EDGE-U-CATE, LLC 2018 CPMSM/CPCS CERTIFICATION FOCUSED STUDY PROGRAM Developed by Janet Wilson, CPMSM, CPCS ©Edge-U-Cate, LLC This documentation is proprietary and cannot be used or  duplicated without the express permission of Edge-U-Cate, LLC

WHY CREDENTIAL? HOSPITALS/SURGERY CENTERS = Assure that only qualified practitioners are granted membership and privileges MANAGED CARE = Assure that only qualified practitioners are approved to provide services to members

Review of Accreditation and Regulatory Entities The Joint Commission (TJC) accredits subscriber hospitals, ambulatory care centers, surgery, rehab centers, long term care centers, etc. Healthcare Facilities Accreditation Program (HFAP) provides accreditation programs for allopathic and osteopathic acute care hospitals, critical access hospitals, ambulatory surgical centers, ambulatory care/office based surgery, clinical laboratories, and behavioral health facilities. While previously primarily osteopathic focused, HFAP is now authorized by the Centers for Medicare and Medicaid Services (CMS) to survey all hospitals for compliance with the Medicare Conditions of Participation and Coverage.   The Centers for Medicare & Medicaid Services (CMS) is a branch of the U.S. Department of Health and Human Services. CMS is the federal agency that administers the Medicare program and monitors the Medicaid programs in each state.

Review of Accreditation and Regulatory Entities The National Committee for Quality Assurance (NCQA) manages voluntary accreditation programs for individual physicians, health plans, medical groups. NCQA also manages certification programs for CVO’s. URAC, formerly known as the Utilization Review Accreditation Commission promotes healthcare quality by accrediting healthcare organizations including medical management organizations (disease management, case management, health call centers, Independent Review Organizations, etc.), health plans (HMOs, PPOs, etc.), hospitals and health websites

Review of Accreditation and Regulatory Entities The Accreditation Association for Ambulatory Health Care (AAAHC), accredits ambulatory health care organizations, including ambulatory surgery centers, office-based surgery centers, endoscopy centers, and college student health centers, as well as managed care organizations, such as health maintenance organizations and preferred provider organizations. DNV-GL – not included in 2018 certification exams

REVIEW OF CREDENTIALING STANDARDS/ REQUIREMENTS

Pre-Application (screening tool) State Mandated Applications Addendums CAQH (Council for Affordable Quality Healthcare) Don’t Modify Applications – legal document

Complete Application Best Practice Don’t start verification process until all information complete and attachments received Reality Use best judgment based on documents received and required turn around times Follow bylaws/policies

Verification Process (I) = Initial Application Process (R) = Reappointment/ Reappraisal Process

Practitioners Credentialed- TJC Licensed Independent Practitioner (LIP) = Any LIP permitted by law and organization to provide care, treatment, and services without direction or supervision within the scope of the individual’s license and consistent with individually granted privileges. Traditionally MD, DO, DMD, DDS, DPM

APN or PA - TJC If APN or PA function as LIP, they must be credentialed through organized medical staff If non-LIP APN or PA, may be credentialed through medical staff standards or human resources equivalent process. Equivalent process must be approved by governing body and must include communication and input from MEC

APN or PA - TJC Equivalent process must include: - a documented evaluation of the applicants credentials - a documented evaluation of the applicants current competence - documented peer recommendations - process must include input from individuals and committees,including the medical executive committee, on order to make an informed decision regarding request for privileges

Practitioners Credentialed – NCQA P&P’s that apply to all licensed practitioners who provide care to the organization’s members All LIP’s certified or registered by the state to practice independently Must be credentialed - Physicians (MD/DO), Oral Surgeon/Dentists, Podiatrists, Chiropractors, non- physician practitioners with independent relationship with organization. Further defined as when organization selects and direct members to individual or group (ie. practitioners members can select as PCP)

Practitioners Credentialed – NCQA Must credential behavioral health specialists who are licensed, certified or registered by state and practice independently including Psychiatrists, Addiction Medicine Specialists, MSN, MSW who practice independently Do not have to credential: Practitioners contracted to practice exclusively in inpatient setting (Pathologists,Radiologists,Anesthesiologists, Hospitalists, Telemedicine, Neonatologists, ED phy) Dentists who provide primary dental care Locum Tenens

Practitioners Credentialed - CMS Governing body determines, in accordance with state law, which categories of practitioners are eligible for appointment to the medical staff At a minimum, medical staff must be composed of physicians (MD/DO) Other practitioners may be included as defined by Social Security Act (DDS/DMD, OD, DC) Others as defined by governing body (ie. NP, PA, CRNA, Midwives)

Practitioners Credentialed - CMS Non-physicians performing surgical tasks (dentists, podiatrists, RN first assistant, NP, surgical techs) Requires definition of surgical procedures that must be supervised and degree of supervision (ie. present in OR, in line of sight) Practitioners may be granted privileges without membership

Practitioners Credentialed - HFAP Governing body determines, in accordance with state law, which categories of practitioners are eligible for appointment to the medical staff At a minimum, medical staff must be composed of physicians (MD/DO) Other practitioner disciplines as defined by governing body Medical staff membership limited to licensed physicians, DDS, DPM

Practitioners Credentialed - HFAP Allied health practitioners (AHP) may be granted privileges Governing body, following consultation with medical staff, determines AHP disciplines All practitioners that provide medical/surgical care either directly or under supervision must be credentialed

Practitioners Credentialed - URAC Credentialing Program Plan defines participating providers and facilities who must be credentialed. At a minimum: Participating providers who are contracted to provide health care services to consumers Facilities that provide covered health care services to consumers Practitioners/facilities listed in directory

Practitioners Credentialed - AAAHC As approved by the Board, Bylaws or P&P, establish minimum training, experience, and other requirements for physicians and other healthcare practitioners. At a minimum, physicians and dentists.

Primary Source Verification The original source that can verify the accuracy of a credential, qualification, or other information reported by the practitioner Required by all accrediting bodies

Designated Equivalent Source (DES) - TJC Primary source may designate another organization as its agent Entities that have been determined to maintain specific credentials information identical to information at primary source AMA, AOA, ECFMG, etc.

