representative of routine/regular practice © Joint Commission Resources § Limited: issue is a “unique occurrence”

A Picture is Worth 1000 Words… HIGH MM. 03. 01, EP 8 NPSG. 05. 02. 01 MODERATE EC. 02. 01, EP 2 PC. 01. 02. 01, EP 4 PC. 01. 03. 01, EP 1 PC. 01. 03. 01, EP 5 LOW MM. 03. 01, EP 7 IM. 02. 01, EP 3 PC. 01. 02. 03, EP 6 IC. 02. 01, EP 2 IC. 02. 01, EP 4 RC. 01. 01, EP 19 RC. 02. 03. 07, EP 4 LIMITED PATTERN WIDESPREAD © Joint Commission Resources Likelihood to Harm a Patient/Visitor/Staff Immediate Threat to Life

Aggregate SAFER Data For Full and Initial HOSPITAL/CRITICAL ACCESS HOSPITAL surveys from 1/1/17 through 12/31/17 (N=1503) HIGH 1. 54% 1. 65% 1. 56% 4. 75% MODERATE 16. 53% 12. 88% 4. 37% 33. 78% LOW 42. 05% 15. 17% 3. 87% 61. 09% 60. 12% 29. 70% 9. 80% LIMITED PATTERN WIDESPREAD Scope © Joint Commission Resources Likelihood to Harm a Patient/Staff/Visitor Immediate Threat to Life 0. 37%

Most Frequent High Likelihood to Harm – Clinical Standards For Full and Initial HOSPITAL/CRITICAL ACCESS HOSPITAL surveys from 1/1/17 through 12/31/17 (N=1503). Excludes EC and LS Chapters © Joint Commission Resources Note: the numbers on the bar graphs do not represent the number of RFIs, rather the number of scored observations under each EP.

Post-Survey: © Joint Commission Resources Report, Clarifications

Follow-up Actions © Joint Commission Resources § Follow-up customized and prioritized according to placement within SAFER Matrix

Prioritized Follow-up Action SAFER Matrix™ Placement HIGH/LIMITED, HIGH/PATTERN, HIGH/WIDESPREAD MODERATE / PATTERN, MODERATE/WIDESPREAD MODERATE / LIMITED, Required Follow-Up Activity • 60 day Evidence of Standards Compliance (ESC) - ESC will include Who, What, When, and How sections • ESC will also include two additional areas surrounding Leadership Involvement and Preventive Analysis • Finding will be highlighted for potential review by surveyors on subsequent onsite surveys up to and including the next full triennial survey • 60 day Evidence of Standards Compliance (ESC) - ESC will include Who, What, When, and How sections LOW / WIDESPREAD LOW/LIMITED • 60 day Evidence of Standards Compliance (ESC) - ESC will include Who, What, When, and How sections © Joint Commission Resources LOW / PATTERN,

Prioritized Follow-up Action Placement of RFI on SAFER Matrix and Follow-Up Activity LOW / LIMITED MODERATE / LIMITED LOW / PATTERN LOW / WIDESPREAD MODERATE/PATTERN MODERATE/WIDESPREAD HIGH/LIMITED HIGH/PATTERN HIGH/WIDESPREAD Evidence of Standards Compliance (ESC) 60 Pull into surveyor technology for potential review during subsequent surveys © Joint Commission Resources Evidence of Standards Compliance (ESC) 60 - Plus - Additional fields for sustainment plan

ESC Changes § All Requirements for Improvement (RFIs) due in a 60 day ESC – 45 day ESC no longer applicable § All findings will require an ESC § Findings of higher risk will require 2 additional ESC fields © Joint Commission Resources – OFI section of the report no longer applicable

