FTCA Marti Wolf, RN, MPH Clinical Programs Director North Carolina Community Health Center Association

When submitting FTCA application, it should include all providers, including new hires who are not yet working at the health center. Minutes of meetings are adequate for documenting Board approval. We are Joint Commission Accredited. Therefore our Credentialing/Privileging meets or exceeds HRSA standards. QI/QA and Risk Management Plans should be approved every 3 years. For Peer Review, NPs and PAs can review MDs. Assessment

FTCA Remember you are working a year in advance Annual Re-deeming 2014 FTCA applications went in March 2013 Annual Re-deeming New deeming can be done any time during the year FTCA

Elements of FTCA Credentialing and Privileging Quality Improvement Risk Management Peer Review FTCA “Bibles” PIN 2001-16 PIN 2002-22 Annual PIN Elements of FTCA

RISK MANAGEMENT

FTCA- Risk Management Assess, identify, analyze Control/avoid/minimize/eliminate events Cause a loss to the organization Adverse outcomes Harm Proactive instead of Reactive FTCA- Risk Management

Risk Management is comprehensive of the entire organization. Risk Management is Board driven and Board overseen. Risk Management and/or QI programs audit Cred/Priv processes to ensure compliance. Risk Management PLAN https://members2.ecri.org/Components/HRSA/Pages/PSRMPol10.aspx FTCA- Risk Management

FTCA-Risk Management Governance Administrative Business/Finance Environment Human Resources IT Clinical FTCA-Risk Management

FTCA- Risk Management Clinical risk management includes: Annual risk assessment Clinical protocols Peer reviews Supervision of health center staff: clinical and nonclinical Medical records policies Triage policies (walk-in and phone) No show appointment policies Tracking policies: referrals, hospitalizations and diagnostic testing FTCA- Risk Management

NonClinical Building and Grounds- Safety and Security- Equipment management-Board Responsibilities- Contracts and Procurement- Record Retention- Corp/Regulatory/Grant Compliance-Disaster Prep- Incident Report management- Finance/billing- Human Resources compliance (FMLA, at will employment)- Staff Training- Credentialing-IT (backup, security levels)- Patient satisfaction- Disaster Response- HIPAA FTCA-Risk Management

FTCA- Risk Management Staff training in Risk Management Description of available opportunities Process to ensure staff receive RM training FTCA- Risk Management

FTCA- Risk Management Training Topics- depending on your Scope Patient safety Infection control/hand hygiene Teamwork and communication Medication safety Fall prevention Fire safety Documentation Disaster planning Obstetrics safety OSHA Bloodborne Pathogen Hazard Communication/ Disclosure Hand Hygiene Sharps Injury Prevention PPE MSDS FTCA- Risk Management

FTCA-Risk Management Prevention of Medical Malpractice Scope of grant and privileging Clinical outcomes measurement Event/incident monitoring Supervisory agreements NPDB Claims reviews FTCA-Risk Management

FTCA- Risk Management Implementation is documented by P/P Training- right up to BOD Data on RM activities Minutes showing data being reviewed Solutions to identified problems are implemented On-going monitoring and risk assessment Board reports FTCA- Risk Management

FTCA-Risk Management P/P Triage No shows Supervision of staff Referrals/Hospitalization/Diagnostics FTCA-Risk Management

QUALITY IMPROVEMENT

FTCA- Quality Improvement Plan should include: Statement of purpose Scope of plan Administrative responsibility Risk management systems Committee membership Committee accountability Activities; tracking Approval; review https://members2.ecri.org/Components/HRSA/Pages/PSRMPol20.aspx https://members2.ecri.org/Components/HRSA/Pages/PSRMPol21.aspx FTCA- Quality Improvement

FTCA- Quality Improvement QI and Board meeting minutes should: Include specific data about ongoing QI projects Report performance on selected measures from QI plan Progress on goals for QI program MINUTES FROM ANY 6 MEETINGS* FTCA- Quality Improvement

FTCA- Quality Improvement Clinical Protocols Frequent conditions Standards of Care Updated Provider/clinical staff training Peer review based on Clinical Protocols QI metrics FTCA- Quality Improvement

Credentialing and Privileging

FTCA-Credentialing and Privileging Credentialing: The process of assessing and confirming the qualifications of a licensed or certified healthcare practitioner to render specific health care service(s). Privileging: The process of granting the qualified health care provider (Licensed independent practitioners ) the permissions to render specific health care services and perform specific health care procedures for a limited time (2 years). FTCA-Credentialing and Privileging