Secondary Source – TJC First must attempt to verify primary source If entity closed or records not available.. - may contact another hospital to verify information - may contact practitioner who served at hospital at same time

Secondary Source - AAAHC Info from another healthcare organization that has performed PSV can be used provided as long copies of original documents can be received and relied upon

Medical Education TJC Requirement (I) primary source verification from Medical School Accepted designated equivalent sources: AMA Profile (US and Puerto Rico), AOA Profile, ECFMG NCQA Requirement (I) Primary source verification from Medical School Not required if board certified or if residency has been verified Alternate sources: Medical School, AMA/AOA profile,ECFMG (after 1986), state licensing agency If state licensing agency is utilized, documentation must be updated annually

Medical Education CMS Requirement Medical staff must have a mechanism to examine evidence of professional education Must be included in criteria for membership/privileges CMS does not specify acceptable sources for verification HFAP Requirement Primary source verification required Additional source: AMA Profile, AOA Profile, ECFMG

Medical Education URAC Requirement Credentialing application includes history of education PSV not required if board certified May use state licensing board if documented AAAHC Requirement PSV required at initial appointment

Post Graduate Training TJC Requirement (I) Primary source verification from training programs Accepted Designated Equivalent Sources for U.S. and Puerto Rico: AMA Profile, AOA Profile NCQA Requirement (I) Primary source verification from residency training program Alternate sources: AMA Profile, AOA Profile, state licensing agency Not required if board certified

Post Graduate Training CMS Requirement Medical Staff must have a mechanism to verify training and experience Governing Body ensures criteria for selection is based on : (1)character (2)competence, (3)training (4)experience (5)judgment HFAP Requirement Training must be sufficient to support requested privileges PSV required through training program, AMA Profile, or AOA Profile

Post Graduate Training URAC Requirement If not board certified must verify highest level of education. Must document history of education/training on application Time limit: six months AAAHC Requirement Primary source verification required at initial appointment

Board Certification TJC Requirement Not required unless bylaws/privileges require board certification (I & R) Verify through ABMS Display Agents, AMA/AOA profile or specialty board NCQA Requirement Not Required (I & R) Verify through ABMS display agents, AMA/AOA profile, state licensing agency if board certified May not use ABMS consumer website (I & R) Lifetime certification must be documented 180/120 day time limit

NCQA Definitions 180/120 day time limit When document is submitted to Credentials Committee, verification date may not be older than 180 days. When CVO submits verification to Health Plan, verification date may not be older than 120 days. 365/305/180 Medicare Advantage - time limit When file is submitted to Credentials Committee, attestation date may not be older than 365 days. When CVO submits file to Health Plan, attestation date may not be older than 305 days. If physician on Medicare Advantage plan, attestation may not be older than 180 days.

Board Certification CMS Requirement No requirements Organization may not make decisions based solely on board certification – must consider all elements (license, training, experience, etc.) ABMS Display Agents, AMA Profile, AOA Profile HFAP Requirement Not required Membership and Privileges cannot be dependent solely upon certification, fellowship or membership in specialty body / society Must include other criteria, training, character, competence, judgment. Must document certification status and verification must include sanction information ABMS Display Agents, AOA Profile

Board Certification URAC Requirement Not Required Verify through ABMS display agents, AMA Profile, AOA Profile, state licensing agency if board certified (I) Verify at initial and upon expiration Six month time limit AAAHC Requirement Not Required PSV verify if organization requires board certification Continuous monitoring required – verify upon expiration

STATE LICENSE TJC Requirement (I & R) Primary source verification required at initial appointment, reappointment, revision/addition of privileges; also at expiration Verify through state licensing board NCQA Requirement Statement on application re: history of loss of license (I & R) Primary source verification thru state licensing board -required for all states where practitioner provides care License must be current when file presented to Credentials Committee NOTE: Utilize AIM DocFinder only if directed to site by state board 180/120 time limit

STATE LICENSE CMS Requirement HFAP Requirement Medical staff must have mechanism to verify current license No defined acceptable sources – assumption would be licensing board Silent regarding verification at time of expiration HFAP Requirement PSV required for all states where practitioner practices or intends to practice Also PSV all previous licenses held Telemedicine – must be licensed in state practitioner and patient are located

STATE LICENSE URAC Requirement PSV required Verification must include date of expiration, date verified and sanction status License must be current and valid when presented to Credentials Committee AAAHC Requirement PSV required Ongoing monitoring required

License Sanctions TJC Requirements NCQA Requirements (I & R) The doctor must provide information regarding challenges to licensure or registration & voluntary/involuntary relinquishment of license or registration Info must be evaluated before recommending privileges TJC silent on verification - May be verified thru licensing board NPDB or FSMB NCQA Requirements (I & R) Primary source verification of sanctions, restrictions on licensure, limitations on scope of practice for past five years in all states where applicant licensed Verify through state license board, NPDB,FSMB,HIPDB 180/120 time limit

License Sanctions HFAP Requirement CMS Requirement Not addressed HFAP Requirement (I) PSV of license sanctions for all current licenses, state of current practice or intended practice, all previous licenses held (R) PSV all current licenses Include previously successful and/or currently pending challenges to license; voluntary/ involuntary relinquishment of license NPDB & FSMB or FACIS

License Sanctions URAC Requirement List all current and historical licenses/sanctions on application PSV required for past five years practice history AAAHC Requirement List current/past license revocation, suspension, voluntary status, probationary status on application PSV and review at initial and reappointment

Malpractice Insurance TJC Requirements Not Required Primary source verification not required unless required by bylaws. (I & R) Verify through carrier or by current copy of policy showing dates and amount of coverage NCQA Requirement Primary source verification not required (I & R) Attestation by doctor, or policy face sheet showing dates and amount of coverage 365/305/180Medicare Advantage - time limit

Malpractice Insurance CMS Requirement Not required PSV not required HFAP Requirement PSV not required unless stated in bylaws (I & R) Verify through carrier or by current copy of policy showing dates and amount of coverage

Malpractice Insurance URAC Requirement Copy of cover sheet or attestation required for proof of insurance; must include name of practitioner, expiration date, and liability covered. If cover sheet does not include the name of the practitioner, then a copy of those covered under plan should be printed on insurer's letterhead and attached to cover sheet. AAAHC Requirement Evidence of policy if required by organization Applicant provides evidence of refusal or cancellation of coverage at initial and reappointment

Malpractice History TJC Requirement (I & R) Applicant must provide information regarding claims history (at a minimum must include final judgments/settlements) (I & R) Medical Staff must evaluate evidence of unusual pattern or excessive # of actions resulting in final judgment May verify with carrier or NPDB NCQA Requirement (I&R) Doctor must provide malpractice history for past five years. Five years history verified through carrier or NPDB (self query info from applicant not acceptable) 180/120 time limit

Malpractice History CMS Requirement Not addressed in standards HFAP Requirement 5 year history evaluated Malpractice history required from carrier or NPDB