© Joint Commission Resources Leadership Involvement - ESC

© Joint Commission Resources Preventive Analysis - ESC

ESC – Redesigned Format THEN NOW § § – LEADERSHIP INVOLVEMENT § § § WHAT actions were completed WHEN were each of the actions § completed HOW will compliance be sustained – PREVENTIVE ANALYSIS § ASSIGNING ACCOUNTABILITY – Who is ultimately responsible – Leadership Involvement CORRECTING THE NONCOMPLIANCE – Preventive Analysis – What actions taken and when ENSURING SUSTAINED COMPLANCE • Expanded How section to focus on sustainment! • • • What procedures or activities have been identified to monitor compliance? What is the frequency of the monitoring activities? What data will be collected from these activities? To whom, and how often, will this data be reported? © Joint Commission Resources WHO is ultimately responsible

Changes to Clarification Process § Still have 10 business days after survey ends for this process. – Required Documents as listed in the “Checklist of Required Documents”(Now includes Medical Staff Bylaws) on the home page of your extranet – Clerical Errors as a reason to remove a finding – Need for an audit process…No “c” elements of performance © Joint Commission Resources § NOT Accepted During Clarification Process:

© Joint Commission Resources Top Scored Standards

© Joint Commission Resources Top Scored Standards of 2016

© Joint Commission Resources Top Scored Standards of 2017

Increase in Volume of RFIs: January – June 2017 © Joint Commission Resources § Immediate Need: Managing Expectations

Survey Process and Report Changes in © Joint Commission Resources 2018

© Joint Commission Resources Accreditation Report (Old Version)

© Joint Commission Resources New Accreditation Report

Customer Driven Improvements Survey Report Redesign Report Improvement This new section associates each standard and EP contained in the survey report, with its required followup activity. © Joint Commission Resources Customer Concern Customers want an overview of the survey outcomes.

© Joint Commission Resources Accreditation Report (New Version)

© Joint Commission Resources Export to Excel

Potential to Add Key Words/Phrases for Standards/EPs Likelihood to Harm a Patient/Staff/Visitor Immediate Threat to Life NPSG 15. 01, EP 3 (Provide suicide prevention info to pt. & family) HIGH IC. 02. 01, EP 3 (Disposing of medical equipment & supplies) MODER ATE LOW EC. 02. 01, EP 11 (Product recalls & notices) LIMITED EC. 02. 01, EP 10 (Incident reporting) PATTERN Scope WIDESPREAD © Joint Commission Resources RI. 01. 01, EP 2 (Inform pt. of rights)

Enhanced Leadership Session/Safety Culture § If The Joint Commission (TJC) is going to help healthcare organization’s move toward high reliability, we need to address safety culture. § Currently the survey process does not have a formalized assessment of safety culture as a part of the survey process. and better educate and inspire organizations to improve. © Joint Commission Resources § TJC must strengthen the assessment of safety culture

Enhanced Leadership Session/Safety Culture – Updates to the survey process using the Leadership Session in a enhanced manner – Ensuring that safety culture is evaluated at all points in survey – Pulling the threads through for the organization – More focused questions – Looking at safety culture survey data – Formalized assessment of safety culture © Joint Commission Resources § By mid-2018, expect to see:

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Resources § E-Alerts § FAQs § Leading Practice Library © Joint Commission Resources § Editor’s Exclusives NEW!

© Joint Commission Resources What’s New in Medical Staff Chapter

What’s New!! MS. 03. 01. 03 EP 2 DELETED Effective 1/1/2018 The hospital educates all licensed independent practitioners on assessing and managing pain. But don’t get too excited… © Joint Commission Resources § Standard MS. 03. 01. 03 § The management and coordination of each patient’s care, treatment, and services is the responsibility of a practitioner with appropriate privileges.

New Pain Management Standards § Effective January 1, 2018 § FAQs coming soon! © Joint Commission Resources § Includes Leadership (LD); Medical Staff (MS); Provision of Care, Treatment, and Services (PC); and Performance Improvement (PI) chapters

New Standards/EPs § LD. 04. 03. 13 EP 1 -7: Pain assessment and pain management, including safe opioid prescribing, is identified as an organizational priority for the hospital. § MS. 05. 01 EP 18: The organized medical staff has a leadership role in organization performance improvement activities to improve quality of care, treatment, and services and patient safety. § PI. 01. 01 EP 56: The hospital collects data to monitor its performance. § PI. 02. 01 EP 18: The hospital compiles and analyzes data © Joint Commission Resources § PC. 01. 02. 07 EP 1 -8: The hospital assesses and manages the patient’s pain and minimizes the risks associated with treatment.