AND is the operative phrase Credentialing IS NOT THE SAME as Privileging FTCA-Credentialing and Privileging

FTCA-Credentialing and Privileging Ensures all health care providers (LIP’s) and clinical staff (licensed and certified) are qualified to render the type of care for which they are employed. Involves evaluating a practitioner’s eligibility to provide clinical services at the health center and evaluating the provider’s competency for specific clinical privileges. Failure to fully credential may result in liability if a patient is harmed. FTCA-Credentialing and Privileging

FTCA-Credentialing and Privileging Policy Information Notice (PIN) 2001-16, Credentialing and Privileging of Health Center Practitioners requires that "all Health Centers assess the credentials of each licensed or certified health care practitioner to determine if they meet Health Center standards." This policy applies to all health center practitioners, employed or contracted, volunteers and locum tenens, at all health center sites. http://bphc.hrsa.gov/policiesregulations/policies/pin200222.html FTCA-Credentialing and Privileging

FTCA-Credentialing and Privileging You must comply with HRSA policies Joint Commission or other accreditation/recognition bodies do not supersede HRSA requirements Must comply with any state regs Cross check with your Scope to ensure they match your privileging/services provided FTCA-Credentialing and Privileging

FTCA-Credentialing and Privileging DOCUMENTATION: Attachment E: upload the credentialing list (excel spread sheet). FTCA-Credentialing and Privileging

FTCA-Credentialing and Privileging On your credentialing list All practitioners, employed or contracted, volunteer and locum tenens From all of your sites ONLY THOSE CURRENTLY WORKING AT TIME OF THE SUBMISSION FTCA-Credentialing and Privileging

FTCA-Credentialing and Privileging DOCUMENTATION: ATTACHMENTS F1 AND F2 Approval of the Cred/Priv Policy F1- your credentialing and privileging POLICY Board approved- date and signature of board chair F2- board minutes as proof of board approval Signed and dated and clearly indicate board approval of the Policy FTCA-Credentialing and Privileging

FTCA-Credentialing and Privileging Credentialing Procedure (plan) Addresses your duty to care for patients and prevent harm STEP by STEP PROCESS Provides for on-going education, training and licensure/certification “Provides a clear pathway… to hire and/or dismiss clinical staff” All LIPs, and other licensed/certified practitioners FTCA-Credentialing and Privileging

FTCA-Credentialing and Privileging TIPS For a HAPPY Credentialing Plan HRSA likes to see the PINS referenced in the Policy and Procedure Specifically indicates when primary and 2ndary sources are used (… see PINs ) Specifies re-credentialing every 2 years Includes Board approval or specifies how Board approval of Policy and Credentialing are delegated Policy and Plan should be approved and re- signed every 3 years FTCA-Credentialing and Privileging

Common Confusion FTCA-Credentialing and Privileging PRIMARY SOURCE VERIFICATION Direct written correspondence telephone Internet CVO report (cred verification org) AMA Master File, other medical boards SECONDARY SOURCE VERIFICATION Original credential Notarized copies Copy of credential – must be made by approved health center staff member FTCA-Credentialing and Privileging

FTCA-Credentialing and Privileging Primary source verification for LIPs is obtained for the following: Applicant’s license Applicant’s education, training, experience Applicant’s registration Application’s certifications Applicant’s current competence Applicant’s ability to perform services for which privileges are requested Secondary source verification for LIPs is obtained for the following: Government-issued photo ID DEA registration (if applicable) Hospital admitting privileges (if applicable) Immunization and PPD status FTCA-Credentialing and Privileging

FTCA-Credentialing and Privileging Primary source verification for other providers is obtained for the following: Applicant’s license Secondary source verification for other providers is obtained for the following: Applicant’s education, training, experience Applicant’s registration and certifications Applicant’s current competence Applicant’s ability to perform services for which privileges are requested Government-issued photo ID DEA registration (if applicable) Hospital admitting privileges (if applicable) Immunization and PPD status FTCA-Credentialing and Privileging

FTCA-Credentialing and Privileging CHECKLIST of required information Curriculum vitae (CV) Diplomas (e.g., undergraduate, post-graduate, medical school, residency, fellowship) Statement confirming health fitness Certificates (e.g., board certification, BLS, ACLS) Medical licenses Drug Enforcement Administration (DEA) registration (if applicable) Controlled Dangerous Substances (CDS) registration (if applicable) Peer references FTCA-Credentialing and Privileging