Malpractice History URAC Requirement Organization defines time frame for history that must be provided by applicant and then evaluated Malpractice history (settlements and final judgments required from carrier or NPDB AAAHC Requirement Applicant must provide claims history on application Organization must evaluate

Work History TJC Requirement NCQA Requirement Term not used, However, evidence of current competence is required Organization should obtain information regarding licensure, education, training, experience and competence. NCQA Requirement (I) Doctor must provide five year work history on application or CV (should include month and year in all dates) No verification required but must explain gaps of 6 months or more verbally or in writing; if gap more than one year must explain in writing 365/305/180

Work History CMS Requirement Terminology not addressed in standards However, examination of experience and competence is required HFAP Requirement Applicant must provide healthcare employment and affiliation PSV required to include pending investigations, disciplinary actions, voluntary resignations, relinquishment of memberships/privileges/contracts

Work History URAC Requirement Not specifically addressed AAAHC Requirement Applicant to provide work history with explanation of time gaps Experience reviewed for continuity and relevance

CURRENT COMPETENCE Initial Application - TJC Primary source verification from post graduate training facilities, hospitals or other relevant organizations Must contain informed opinions of applicant’s professional performance Can use peer reference if specific questions about competency included on verification form Should include information about six general competencies

ACGME/ABMS - Six General Competencies Patient Care Medical/Clinical Knowledge Practitioner-based learning and improvement Interpersonal and communication skills Professionalism Systems-based practice

Focused Professional Practice Evaluation – (FPPE) TJC Process whereby the organization evaluates the privilege-specific competence of a practitioner who does not have documented evidence of competently performing privileges at the organization Used when question arises regarding a practitioner’s ability to perform safe, high quality patient care

Focused Professional Practice Evaluation – (FPPE) TJC Required for all initially requested privileges Review period defined by the medical staff and can include extension or different type of evaluation process if needed FPPE may include chart review, monitoring clinical practice patterns, simulation, proctoring, external peer review, discussion with others involved in patient care (ie. physicians, nurses, admin, surgical assistants, etc.)

Clinical Competence Reappointment - TJC Determined by results of Ongoing Professional Practice Information (OPPE) and ongoing performance improvement activities, peer recommendation if no OPPE data available, department recommendation Data must be based on ongoing monitoring of performance Should include information about six general competencies

Ongoing Professional Practice Evaluation (TJC - OPPE) Evaluation of the outcome of operative or other clinical procedures Use of blood and pharmaceutical products Utilization of testing and procedures Length of stay Morbidity and mortality data Use of consultants Other information as deemed relevant

Ongoing Professional Practice Evaluation (TJC - OPPE) OPPE information may be obtained by: Chart review Concurrent observation Monitoring of diagnostic and therapeutic treatments Discussion with others involved inpatient care (ie. physicians, nurses, admin, surgical assistants, etc.)

Current Competence - CMS (I) Medical staff must have mechanism to review education, training, experience and supporting references of competence Criteria must be established for determining privileges and consider individual character, competence, training, experience, judgment

Clinical Competence Reappointment - CMS Medical staff must conduct periodic review of members Must evaluate qualifications and demonstrated competence to perform activity within scope of privileges Should include at least current work practice, special training, quality of specific work, patient outcomes, education, maintenance of continuing education, adherence to medical staff rules, certifications, licensure, compliance with licensure requirements

Current Competence NCQA – not addressed in standards URAC – not addressed in standards AAAHC – Applicant provides documentation of current competence with initial application; information is verified with peers

Current Competence - HFAP Initial Appt – Applicant provides documentation regarding clinical activity from training program or healthcare affiliations (ie. procedure logs) Membership criteria requires gathering of information regarding current competence, license, education, training, health, experience, character, judgment. Information is evaluated by medical staff

Current Competence - HFAP Reappointment – Recommends appraisal be conducted at least every 24 months OPPE info factored into decision to maintain privileges. Data collected at least 3 times during 2 year reap cycle. At a minimum include, work/practice, special training, quality of specific work, patient outcomes, education, maintenance of CME, adherence to bylaws, certifications, licensure

Medicare/Medicaid Sanctions TJC Requirements Not addressed in standards NCQA Requirement (I & R) Current or previous sanctions must be verified (at least past three year period) Verify through NPDB, HIPDB, OIG, FSMB, AMA profile, state Medicaid agency 180/120

Medicare/Medicaid Sanctions CMS Requirements Not addressed in standards HFAP Requirements Applicant provides information regarding investigations or disciplinary action taken Verified through NPDB also can use FSMB or FACIS Reviewed by organization

Medicare/Medicaid Sanctions URAC Requirements Applicant must report on application Verify with NPDB or issuing organization Time limit: 6 months AAAHC Requirements Applicants provides information Information evaluated at initial and reappointment

Ongoing Monitoring Of Sanctions TJC Requirements Not specifically addressed in standards NCQA Requirement P&P’s for the ongoing monitoring of sanctions Monitoring occurs as information is published (if not published, reviewed at least every six months). Must review w/in 30 days of release of info 1) Medicare/Medicaid 2) License 3) Patient Complaints (reviewed every 6 months) 4) Identified adverse events (reviewed every 6 months)

Ongoing Monitoring Of Sanctions CMS Requirements Not specifically addressed in standards HFAP Requirements Not specifically addressed in standards

Ongoing Monitoring Of Sanctions URAC Requirements P&P required to identify criteria for review/investigation of potential quality of care issues AAAHC Requirements Gather and review information on complaints or adverse action reports from professional society or licensure board

DEA/CDS -Federal Drug Enforcement Certificate State Controlled Dangerous Substance Certificate TJC Requirement (I & R) Practitioner must provide info regarding previously successful or currently pending challenges or relinquishment of registrations (I & R)Medical Staff evaluates challenge and voluntary or involuntary relinquishment of registration Copy of certificate, NPDB,NTIS, AMA/AOA Profile NCQA Requirement (I & R)Verify through copy of certificates, DEA, NTIS,State CDS, AMA/AOA Profile Verification required in each state where individual provides care DEA/CDS not applicable to chiropractors - CDS not applicable to Dentists 180/120 DOES NOT APPLY TO THIS ELEMENT (Certificates must be current at time of review/approval and/or transmittal by CVO)

DEA/CDS -Federal Drug Enforcement Certificate State Controlled Dangerous Substance Certificate CMS Requirement Not Addressed in standard HFAP Requirement Application includes information regarding actions/sanctions against DEA/CDS PSV through NPDB