LD. 04. 03. 13 Pain Mgmt. NEW § EP 1 The hospital has a leader or leadership team that is responsible for pain management and safe opioid prescribing and develops and monitors performance improvement activities § EP 3 The hospital provides staff and licensed independent practitioners with educational resources and programs to improve pain assessment, pain management, and the safe use of opioid medications based on the identified needs of its patient population © Joint Commission Resources § EP 2 The hospital provides nonpharmacologic pain treatment modalities

LD. 04. 03. 13 Pain Mgmt. NEW § EP 4 The hospital provides information to staff and licensed independent practitioners on available services for consultation and referral of patients with complex pain management needs § EP 5 The hospital identifies opioid treatment programs that can be used for patient referrals § EP 7 Hospital leadership works with its clinical staff to identify and acquire the equipment needed to monitor patients who are at high risk for adverse outcomes from opioid treatment © Joint Commission Resources § EP 6 The hospital facilitates practitioner and pharmacist access to the Prescription Drug Monitoring Program databases. (If available)

Replacement § Standard MS. 05. 01 The organized medical staff has a leadership role in organization performance improvement activities to improve quality of care, treatment, and services and patient safety. – Participating in the establishment of protocols and quality metrics – Reviewing performance improvement data Effective January 1, 2018 © Joint Commission Resources § MS. 05. 01 EP 18 The medical staff is actively involved in pain assessment, pain management, and safe opioid prescribing through the following:

Resources for You © Joint Commission Resources § Pain Management Portal https: //www. jointcommission. org/topics/pain_management. aspx § Opioid Overdose Prevention Toolkit § R 3 Report: Pain Assessment and Management Standards for Hospitals

Proposed Changes for © Joint Commission Resources Contracted LIPs

§ Elimination of MS. 13. 01 and MS. 13. 01. 03 © Joint Commission Resources Once again…don’t get too excited…

LD. 04. 03. 09 Proposed Changes 4. Leaders monitor contracted services by establishing expectations © Joint Commission Resources for the performance of the contracted services, by communicating the expectations in writing to the provider of the contracted services (used to be EP 5), by evaluating these services in relation to the hospital's expectations (used to be EP 6), and for hospitals that use Joint Commission accreditation for deemed status purposes: The governing body makes sure that the contracted provider furnishes services in a manner that permits the hospital to be in compliance with the Medicare Conditions of Participation (used to be EP 23).

26. When the hospital contracts with another organization for patient care, treatment, and services provided by a licensed independent practitioner, it does the following: § Verifies the credentials of contracted practitioners and grants privileges through its own process. § For telemedicine services provided by contract, the hospital may use credentialing and privileging information provided by the contracted site and grant hospital-specific privileges through its own process. The hospital obtains a current list of the licensed independent practitioner’s privileges from the contracted organization. § The method for credentialing and/or privileging is documented in the contract and meets the credentialing and privileging requirements in the “Medical Staff” (MS) chapter (Standards MS. 06. 01. 03 through MS. 06. 01. 07). © Joint Commission Resources LD. 04. 03. 09 Proposed Changes

§ EP 26 (continued) § Note 1: For hospitals that do not use Joint Commission accreditation for deemed status purposes: The processes described in EP 26 may be used for all contract services. § Note 2: The contracted practitioner has a license that is issued in or recognized by the state in which the patient is receiving care, treatment, and services. § Note 3: The language of the Medicare Conditions of Participation pertaining to telemedicine can be found in Appendix A at 42 CFR 482. 12(a)(1) through (a)(9) and 482. 22(a)(1) through (a)(4). © Joint Commission Resources LD. 04. 03. 09 Proposed Changes

LD. 04. 03. 09 Proposed Changes © Joint Commission Resources § 27. The hospital sends information to the provider site that is relevant to a licensed independent practitioner’s quality of care, treatment, and services for use in privileging and performance improvement. This includes all adverse outcomes and substantiated complaints about the practitioner.

