matching privileges with competency 9/17/2018 6:39 PM matching privileges with competency Kathy Matzka, CPMSM, CPCS 1304 Scott Troy Rd, Lebanon, IL 62254 (618) 624-8124 kathymatzka@kathymatzka.com www.kathymatzka.com © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION. 1

What We Will Cover… CMS Regulations/TJC Standards Regarding Competency Developing Privilege Forms Monitoring (QAPI/FPPE/OPPE) and Proctoring Documenting Recommendations

What is competence? Ability to do a particular activity to a prescribed standard or a desirable outcome Based on knowledge, traits, skills, and abilities

Competency for Privileges Matching Privileges with Competency Competency for Privileges Training Recently performed # of patients admitted/discharged/consulted/treated # of procedures performed Documented good results through performance improvement activities/OPPE reports/report cards

CMS Regulations and Interpretative Guidelines for Hospital

Medicare CoP Privileging Criteria Character Competence Judgement Experience Training Criteria

Hospital IG §482.22(a)(2) Medical Staff Evidence of Current Licensure References of Competence Privileges Request Documented Experience Evidence of Training and Education Credentials Examined See Sample Letters Pages 1-11

Medicare CoPs Interpretative Guidelines §482.22(a)(2) Medical Staff It cannot be assumed that every practitioner can perform every task/activity/privilege that is specified for the applicable category of practitioner. The individual practitioner’s ability to perform each task/activity/privilege must be individually assessed

Joint Commission Hospital Standards for documenting competency

Morbidity and mortality data, when available MS.06.01.05 – Privileging – Before recommending privileges MS evaluates Relevant practitioner-specific data as compared to aggregate data, when available Morbidity and mortality data, when available Hospital has a process to determine if it has adequate clinical performance information to make its decision regarding the granting, limiting, or denial of privileges

Clinical Privileges

Privileging Involves documentation and evaluation of the actual patient care, treatment, or services that will be provided at your facility

Delineation of Privileges Should Include: Clear indication of what procedures can be requested by whom Criteria for requesting and maintaining

Privileging Systems Categories or Levels Lists or “Laundry Lists” Core Combination

“Special Privileges” Require additional skills/training May differ depending on when technology was developed Contractual considerations

Transference of skill A transference of skill occurs when the same skills are utilized for different procedures If a physician has not performed a specific procedure, but has performed another procedure where those skills would transfer these can be grouped together May not apply to surgeries requiring more specialized skills or for complex surgeries not regularly performed

Adding New Privileges Who will be able to do it? What training/experience is required? Are there any other requirements? CME, board certification, training course, peer recommendations Will proctoring be required? How will we follow up/review quality? Is there a transference of skill? See worksheet page 49

Monitoring/Proctoring FPPE/OPPE/QAPI

Provisional Appointment Clinical work is subject to review and evaluation for a period of time May include proctorship, chart review

See Sample FPPE Plan page 12

Proctoring Can use more than one proctor Partners may be proctors (or not) All proctors complete same review form and report findings via standard process See Sample Forms Pages 13 - 14

Specialty OPPE and FPPE Indicators Matching Privileges with Competency Specialty OPPE and FPPE Indicators   DEPART-MENT FPPE Initially Granted "Core" Privileges (Focused Review) Triggers OPPE Indicators General Surgery Direct observation of X procedures and complete Surgical Review Form for each… AND/OR Review of x charts for adequacy of consultation and operative reports … … in each of the following categories Head & neck Alimentary tract Abdomen Vascular Ambulatory surgery patient admitted for complications of procedure Unplanned injury/ repair/laceration Consult delay > 24 hours Retained foreign body Wrong site surgery Unplanned removal of organ Unplanned return to surgery rate Rate of compliance with surgical infection prevention measures Complication rates Rate of compliance with DVT prevention measures Informational letters sent Medical records Clinical protocols Medicine Review of X charts and complete Medical Review Form for each … Review of X charts for adequacy of H&Ps and consultation reports … in specific DRGs/diagnoses Unplanned transfer to special care unit Adverse outcome unrelated to natural course of illness Critical/abnormal lab result unaddressed Death in low mortality DRGs Pneumonia measures CHF measures Acute MI measures ALOS Informational letters Other R&R

Attributing Care – Medical Staff Decision… Should a patient or service be associated with only a single MD or with a group of MDs? Should hospitalists be carved out of general internal medicine? Good Resource: Pay for Performance in Health Care: Methods and Approaches http://www.rti.org/rtipress

Competency for Re-privileging Matching Privileges with Competency Competency for Re-privileging Procedures Performed # of patients admitted/discharged/consulted/treated # of procedures performed Diagnoses Treated Admissions/Consults by DRG Compare to privilege list Are criteria met? Transference of skill? Good Results From QAPI/FPPE/OPPE Comparative data Remember Frigo vs. Silver Cross!

Documenting Recommendations Use standardized forms FPPE/OPPE Appointment/Privileges Document in minutes See Sample Forms and Minutes Language Pages 15 - 19

Dealing with Low or No Volume Practitioners

Get Data From Another Organization/Office Need policy and appropriate consent/release Will not replace OPPE, but can use to supplement Office data Kinds of patients Procedures performed Keep in mind - may not be relevant to hospital privileges See sample letter pages 7 and 8

Ask Why they Want to be on Staff Practices change over time Office assistants complete forms Managed care may require admitting privileges See sample letter and survey pages 20 - 21

Questions ? Comments!