DEA/CDS -Federal Drug Enforcement Certificate State Controlled Dangerous Substance Certificate URAC Requirements Applicant must submit DEA/CDS with application Time limit: 6 months AAAHC Requirements Information gathered, evaluated at initial appointment with required ongoing monitoring

Ability To Perform Clinical Privileges Requested (Health Status) TJC Requirement (I&R) Applicant must provide information regarding health problems that might affect his ability to exercise privileges (I&R) Information should be confirmed by training program director, peer reference, dept chief or chief of staff at another hospital (I & R) Must evaluate ability to perform privilege (health) External evaluation may be required NCQA Requirement (I&R) Doctor must provide current, signed attestation documenting if he is unable to perform essential functions with or without accommodation and a statement regarding lack of present illegal drug use 365/305/180MA

Ability To Perform Clinical Privileges Requested (Health Status) CMS Requirements Not addressed in medical staff standards Surgical services standards requires written assessment of health status HFAP Requirements Professional reference should include questions regarding physican and mental health status. Application review process requires evaluation of health status at (I) and (R) Membership criteria includes health status information

Ability To Perform Clinical Privileges Requested (Health Status) URAC Requirements Applicant must disclose any physical, mental or substance abuse problems that could without reasonable accommodation, impede the practitioners ability to provide care or pose a threat to the health or safety of patients AAAHC Requirements (I&R) Gather and review information regarding physical, mental health, or chemical dependency problems that would interfere with the ability to provide high-quality patient care or services

Hospital Membership/Privileges TJC MedStaff must evaluate info regarding history of voluntary or involuntary termination of medical staff membership and the voluntary or involuntary limitation, reduction, or loss of clinical privileges at another hospital May grant membership without privileges and vice versa NCQA Application must include signed, dated attestation statement from applicant regarding history or limitation of loss of clinical privileges or other disciplinary action at all hospital affiliations NOTE: NCQA does not require doctors to have clinical privileges at an acute care facility; however, managed care companies may have this requirement 365/305/180MA

Hospital Membership/Privileges -CMS No specific requirements for verification/evaluation of previous or current membership and/or clinical privileges on a medical staff Bylaws describe criteria for determining privileges to be granted and procedure to apply Criteria cannot be solely dependent on board certification Scope of Privileges defined Ensure competency to perform granted privileges

Hospital Membership/Privileges - HFAP Bylaws describe criteria for privileges - may not be based only on board certification. Surgical privileges must be delineated based on competency. Degree of supervision must be defined for AHP's and included on surgical privilege list. Application requires list of all healthcare employment/medical staff membership/ privileges Must verify information to include pending investigations of disciplinary actions/ voluntary resignation/ relinquishment of membership/ privileges/contracts

Hospital Membership/Privileges URAC Requirements Applications must list hospital affiliations and privileges Applications cannot be more than 180 days old at approval date AAAHC Requirements Governing body must establish minimum training, experience and other requirements for physicians and non-physicians. Governing body must either directly or by delegation, make initial appointment, reappointment, assignment or curtailment of privileges based on peer evaluation

Clinical Privileges System- TJC Med Staff responsible for planning/ implementing priv process (develop and approve procedures list, process application, evaluate applicant-specific information, submit recommendations to board, notify applicant and relevant personnel of privilege decision, monitor use of privilege and quality of care issues) Decisions to grant/deny are objective, evidence based processes Must be approved by board Criteria established and consistently evaluated - Should include six general competencies Org must assure facility resources are available (I) Peer and/or faculty recommendations are obtained along with practice info from another organization (R)OPPE Requirement for setting specific privileges deleted

Clinical Privileges System - CMS Qualifications/criteria must be defined (consider character, competence, training, experience, judgment) – must be approved by Governing body Practitioner must be evaluated for competency to perform requested privileges Practitioners ability to perform each task/activity/privilege must be individually assessed Organization must have process to ensure practitioner working within scope of privileges Periodic appraisal conducted to determine if clinical privileges should be continued/discontinued/revised Surgical Services COP’s require that a current roster listing each practitioners specific privileges, must be available in surgical suite and surgery scheduling (suspension /privilege restricted list must also be available)

Clinical Privileges System- HFAP Bylaws define process for granting privileges to all practitioner categories Qualification/criteria and how criteria applied must be defined. Must be approved by Board. Facility resources must be considered. Surgical privileges must be delineated based on competencies. Qualifications/competencies must be reviewed for each privilege. Evaluate education, training, current practice, quality of work, outcomes, CEU/CME, adherence to requirements. AHP criteria must identify privileges performed with/without supervision AHP’s must have an annual competence/skill assessment

Clinical Privileges System-AAAHC 3 step process – 1) determine clinical procedure/treatment offered to patient; (2) determine qualifications related to training and experience that are required to authorize an applicant to obtain each privilege; 3) establish a process for evaluating the applicant's qualifications using appropriate criteria and approving, modifying, any and all of the requested privileges in a non-arbitrary manner. May not be based solely basis of privileges at another facility. Must be periodically appraised

National Practitioner Data Bank TJC/AAAHC/HFAP Requirement (I&R) Required at initial membership and privileges, recredentialing and granting of additional or expanded clinical privileges Required for physicians, dentists and other practitioners granted privileges through medical staff NCQA Requirement As of July 2003, NCQA no longer requires separate query of NPDB. CMS/URAC Requirement Standards silent regarding querying, must follow state/federal laws regarding querying/ reporting

History Of Felony Convictions TJC Requirements Verification not required Must verify if required by bylaws or state law Practitioners employed by hospital –background check required as defined by HR standards NCQA Requirements (I&R) Application must contain statement from applicant regarding his history of loss of license and felony conviction 365/305/180MA CMS – Standards silent

History Of Felony Convictions HFAP Requirement Application must request info on criminal history for past 7-10 years Information must be verified URAC Requirement Not addressed in standards AAAHC Requirement Gather and review info regarding conviction of criminal offense (excluding minor traffic violations) at initial and reappointment

Identity - TJC TJC Requirement (I) Credentialing process must include a mechanism to ensure that the applicant is the same person as identified in the credentialing documents Must view picture hospital ID or valid picture ID issued by state or federal gov (drivers license or passport)

Attestation Statement TJC/CMS/HFAP Requirements Terminology not used NCQA Requirements Applicant must provide a current, signed attestation statement attesting to the correctness and completeness of application, health status, history of loss or limitations of license or privileges 365/305/180MA