MS. 01. 01 § “The Bylaws Standard” § EP 3: Most commonly scored EP, must be scored if one of EPs 12 -37 is scored © Joint Commission Resources

§ Every requirement set forth in MS. 01. 01, Elements of Performance (EPs) 12– 37, is in the medical staff bylaws. These requirements may have associated details, some of which may be extensive; such details may reside in the medical staff bylaws, rules and regulations, or policies. The organized medical staff adopts what constitutes the associated details, where they reside, and whether their adoption can be delegated. Adoption of associated details that reside in medical staff bylaws cannot be delegated. For those EPs 12– 37 that require a process, the medical staff bylaws include, at a minimum, the basic steps required for implementation of the requirement, as determined by the organized medical staff and approved by the governing body. © Joint Commission Resources MS. 01. 01 EP 3

MS. 01. 01 EP 16 © Joint Commission Resources § EP 16 : The requirements for completing and documenting medical histories and physical examinations. The medical history and physical examination are completed and documented by a physician, an oralmaxillofacial surgeon, or other qualified licensed individual in accordance with state law and hospital policy.

MS. 01. 01 EP 16 H & P (482. 22 (c)(5)(i)) Update (482. 22 (c)(5)(ii)) © Joint Commission Resources EP 16: Note 2: The requirements referred to in this element of performance are, at a minimum, those described in the element of performance and Standard PC. 01. 02. 03, EPs 4 and 5.

MS. 01. 01 EP 5 § EP 5: The medical staff complies with the medical staff bylaws, rules, and regulations (482. 22 (a)(1) (482. 22 (c) © Joint Commission Resources § If deficiencies are present in histories, physicals or updates…it will be scored here

§ MS. 01. 01 EP 37 § For hospitals that use Joint Commission accreditation for deemed status purposes: When a multihospital system has a unified and integrated medical staff, the bylaws describe the process by which medical staff members at each separately accredited hospital (that is, all medical staff members who hold privileges to practice at that specific hospital) are advised of their right to opt out of the unified and integrated medical staff structure after a majority vote by the members to maintain a separate and distinct medical staff for their respective hospital. (482. 22 (b)(4)) © Joint Commission Resources MS. 01. 01 EP 37

MS. 01. 05 EP 1 -4 § MS. 01. 05 EP 1 -4 contain the details of what is required in multihospital systems and all begin § “If a multihospital system with separately accredited hospitals chooses to establish a unified and integrated medical staff, the following occurs: ” © Joint Commission Resources with the same language as a reminder:

Tips for Success © Joint Commission Resources § Take a copy of the bylaws and the standard EPs 12 -37 and tab where each of the EP’s is located § If the details of any of EPs 12 -37 are in other areas such as the rules, regs, or policies, keep these handy and updated. § Keep these updated every time bylaws, etc. , are revised

MS. 08. 01. 03 Ongoing Professional Practice Evaluation © Joint Commission Resources (482. 22 (a)(1))

MS. 08. 01. 03 § MS. 08. 01. 03: – EP 1: A clearly defined process that helps evaluate each practitioner’s professional practice • All privileged practitioners, including PAs, NPs • Evaluates their “professional practice” – EP 2: Individual departments determine the data to be collected, as approved by the Medical Staff • Clinician-driven standards 68 © Joint Commission Resources – EP 3: The data is used in privileging decisions

OPPE Standard: What’s NOT There § Specific number of metrics § Specific things to be measured § An allowance for data to be used from other sites to assess performance at your organization, i. e. its intent is to reflect performance at YOUR organization! § An explanation of the survey process expectations 69 © Joint Commission Resources § When “zero” data is acceptable and when it is NOT

In other words… § Who? § When? § What? 70 © Joint Commission Resources § How?