FTCA-Credentialing and Privileging But Wait! There’s MORE! CHECKLIST of required information Proof of liability insurance Summary of malpractice claims/adverse actions filed against the provider National Practitioner Data Bank (NPBD) query q 2 yr Delineation of privileges Government-issued picture identification Immunization and PPD status Life support training (if applicable) Fit for duty Verification of hospital and/or facilities privileges FTCA-Credentialing and Privileging

Your responsibilities Maintain complete and organized required credentialing documentations and records. Regularly identify expiring credentials before expiration Review each file once per year to identify any missing items. If you use a credentials verification organization (CVO): Ensure the CVO understands FTCA requirements. The contract with the CVO speaks to privacy, document owners, document retention. Ensure your privacy release (signed by LIP) speaks to the use of a CVO by the organization. Your responsibilities

Each practitioner should be privileged specific to the services prior to rendering services. Privileging processes verifies clinical privileges and medical staff membership at local facilities (admitting privileges, etc) Renewal or revisions of privileges for LIPs and other licensed or certified practitioners must occur at least every two years. Full and temporary privileges need to be clearly defined (time limited with only specific reasons for temporary).- at least q 2 yrs Providers must be privileged prior to rendering health care services. Privileges

Approved applicants are notified in writing within a defined timeframe. Approved applications and a copy of the approval letter are forwarded to appropriate internal personnel within a defined timeframe. Applications whose requests are denied are notified within a defined timeframe. The health center has a defined policy for making changes to final approved/denied applications. Board must approve privileges or must formally delegate this activity to a committee Board must document approval of privileges Privileges

Peer Review Peer Review is a QI process Quality of care Patient safety Learn from past performance, errors, near misses Is integral to credentialing and privileging Per FTCA, Midlevels can review MDs Peer Review

Peer Review Who is in charge of Peer Review Process Duties/Responsibilities of that person Frequency of review Number of charts reviewed per provider How feedback is communicated and documented Maintains pt confidentiality during the process How peer review is communicated to BOD Methodology for improvement strategies Peer Review

ALIGNS WITH PCMH Referral/hospitalization/diagnostic tracking P/P Quality Improvement Plan and Activities ALIGNS WITH PCMH

When submitting FTCA application, it should include all providers, including new hires who are not yet working at the health center. Minutes of meetings are adequate for documenting Board approval. We are Joint Commission Accredited. Therefore our Credentialing/Privileging meets or exceeds HRSA standards. QI/QA and Risk Management Plans should be approved every 3 years. For Peer Review, NPs and PAs can review MDs. Assessment

HRSA Resources FTCA/BPHC Help Line Phone: 1-877-974-BPHC (877-974-2742) 9:00 AM to 5:30 PM (ET) Email: BPHChelpline@hrsa.gov FTCA Website: http://www.bphc.hrsa.gov/ftca/ HRSA Quality Improvement Webinars: http://bphc.hrsa.gov/policiesregulations/quality/ HRSA Resources

ECRI Resources (paid for by HRSA) Sample Risk Management Policy: Physician Office Practice https://members2.ecri.org/Components/HRSA/Pages/PSRMPol3.aspx Patient Satisfaction Questionnaire https://members2.ecri.org/Components/HRSA/Pages/PSRMPol2.aspx Anecdotal Note for Patient Concerns https://members2.ecri.org/Components/HRSA/Pages/OAPol4.aspx Handling Patient Complaints https://members2.ecri.org/Components/HRSA/Pages/OAPol3.aspx Safety Attitudes Questionnaire (Ambulatory Version) https://members2.ecri.org/Components/HRSA/Pages/PSRMPol1.aspx Risk Management Plan: https://members2.ecri.org/Components/HRSA/Pages/RMPlan.aspx Event Reporting Toolkit: https://members2.ecri.org/Components/HRSA/Pages/EventReportToolkit.aspx Webinars https://members2.ecri.org/Components/HRSA/Pages/Webinar_Audioconf_Archive.aspx: Clinical Risk Management Basics Part I Developing a Risk Management Plan ECRI Resource Page: Quality Improvement: https://members2.ecri.org/Components/HRSA/Pages/QI.aspx ECRI Resources (paid for by HRSA)