Attestation Statement URAC Requirement Application must include a signed/dated statement authorizing organization to collect information necessary to verify the information in the credentialing application Must include a statement attesting that the information on application is complete and accurate to the practitioners knowledge 180 day time frame applies for initials AAAHC Requirement Signed and dated release and attestation statement regarding complete and correct information on application Required for initial and reappointment

Peer Recommendations TJC Requirements (I) Required - Must be within same professional discipline with knowledge of ability to practice, ability to work as team and ethical behavior Recommendations should address medical/clinical knowledge, technical/ clinical skills, judgment, communication/interpersonal skills, professionalism (R) Required only if there is insufficient practitioner specific data to be evaluated. May use PI committee review, department chief, MEC. NCQA Requirements (I&R)Credentials Committee (using a peer review process) designated to make recommendations regarding credentials decisions. Representation from range of participating practitioners May delegate “clean” files to medical director CMS – Medical Staff must have mechanism to verify supporting references of competence

Peer Recommendations HFAP Requirement Initial - one peer in same professional discipline and includes statement regarding current competence, ethical standards, physical, mental health related to privileges requested Reappointment – not required but may obtain info from peers familiar with their practice and reviews conducted by medical staff process/committees AAAHC Requirement Initial - peer evaluation for current competency by an individual who can address clinical, ethical, and professional performance and, when available, by data regarding treatment outcomes Reappointment - solo practitioner offices will be reviewed by a peer every 3 years to assure currency, accuracy and completeness.

Site Visit – NCQA Only Organization establishes office site standards to include medical/treatment record keeping and performance standards and thresholds. Assessment includes quality, safety, accessibility. Criteria includes physical accessibility, physical appearance, adequacy of waiting and exam rooms, appointment availability, adequacy of treatment record keeping practices Ongoing organization monitoring and investigates complaints and establishes threshold number that would trigger a site visit Must be done within 60 days of site reaching threshold Actions taken to improve offices not meeting standards must be evaluated every six months until standards are met Clinical personnel not required but surveyors must be trained/qualified

Temporary Privileges – TJC Important Patient Care Need Must verify current competence and current licensure Time limited as specified by bylaws, P&P Granted by CEO or designee Granted upon recommendation of medical staff president or designee

Temporary Privileges – TJC Pending Application New applicant – complete application No identified concerns Pending recommendation by MEC and approval of governing body May not exceed 120 days Verify licensure, training, current competence, ability to perform privileges NPDB and evaluation of outcome No current or previously successful challenge to licensure/registration No history of involuntary termination of med staff membership No history of involuntary limitation, reduction, denial or loss of clinical privileges Granted by CEO or designee Granted upon recommendation of medical staff president or designee

Provisional Credentialing - NCQA First time applicants May be provisionally credentialed only one time File must contain verification of current licensure w/in 180 days Verification of five year claims history from carrier or NPDB w/in 180 days Current, signed application and attestation signed w/in 365 days Granted for no more than 60 days Granted by Credentials Committee or Medical Director

Temporary Privileges - CMS Terminology not used CMS interpretation states there is no abbreviation of privileging process thus applicable CMS standards for privileging must apply. CMS does not recognize a shortened process for privileging except for emergencies such as a disaster Bylaws must demonstrate compliance with CMS standards with regard to granting temporary privileges

Temporary Privileges - HFAP 1) Completed application waiting for MEC and governing body approval 2) Care of Specific Patient Privileges 3) Locum tenens 4) Emergency/disaster CEO grants time limited temporary privileges following recommendation from chairman of department/service Verification required License Copy of DEA Professional liability coverage One reference from previous hospital chief or department chair

Approval Process TJC Requirement Medical Staff recommendation (if depts exist) MEC recommendation Governing body has final authority to grant/renew or deny privileges NCQA Requirement Credentialing Committee review and approval Criteria may be established for Medical Director to approve “clean files” HFAP Requirement Applicants appointed by governing body following recommendation from medical staff. Summary of application and supporting documentation reviewed by med staff leaders, committees, governing body

Approval Process - CMS Governing body determines whether to grant, deny, revise or limit specified privileges, including medical staff membership, after considering the recommendation from the medical staff No requirement for medical staff departments, a credentials committee or an MEC. If MEC does exist, majority of members must be MD’s or DO’s

Approval Process - AAAHC AAAHC Requirement- Governing body must either directly or by delegation make initial appt/reap and assignment or curtailment of privileges based on peer evaluation

Approval Process - URAC URAC Requirement Credentials Committee approves application - may delegate "clean" applications to senior clinical staff person, provided that such designation is documented and provides reasonable guidelines. Senior clinical staff person has oversight of credentialing program. Credentials committee must contain one participating provider who is a practitioner and who has no other role in organization management. Credentials plan describes mechanism for checking completeness, accuracy, and conflicting information prior to submission to credentials committee

Expedited Approval Process TJC MEC reviews and recommends to Board Board may delegate to sub-committee (must include 2 board members) Pre-defined criteria must be approved by med staff and board (includes ineligibility criteria) Ineligible if: application incomplete and MEC recommendation contains limitations on privileges current or previous challenge to license/registration Involuntary limitation, reduction, denial or loss of clinical privileges Unusual pattern or excessive number of professional liability actions resulting in final judgment

Expedited Approval Process NCQA “Clean files” based on criteria may be reviewed and approved by medical director CMS Standards do not provide for expedited process URAC “Clean files” may be delegated to Senior Clinical Staff person AAAHC Governing body must either directly or by delegation make initial appt/reap and assignment or curtailment of privileges HFAP Committee or individuals may be delegated “fast track” credentialing following thorough review of clinical competence

Notification TJC (I & R) Time frame defined in bylaws. If privilege limited or denied, notification includes reason and applicable rights of due process (HCQIA) HFAP Practitioner informed of privileges granted to include revisions/revocations of privileges URAC Must notify applicant within 10 days of determination NCQA (I & R) P&P’s include requirement that applicant must be notified within 60 days CMS/AAAHC Standards silent Requires privileging process be defined in bylaws thus notification would be described within this process

Hearing/Appeals Process TJC Bylaws outlines fair hearing & appeal review process Provides review of decisions regarding reappointment, denial, reduction, suspension, or revocation of privileges that involve quality of care issues Outlines scheduling a hearing, hearing procedure, stipulates composition of hearing panel, Outlines process to appeal adverse decision to governing body NCQA Practitioner is notified of their right to review credentialing info received (no access to peer review info) Notified if info differs from info provided by practitioner (I) Given right to correct any info that is erroneous P&P defines appeals process if adverse decision made based on quality of care or service issues

Hearing/Appeals Process - CMS Standards silent on provision of hearing/appeals CMS requires bylaws describe privilege process thus practitioner rights to a hearing/appeal are included in language National standard provides for two levels: Hearing before medical staff Appeal to governing body

Hearing and Appeals Process URAC Requirement Providers must be able to obtain info re: status of application and have opportunity to provide accurate info if there is a problem. AAAHC Requirement Governing body must approve mechanisms for initial, reappointment, and granting of privileges, suspending or terminating privileges, including provisions for appeal of such decisions. Mechanisms must be in place to notify licensing and/or disciplinary bodies or other authorities when privileges are suspended or terminated.