Who, When… § WHO • Who will be responsible for reviewing data – Department chair, credentials committee, the MEC, or a special committee – Review must be medical staff driven process; not clerical function • How often the data will be reviewed – Frequency defined by the organizations medical staff such as every three to nine months (twelve months is periodic rather than ongoing) © Joint Commission Resources • WHEN

What… § WHAT – Defined by individual medical staff departments and approved by the organized medical staff – Departments will know best what type of data will reflect both good and problem performance for the various practitioners in their departments – Data not just negative/outlier/trending data, but also data on good performance © Joint Commission Resources • This can be as department specific as warranted by the organization’s service lines

So, OPPE Should Be… § Ongoing (vs. “periodic”) information… § …able to help make privileging decisions… § …for all privileged providers It’s an ongoing assessment of clinical competency – similar to what most of the rest of the healthcare team 73 © Joint Commission Resources have been doing for decades

“ Ongoing” (cont. ) § Examples of effective “ongoing” assessments: 74 © Joint Commission Resources – Promptly assessing all post-op infections against a set of indicators (rather than simply aggregating a year’s worth of post-op infections to look for trends) – Collecting data on response time for pages in ER, ICU, etc – Compliance with measures already being collected, i. e. required data sets from TJC, CMS, DOH, etc.

“Ongoing” (con’t) HOWEVER, § Don’t make the mistake of including every piece of data that is currently being gathered in OPPE. This will dilute the value of the process to the physicians…they need to see the value. So guide department chairs to should lead to an improvement in care 75 © Joint Commission Resources guide their members to choose the data to track that

“…able to help make privileging decisions…” § Ideally, measures will be based on “SMART” goals: Specific Measurable Attainable Relevant Turn-Around in Care 76 © Joint Commission Resources – – –

“…for all privileged providers” § Measures will vary by specialty, clinical setting, and aspect to be assessed; must be consistent for all providers holding a privilege § So, it is important to remember…if an employed practitioner (whose practice is a part of the survey) holds the privilege for which metrics are being used in OPPE, by the same metric(s) 77 © Joint Commission Resources then an independent practitioner must also be evaluated

“…for all privileged providers” § So, now, look at the metrics being followed for OPPE. For example, items you may be able to track for all ambulatory practitioners may be: 78 © Joint Commission Resources – Acceptance of recommendations from radiologists when test appropriateness is questioned – Response time for critical test results/values – Communication with hospitalists regarding patient care

“…for all privileged providers” § In other words, don’t say you are tracking Hgb. A 1 C levels or performance of heart failure education if this data is not available on all LIPs with the same privileges § You may still track any and all of these items for your OPPE. 79 © Joint Commission Resources employed physicians, but they don’t have to be a part of

“…for all privleged providers” § Remember, you are assessing the ability to perform a privilege, not their choice of employment status. § It is not OK to say to a surveyor, “We can only get the information on our employed doctors” § If this is the issue, then review the medical staff – For example: Do you have a “refer and follow” category with no clinical privileges? 80 © Joint Commission Resources categories and their associated privileges

“…for all privileged providers. ” § If they have privileges, they’re subject to OPPE (and – PAs, NPs, CRNAs, etc. – RN First Assists: CMS expectation is that they are credentialed. – Surgical Techs (non-PA, RN, NP): not necessarily, but if in HR, they need to be evaluated the same whether employed by hospital or doctor – Private physician’s employed RN: Should be under HR 01. 07. 01, EP 5, not credentialed. If credentialed, need privileges and OPPE 81 © Joint Commission Resources FPPE)

(Potential) Barriers to Success § Data – Trying to collect data which is too difficult to obtain – Attribution – Inaccurate Data: review signed anyway – Seen as “another program/mandate” – Fear of misuse – or even proper use – Can be a tool to lead to self-correction 82 © Joint Commission Resources § Getting buy-in

§ EP 16 For hospitals that use Joint Commission accreditation for deemed status purposes: The medical staff determines the qualifications of the radiology staff who use equipment and administer procedures. § Can now be done by the Radiology Medical Director (482. 26 (c)(2)) © Joint Commission Resources MS. 03. 01

EP 17 For hospitals that use Joint Commission accreditation for deemed status purposes: The medical staff approves the nuclear services director’s specifications for the qualifications, training, functions, and responsibilities of the nuclear medicine staff. § Can now be done by the Radiology Medical Director (482. 53 (a)(2)) © Joint Commission Resources MS. 03. 01

MS. 03. 01 § This standard often scored if deficiencies are seen in histories and physicals which are scored at MS. 01. 01, EP 5, if no process is in place to monitor © Joint Commission Resources § EP 7 The organized medical staff monitors the quality of the medical histories and physical examinations.

