JOINT COMMISSION PANEL Panel discussion regarding recent joint commission surveys MASSACHUSETTS ASSOCIATION OF MEDICAL STAFF SERVICES May 11, 2017

PANEL MEMBERS Kimberley M. Coon, BA, CPMSM, CPCS – Director of Medical Staff Services/Provider Enrollment, Southcoast Health System Barbara E. Prats, CPMSM, CPCS – Manager Baystate Health, Central Verification Organization Karen Roy, CPCS, Sr. Credentials Specialist, Emerson Hospital Inna Voskresensky, MHA, CPCS, CPMSM – Spaulding Rehabilitation Network Credentialing Manager

PANEL MEMBERS This interactive panel will share their experience with their most recent JC survey, the focus areas of the surveyors, survey findings, and the surveyor’s recommendations and suggestions for improving our practices.

Key Learning Objectives How to prepare for a successful JC survey Review of the recent JC surveys & lessons learned Review of the best practices shared by the surveyors The survey is over – now what?

Preparing for the JC survey MOCK survey The JC binder (include MS governing documents, credentialing policies and procedures, etc.) Credentialing files audit FPPE/OPPE audit Policies revision Evaluation of compliance with the JC MS standards Follow up on findings/things that need to be fixed Educational flyers

Preparing for the JC Survey (cont’d) Notes for surveyor Arrange scribing of the JC MS session Review most recent JC surveys notes/findings from other institutions Prepare your Credential Committee Chair and Medical Staff President Once the JC arrives

Preparing for the JC Survey (cont’d) Identify key staff and leaders to attend the session: Credentials Office Staff Credentials Committee Chair Chief Medical Officer Department of Medicine Chair Department of Surgery Chair FPPE/OPPE Coordinator Professional Review Committee Chair

Preparing for the JC Survey (cont’d) Send Bylaws and other policies to the team leader for the JC surveyors if you haven’t at this point Wait to receive your list of files for the audit, then review your files prior to the scheduled session with the JC Know your surveyor (google him/her) prior to meeting him/her

SURVEY “HOT TOPICS” Authentication of providers orders FPPE/OPPE – Your own policy needs to be followed Restraint documentation is properly completed and timeline is followed Temporary Privileging process Expedited Privileging process Medical Executive Committee recommendation to Board of Trustees for all credentialing matters Medical Executive Committee meeting minutes carefully reviewed

SURVEY “HOT TOPICS” (cont’d) Credentialing telemedicine providers Residents and fellows oversight (GMEC role and responsibilities) Orientation/onboarding of new providers Education of clinical staff on how to check who is credentialed and what privileges practitioner has Practitioners with procedural privileges in regards to F/OPPE FPPEs – when, how, who

SURVEY “HOT TOPICS” (cont’d) OPPE for Advanced Practitioners Services Contract – particularly the opt out clause if metrics and expectations weren’t met Credentials Committee Chair’s knowledge of the FPPE and OPPE Proof of valid ID for Providers Transition from a paper file to an electronic credential file

Best Practice - Medical Staff Leadership Collaboration = Survey Success Build a partnership with medical staff members and leaders Provide education regarding standards Collaborate to identify opportunities for process improvement Accountability to the Medical Staff Office – for a win/win outcome Reinforce the value of going the extra mile

BEST PRACTICES IDENTIFIED BY SURVEYOR State license and NPDB report completed within 2 months from the Board approval date Consistency in how you address outliers (OPPE) Telemedicine providers OPPE completed by the distant site The use of a Premier Benchmarking Report on our Physicians for OPPE The review of electronic files

Best Practice Identified for OPPE OPPE Preparation: Create a dashboard “on paper” showing the metrics of interest for each group, listed by practitioner name The dashboard was created using PowerPoint. It consisted of screen shots from a physician performance evaluation tool, excel pivot tables, and excel graphs. Once the list of practitioners to be audited were identified; names were highlighted for easy identification. Snap shots of “sign offs” were also prepared to validate timely approvals.

THE SURVEY IS OVER – WHAT’S NEXT? Present the findings/recommendations/suggestions to the Credentialing Committee & Medical Staff Executive Committee Develop a plan to improve current practices (include goals, timelines for implementation, responsible parties, etc.) Monitor new practices Measure success Re-educate, re-evaluate

THE SURVEY IS OVER – WHAT’S NEXT? If major findings, submit any improvement plan to the JC by the required time frame

Appreciation/M0tivation for Staff