Length Of Appointment Period TJC Requirement May not exceed two years (to the day) CMS Requirement No specific requirement Other requirements include periodic appraisal CMS recommends 24 months HFAP Requirement No Standard for initial appointment - periodic appraisal every two years NCQA Requirement Credentialing period may be up to 36 months (to the month) State laws may define two years URAC Requirement May recredential at least every 3 years. Note: For military practitioners, if the organization cannot credential the practitioner before he or she has been deployed, then it must credential the practitioner within 60 days of returning to the organization’s network. AAAHC Requirement May not exceed 3 years

Continuing Medical Education TJC Requirement All practitioners participate in CE (R) CE information considered privilege reap process as defined by bylaws HFAP Requirement Documentation requested every two years at time of reappointment NCQA/URAC/CMS/ AAAHC Requirement Standards silent

Time Frame For Completion TJC Requirement (I & R) Bylaws describe credentialing and medical staff appointment and privileging process Complete applications must be acted upon within reasonable time frame as specified in bylaws AAAHC Requirement Governing body must make provisions for expeditious processing of clinical privileges applications NCQA Requirement Credentials information must be no more than 180 days old at the time of credentialing committee’s decision 180/120 CMS Bylaws/related medical staff documents must describe process and define timeframes HFAP Bylaws define time frame. Recommendation must be made to MEC within 60 days of receipt of complete app

Nondiscrimination NCQA – P&P state credentialing and recredentialing decisions are not based solely on applicant’s race, ethnic/national identity, age, sexual orientation, or type of procedure or patient the practitioner serves HFAP – Bylaws or P&P contains statement regarding nondiscrimination for sex, race, creed, national origin, disability

Disaster Privileges – TJC Only Granted when emergency operations plan has been activated and organization unable to handle immediate patient needs Bylaws identify individuals responsible and capable of granting disaster privileges P&P define medical staff responsibilities to oversee volunteer LIP Hospital will define mechanism to identify volunteer LIP PSV of license begins as soon as the immediate situation is under control – must be completed within 72 hours of when practitioner granted disaster privileges Within 72 hours, hospital determines whether the practitioner’s privileges will be allowed to continue based on information obtained regarding the practitioner’s professional performance

Disaster Privileges May be granted to LIP upon presentation of: Drivers license/passport (government issued ID) and one of following: Current picture ID from healthcare organization that identifies LIP’s professional discipline Primary source verification of license ID as member of disaster team ID indicating authority by government entity to provide clinical care during disaster Affirmation by a current hospital member of personal knowledge of individual

Additional Information Review of NCQA Additional Information Delegation Requirements Physician Directories

NCQA Delegation Agreement 1) describe responsibilities of the organization and the delegate; 2) describe delegated activities; 3) require semiannual or more frequent reporting to organization; 4) describe process organization uses to evaluate delegate's performance; 5) describe remedies available to the organization if the delegate does not perform to satisfaction including revocation of delegation; 6) specific responsibilities must be defined for both entities ie. which will process apps, reapps, attestation, collect required data; conduct site visits, make credentialing decisions; 7) specific responsibilities that are delegated must be described;

NCQA Delegation Agreement 8) specify data elements in report to organization ie. name, specialty, cred decision, cred date, etc.; 9) describe process organization will use to evaluate delegate's performance on an annual basis with volume of files to be reviewed (8/30 methodology – if first 8 are in compliance, no need to review others); 10) describe consequences of nonperformance ie. revocation, corrective action plans and onsite reviews; 11) provision for PHI to include a list of allowed uses of PHI, description of delegate's safeguards to protect PHI with stipulation sub-delegates will have same safeguards, stipulation that delegate provide individuals with access to their PHI, stipulation that delegate informs org of inappropriate use of PHI, stipulation that PHI is returned, destroyed or protected if delegation ends.

NCQA Physician Directories Web-based physician directory that includes the following information on physicians to help members and prospective members choose physicians. 1) Name 2) Gender 3) Hospital Affiliations 4) Medical Group Affiliations 5) Board Certification (include expiration of board certification or include a link directly to ABMS or AOA boards or include instructions on how to check the most current board website) 6) Accepting new patients?? 7) Languages spoken by physician or staff 8) Office locations

Additional Information - Review of NPDB-HIPDB, Title 21, PDS-Continuous Query Review of Roberts Rules of Order Review of EMTALA

National Practitioner Data Bank - NPDB Established through Title IV of Public Law 99-660 – The Healthcare Quality Improvement Act of 1986 Began operations in 1990 Intent – enhance the quality of health care, encourage greater efforts in professional peer review and restrict the ability of incompetent health care practitioners to move from State to State without discovery of previous substandard performance or unprofessional conduct Collects and discloses information related to professional competence and conduct Physicians, Dentists and other health care practitioners

National Practitioner Data Bank - NPDB NPDB contains the following information: Adverse licensure actions Clinical privileges actions Professional society membership actions Paid medical malpractice judgments and settlements Exclusions from participation in Medicare/Medicaid programs Registration actions taken by the US Drug Enforcement Administration (DEA)

National Practitioner Data Bank - NPDB Federal law specifies the NPDB make reported information available to: Hospitals, healthcare entities with formal peer review processes Professional societies with formal peer review State licensing authorities Healthcare practitioners (self-query) Researchers (statistics only) Plaintiffs Attorneys (limited circumstances)

National Practitioner Data Bank - NPDB Organizations that must report to the NPDB include: Hospitals and other health care entities that follow a formal peer review Medical and dental State licensing boards State health care practitioner and health care entity licensing boards Medical malpractice payers Professional societies that follow a formal peer review Private accreditation organizations Peer review organizations HHS Office of Inspector General U. S. Drug Enforcement Administration