MS. 03. 01 (482. 52 (a)(3)) (482. 12 (c)(2)) (482. 12 (a)(1))… © Joint Commission Resources § EP 2 Practitioners practice only within the scope of their privileges as determined through mechanisms defined by the organized medical staff.

Tips for Success © Joint Commission Resources § Encourage medical staffs to develop audit tool for H and P’s and review these regularly and track data and actions taken § Check applications carefully for possible omissions or oversights

MS. 08. 01 Focused Professional Practice Evaluation © Joint Commission Resources (482. 22 (a)(1))

FPPE: The TJC Standards § FPPE: MS. 08. 01 – EP 1: “A period of focused professional practice evaluation is implemented for all initially requested privileges” • New staff members • Newly requested privileges • No exemption for new Residency grads, etc. 89 © Joint Commission Resources – But the type of evaluation could differ – as long as it’s consistent

FPPE Standards: What’s NOT There § Specific number of metrics § Specific things to be measured § Allowance for use of data from other sites • “Zero is still data”; must ask why no activity § Again, be aware of “local restrictions” 90 © Joint Commission Resources – Data sharing between organizations

“Initial” FPPE: Guidelines § “Begin with the end in mind” – Trying to validate an assumed level of competence – Integrating a new provider into your culture § Ideally, establish indicators which identify potential problem areas § Clearly define what will be expectations during with board letter: ideally send two copies and have them sign one and return to you 91 © Joint Commission Resources appointment process and send a copy to practitioner

“Initial” FPPE Guidelines (cont. ) § Develop criteria which support those objectives – Direct observation? Record review? Testing? • What makes the most sense for the privilege being reviewed? – Some privileges are natural inclusions: i. e. moderate sedation – Adapting to your EMR – Understanding your policies and procedures • Honestly – how effective is a closed record review in assessing robotic surgery skills? ? ? 92 © Joint Commission Resources – What about observing a case or two on a simulator?

“ New Privilege” FPPE Guidelines § Be consistent among requestors – Not necessarily identical • New graduate vs. seasoned provider vs. provider requesting new privilege, but no “free pass” § Be realistic in expectations 93 © Joint Commission Resources – Number and time frame for procedures – will the population support it?

FPPE for Low Volume Providers § Just as for OPPE: – Use what data you have – Consider some “universal” metrics which assess compliance with your policies – Consider granting membership without clinical privileges • Then must decide about voting privileges 94 © Joint Commission Resources • “Zero data is data” • At what point should your organization “close out” FPPE and just implement a 100% review as OPPE if practitioner comes into facility?

FPPE “For Cause”: Guidelines § Remember: it’s a focused evaluation – What’s the focus? – What’s to be evaluated? § Set realistic goals for assessment – Volume and time – Will the patient population support these? – Will they answer your questions? – Reviews/preceptorships at other hospitals – If part of a system, use expertise available 95 © Joint Commission Resources § Consider outside inputs or review

§ EP 6 The credentialing process requires the hospital to verify in writing and from a primary source or CVO: – Current licensure at time of appointment, reappointment, new privilege request, and license expiration. – Relevant training – Current competence (482. 22 (a)(2))… © Joint Commission Resources MS. 06. 01. 03

§ EP 5 The hospital verifies that the practitioner requesting approval is the same practitioner identified in the credentialing documents by viewing one of the following: – Current picture hospital ID – A valid government issued photo ID © Joint Commission Resources MS. 06. 01. 03