Section 1921 Effective March 1, 2010, section 1921 of the Social Security Act, section 5(b) of the Medicare and Medicaid Patient and Program Protection Act of 1987 was implemented. Intent – protect program beneficiaries from unfit health care practitioners and improve the anti-fraud provisions of programs

Section 1921 Expands information contained in the NPDB, includes: Adverse licensure actions taken against ALL licensed healthcare practitioners Negative actions or findings by state licensing agencies, peer review organizations and private accreditation organizations against all health care practitioners and entities Private sector hospitals (not just federal) have access to adverse licensure action taken against ALL licensed healthcare professionals, not just physicians and dentists

Healthcare Integrity and Protection Data Bank (HIPDB) Established under Section 1128E of the Social Security Act as added Section 221(a) of the Health Insurance Portability and Accountability Act of 1996 Began operations in 2000 Intent – to combat fraud and abuse in health insurance and health care delivery

Healthcare Integrity and Protection Data Bank (HIPDB) Contains the following information: civil judgments against health care providers, suppliers or practitioners related to the delivery of a health care item or service Federal or state criminal convictions again health care providers, suppliers or practitioners related to the delivery of a health care item or service Actions by federal or state agencies responsible for the licensing and certification of health care providers, suppliers or practitioners

Healthcare Integrity and Protection Data Bank (HIPDB) Exclusions of providers, suppliers or practitioners from participation in Federal or state health care programs Any other adjudicated actions against health care providers, suppliers or practitioners Info available to federal and state government agencies, health plans, health care practitioners/suppliers (self-query), and researchers (statistics only)

Healthcare Integrity and Protection Data Bank (HIPDB) Organizations that must report to the HIPDB (Healthcare Integrity and Protection Data Bank) include: Federal and State government agencies Health plans

Continuous Query (CQ) Previous Name – Proactive Data Service (PDS) Subscribers will received notification within 24 hours of the NPDB receipt of report Enroll practitioners annually Cost $2.00 annual enrollment per practitioner Meets mandatory querying requirements of HCQIA Accepted by TJC, NCQA and CMS

NPDB Reporting Requirements Medical Malpractice Payors – Must report payment resulting from written claim or judgment. Reports must be submitted to the NPDB and appropriate State licensing board within 30 days of a payment Physicians and Dentists Must report Other health care practitioners

NPDB Reporting Requirements State Licensing Boards Licensure disciplinary action based on reasons related to professional competence or conduct. Reports must be submitted to the NPDB within 30 days of the action. Physicians and Dentists Must report Other health care practitioners Currently no reporting requirements

NPDB Reporting Requirements Hospitals and Other Health Care Entities Professional review action, based on reasons related to professional competence or conduct, adversely affecting clinical privileges for a period longer than 30 days; or voluntary surrender or restriction of clinical privileges while under, or to avoid, investigation. Reports must be submitted to the NPDB and appropriate state licensing board within 15 days of the action Physicians and Dentists Must report Other health care practitioners May report

NPDB Reporting Requirements Professional Societies Professional review action, based on reasons relating to professional competence or conduct, adversely affecting membership. Reports must be submitted to the NPDB and appropriate State licensing board within 15 days of the action. Physicians and Dentists Must report Other health care practitioners May report

NPDB Querying Requirements Hospitals Screening applicants for medical staff appointment or granting of clinical privileges; every 2 years for physicians, dentists, or other health care practitioners on the medical staff or granted clinical privileges At other times as they deem necessary Requirement Must Query Only entity required to Query the NPDB

NPDB Querying Requirements State Licensing Boards (including Medical and Dental) When they deem necessary Requirement May Query

NPDB Querying Requirements Other Health Care Entities Screening applicants for medical staff appointment, membership or affiliation, or granting of clinical privileges; supporting professional review activities Requirement May Query

NPDB Querying Requirements Professional Societies Screening applicants for membership or affiliation; supporting professional review activities Requirement May Query

NPDB Querying Requirements Plaintiff's Attorneys Plaintiff's attorney or plaintiff representing himself or herself who has filed a medical malpractice action or claim in a State or Federal court or other adjudicative body against a hospital when evidence is submitted to HHS which reveals that the hospital failed to make a required query of the NPDB on the practitioner(s) also named in the action or claim Requirement May Query

EMTALA EMTALA – The Emergency Medical Treatment and Labor Act passed as part of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) EMTALA is Section 1867(a) of the Social Security Act, within the section of the U.S. code which governs Medicare

EMTALA Statute that is primarily a non-discrimination statute that governs when and how a patient may be : (1) refused treatment or (2) transferred from one hospital to another when he is in an unstable condition Primary purpose is to prevent hospitals from rejecting patients, refusing to treat them, or transferring them to “charity hospitals” or “county hospitals” because they are unable to pay or are covered under the Medicare or Medicaid programs

DEA Schedules DEA/CDS Schedules I, II, III, IV, V Routine Schedules - 2, 2N, 3, 3N, 4, 5 NOTE: Drugs listed in schedule I have no currently accepted medical use in treatment in the United States and, therefore, may not be prescribed, administered, or dispensed for medical use. Schedule 1 drugs subject to criminal prosecution

Telemedicine – TJC LIP’s responsible for patient care, treatment, services via telemedicine link 2 options for credentialing/privileging First Option Originating site (hospital) fully credentials LIP Or…originating site uses cred/priv information (documentation) from distant site if distant site is TJC accredited

Telemedicine - TJC 2nd option Originating site uses cred/priv decision to make final privileging decision. Requirements: 1. Distant site is TJC accredited hospital or ambulatory care organization 2. LIP is privileged at distant site for services to be provided at originating site 3. Originating site submits internal review of quality to distant site

Highest Level of Authority TJC – Governing Body CMS – Governing Body HFAP – Governing Body AAAHC – Governing Body NCQA - Credentials Committee (clean files delegated to Medical Director) URAC – Credentialing Committee (clean files delegated to Senior Clinical Staff Person)

Governing Documents - TJC The organized medical staff develops medical staff bylaws, rules and regulations, and policies. The organized medical staff adopts and amends medical staff bylaws. Adoption or amendment of medical staff bylaws cannot be delegated. After adoption or amendment by the organized medical staff, the proposed bylaws are submitted to the governing body for action. Bylaws become effective only upon governing body approval Neither the organized medical staff nor the governing body may unilaterally amend the medical staff bylaws or rules and regulations.

Governing Documents CMS – Medical Staff Bylaws HFAP – Medical Staff Bylaws NCQA – Credentialing Policies and Procedures URAC – Credentialing Program Plan is reviewed and updated at least annually – must be approved by the Credentialing Committee AAAHC – Medical Staff Bylaws

TJC – Verbal Orders The hospital identifies, in writing, the staff who are authorized to receive and record verbal orders Documentation of verbal orders includes the date and names of individuals who gave, received, recorded and implemented the orders Additional CMS Deemed Status Requirements – Verbal orders are authenticated within 48 hours Documentation of verbal orders includes the time the verbal order was received

Board Certification Review of Board Certification Information – American Board of Medical Specialties (MOC) American Osteopathic Association (OCC) American Board of Foot and Ankle Surgeons American Board of Podiatric Medicine American Board of General Dentistry Royal College of Physicians and Surgeons of Canada Note: Review General Certificates versus Subspecialty certificates

Maintenance of Certification (MOC) ABMS Maintenance of Certification assures that a physician is committed to lifelong learning and competency in a specialty and/or subspecialty by requiring ongoing measurement of six core competencies adopted by ABMS and ACGME in 1999. Patient Care Medical/Clinical Knowledge Practice-based learning and improvement Interpersonal and communication skills Professionalism Systems-based practice

Maintenance of Certification (MOC) Measurement of competencies happens in a variety of ways, some of which vary according to the specialty. 24 Member Boards use a four-part process that is designed to keep certification continuous

Maintenance of Certification (MOC) Four-part process for Continuous Learning Part I – Licensure and Professional Standing (holds a valid, unrestricted medical license) Part II – Lifelong Learning and Self Assessment (educational and self-assessment programs determined by Member Boards) Part III – Cognitive Expertise (demonstrate specialty-specific skills and knowledge) Part IV – Practice Performance Assessment (demonstrate use of best evidence and practices compared to peers and national benchmarks)

Osteopathic Continuous Certification (OCC) FIVE COMPONENTS OF OCC Component 1 - Unrestricted Licensure:   Requires physicians who are board certified by the American Osteopathic Association (AOA) hold a valid, unrestricted license to practice medicine in one of the 50 states. In addition, physicians are required to adhere to the AOA’s Code of Ethics. Component 2 - Life Long Learning/Continuing Medical Education: Consistent with current commitment to lifelong learning, this component requires all recertifying diplomates fulfill a minimum of 120 hours of continuing medical education (CME) credit during each 3-year CME cycle—though some certifying boards have higher requirements. Of these 120+ CME credit hours, a minimum of 50 credit hours must be in the specialty area of certification. Self-assessment activities will be designated by each of the specialty certifying boards.

Osteopathic Continuous Certification (OCC) Component 3 - Cognitive Assessment: Requires provision of one (or more) psychometrically valid and proctored examinations that assess a physician’s specialty medical knowledge as well as core competencies in the provision of healthcare. Component 4 - Practice Performance Assessment and Improvement: Requires physicians engage in continuous quality improvement through comparison of personal practice performance measured against national standards for applicable medical specialty. Component 5 - Continuous AOA Membership: Membership in the AOA provides physicians with online technology, practice management assistance, national advocacy for DOs and the profession, professional publications and continuing medical education opportunities.

Roberts Rules of Order Parliamentary Procedure A set of rules for conduct at a meeting, that allows everyone to be heard and to make decisions without confusion Motions A method used by members to express themselves A motion is a proposal that the entire membership take action or a stand on an issue

Roberts Rules of Order Study the Order of motions An individual member can….. 1) Call to order 2) Second motions 3) Debate motions 4) Vote on motions

Roberts Rules of Order Four basic types of motions: 1) Main motions – Purpose to introduce items to the membership for consideration 2) Subsidiary motions – Purpose is to change or affect how a main motion is handled, and is voted on before a main motion 3) Privileged motions – Purpose is to bring up items that are urgent about special or important matters unrelated to pending business 4) Incidental motions – Purpose is to provide a means of questioning procedure

Meeting Management Roberts Rules of Order are the industry standard for conducting meetings Medical Staff Bylaws define: 1) organizational structure of the medical staff (including meeting requirements) 2) governance of the medical staff 3) accountability of the medical staff to the governing body 4) all responsibilities of the medical staff

Meeting Management Accrediting/regulatory entities define required committees in their applicable governance documents TJC, HFAP, CMS, AAAHC – Medical Staff Bylaws, Policies and Procedures URAC – Credentialing Program Plan NCQA – Credentialing Policies and Procedures

Meeting Management Required Committees: TJC – Medical Executive Committee (can be medical staff as a whole) CMS – Medical Executive Committee (can be medical staff as a whole) HFAP – Credentials Committee, Medical Executive Committee (MEC can function as Credentials), Utilization of Osteopathic Methods and Concepts Committee

Meeting Management Pre-meeting Responsibilities 1) Meeting Logistics (meeting location, meeting time, audio/visual requirements, required attendees, catering, meeting notices) 2) Develop Agenda (include issues tabled at last meeting) 3) Gather required supporting documents 4) Review agenda/documents with leadership to prepare for meeting

Meeting Management MEETING AGENDA - Follows a fixed order of business (RRO) Call to order Roll call (Record attendees) Review/Approval of minutes from last meeting Officers reports Committee reports Special Orders – important business previously designated for consideration at this meeting Unfinished business New business Announcements Adjournment

Meeting Management Minutes should generally reflect (RRO): Meeting Name, Time/location of meeting, names/titles of attendees Topic Discussions/Conclusions Recommendations Follow-up Required

Meeting Management Documentation “Do’s”: - Confidential, Peer Review Document (HCQIA) - Summary of Discussion - Document conclusions, recommendations, actions Documentation “Do not’s”: - Recommended to not record “Dr. ____said” - Do not record inappropriate/slanderous statements - Names of practitioners in quality/peer review discussions, use # instead

Meeting Management Meeting Follow-up Develop/transcribe minutes (best practice w/in 3 days of meeting) Follow-up on action items – notify responsible individuals of recommendations/questions/requirements, forward minutes/documents to next level Best practice – begin to build next agenda by placing follow-up items on document

Additional Information (separate handout) Review of Legal Cases Review of Legal Terminology Review of Medical Terminology (privileging information) Review of Healthcare Acronyms (Candidate Handbook)

Review of resources www.NAMSS.org NAMSS Comparison of Accreditation Standards NAMSS Certification Candidate Handbook NAMSS CPCS and CPMSM Online Certification Prep Course (NAMSS online store – NAMSS member discount) NAMSS CPCS/CPMSM Practice Exam (namss.org – Certification – Exam Info) Other Resource Verify and Comply – 6th Edition Carol Cairns, HCPRO