§ Spreadsheet and reminders for license or other certification renewals § Process of going up the chain of command § Make sure there is verification of current competence in some way: provide privileges to those who are completing references © Joint Commission Resources Tips for Success

MS. 06. 01. 05 § EP 10 The hospital has a process to determine whethere is sufficient clinical performance information to make a decision to grant, limit, or deny the requested privilege. © Joint Commission Resources (482. 22 (a)(1))

§ Develop solid criteria and use it as a checklist during the credentialing process. § At the time of reappointment, ensure that you have documentation of the performance of a privilege § Pre-populate the privilege forms with the number of times each privilege has been done and outcomes © Joint Commission Resources Tips for Success

MS. 06. 01 © Joint Commission Resources § EP 1 There is a process to determine whether sufficient space, equipment, staffing, and financial resources are in place or available within a specified time frame to support each requested privilege

Tips for Success © Joint Commission Resources § Review privilege lists regularly with medical staff § Keep open lines of communication with directors of departments to get updates if services change

Non-MS Important Standards for © Joint Commission Resources the Medical Staff

Emergency Management © Joint Commission Resources § EM 02. 13 EP 2 The medical staff identifies, in its bylaws, those individuals responsible for granting disaster privileges to volunteer licensed independent practitioners.

Emergency Management © Joint Commission Resources § EM 02. 13 EP 3 The hospital determines how it will distinguish volunteer licensed independent practitioners from other licensed independent practitioners. (Usually in the Emergency Operations Plan)

Emergency Management © Joint Commission Resources § EM 02. 13 EP 4 The medical staff describes, in writing, how it will oversee the performance of volunteer licensed independent practitioners who are granted disaster privileges (for example, by direct observation, mentoring, medical record review).

Emergency Management © Joint Commission Resources § EM 02. 13 EP 5 Before a volunteer practitioner is considered eligible to function as a volunteer licensed independent practitioner, the hospital obtains his or her valid governmentissued photo identification (for example, a driver’s license or passport) AND at least one of the following:

§ A current picture identification card from a health care organization that clearly identifies professional designation § Primary source verification of licensure § Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve Corps (MRC), the Emergency. System for Advance Registration of Volunteer Health Professionals(ESAR-VHP), or other recognized state or federal response organization or group § Identification indicating that the individual has been granted authority by a government entity to provide patient care, treatment, or services in disaster circumstances § Confirmation by a licensed independent practitioner currently privileged by the hospital or by a staff member with personal knowledge of the volunteer practitioner’s ability to act as a licensed independent practitioner during a disaster. § A current license to practice © Joint Commission Resources Emergency Management

Rights and Ethics Medical staff support patients’ rights to: §Make informed decisions regarding care RI. 01. 02. 01 – Be informed of health status – Be able to request or refuse treatment § Formulate advance directives/have staff comply RI. 01. 05. 01 § Have a family member/representative and physician of (482. 13 (b)(1 -4)) § ( ((482. 13 (b)(1)-(4)) 109 © Joint Commission Resources choice notified promptly of hospital admission RI. 01. 02. 01

Rights and Ethics Medical staff support patient rights to: § Informed Consent: RI. 01. 03. 01, RI. 01. 03, RI. 01. 03. 05 § Personal privacy RI. 01. 01 § Freedom from: § (482. 13 (b) (1 -4)) 110 © Joint Commission Resources – all forms of abuse/harassment/punishment RI. 01. 06. 03 – restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff PC. 03. 05. 01

Autopsies § The medical staff should attempt to secure autopsies in all cases of unusual deaths and of medical-legal and educational interest. MS. 05. 01 EP 17 § The mechanism for documenting permission to perform an autopsy must be defined. RI. 01. 05. 01 EP 21 § There must be a system for notifying the medical staff, autopsy is being performed. MS. 05. 01 EP 17 § 482. 22(d) 111 © Joint Commission Resources and specifically the attending practitioner, when an

© Joint Commission Resources Questions?

Contact Information § lmccourt@jcrinc. com © Joint Commission Resources § PH: 216 -409 -4643