1. 1 Comparison of The Joint Commission and DNV- GL HC’s National Integrated Accreditation for Healthcare Organizations (NIAHO ℠ ) MS Standards Kathy Matzka, CPMSM, CPCS

2. 2 History TJC NIAHO 1952 began Unique statutory hospital deeming authority 1965 Medicare statute July 15, 2008, the Medicare Improvements for Patients and Providers Act of 2008 became law 11/09 – CMS approval 4,546 Hospital and CAH in 2011 4,429 Hospital and CAH in 2013 (90% of accredited hospitals) 4,032 Hospital and CAH in 2016 (88% of accredited hospitals) 12/19/07 Application to CMS 09/08 CMS approval 94 Hospital and CAH on 7/14/10 393 Hospital and CAH on 4/17/2016

3. 3 Process TJC NIAHO Three year survey Standards directly related to the CMS as well as self-defined Annual Survey Most MS standards directly related to the CMS ISO 9001 quality management

4. 4 Scoring Process TJC NIAHO Three-point scale: –0 = insufficient compliance –1 = partial compliance –2 = satisfactory compliance Icons –Documentation required –Situational decision rules apply –Direct impact requirements apply –Category A requirement –Category C requirement (based on # of times does not meet standard) –Measurement of Success needed Standards Scored as –Meets requirements –Nonconformity Category I Conditional level – Egregious non-compliance –Nonconformity Category I - Noncompliant –Nonconformity Category II – Occasional or isolated lapse in compliance –Immediate Jeopardy - Immediate threat to patient safety No aggregate scoring

5. 5 Appointment Timeframe TJC NIAHO Two years Three years if state law does not address

6. 6 Continuing Medical Education TJC NIAHO LIPs and other practitioners privileged through the medical staff process must participate in CE Participation must be documented and considered in decisions about reappointment, renewal, or revision of individual clinical privileges All with privileges participate in CE that is at least in part related to their clinical privileges CME considered in decisions about reappointment or renewal or revision of clinical privileges Action on an individual’s application for appointment /reappointment or initial or subsequent clinical privileges is withheld until the information is available and verified

7. 7 Current Competence TJC NIAHO The hospital verifies in writing and from the primary source, whenever feasible, or from a CVO, information concerning the current competence Evaluate data from other organizations where the applicant currently has privileges, if available Initial - MS qualifications include verification of current competence Reap - Review of individual performance data for variation from benchmark Variations to peer review for determination of validity, written explanation of findings and, if appropriate, an action plan to include improvement strategies

8. 8 Malpractice History TJC NIAHO MS evaluates involvement in a professional liability action, including final judgments and settlements involving a practitioner Must evaluate any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant Review of involvement in any professional liability action at initial and reappointment

9. 9 Peer Recommendations TJC NIAHO Required at initial, reap, consideration of termination, or revision/revocation of clinical privileges Address the relevant training and experience, current competence, and any effects of health status on privileges being requested Include evaluation of the applicant’s medical knowledge, technical and clinical skills, clinical judgment, communication skills, interpersonal skills, and professionalism Obtained from a practitioner in the same professional discipline as the applicant with personal knowledge of the applicant’s ability to practice List of appropriate sources Two peer recommenda- tions required at initial appointment

10. 10 Clinical Privileges TJC NIAHO PSV for current licensure or certification PSV of relevant training Evidence of physical ability to perform the requested privilege If available, data from professional practice review from other organization where the applicant currently has privileges Recommendations from peers/faculty On renewal, review of the applicant’s performance within the hospital All permitted by the organization and by law to provide patient care services independently have delineated clinical privileges If available and/or required by the MS, a review of individual performance data variation from criteria determined by the medical staff to identify need for training or proctoring that may be required

11. 11 Telemedicine TJC NIAHO 3 choices –The originating site can fully privilege and credential the practitioner according to MS standards or –Use credentialing information from the distant site if the distant site is a Joint Commission-accredited organization or –Use credentialing and privileging decision from the Joint Commission-accredited distant site Medical staff at both sites make recommendation for services to be provided via telemedicine For non-deeming, can be via contract only if TJC accredited entity 2 choices –The originating site can fully privilege and credential the practitioner according to MS standards or –Use credentialing and privileging decision from telemedicine entity or distant site Medicare participating hospital When services provided by a contracted entity, GB must identify criteria for selection and procurement of services and how to evaluate the entity

12. 12 Temporary Privileges TJC NIAHO 120 days for new applicant with complete file awaiting MEC approval Time as specified in bylaws for patient care need On recommendation of MS President or designee No successful challenges to licensure or registration; involuntary termination of MS appointment; involuntary limitation, reduction, denial, or loss of clinical privileges Not exceed 120 days Locum tenens not to exceed 6 months On recommendation of a MEC member, MS president or medical director (as defined by MS Urgent patient care need Complete application w/o negative or adverse information before action by the medical staff or governing body

13. 13 Temporary Privileges TJC NIAHO Patient care need verify –Current licensure –Current competence New Applicant verify Current licensure Relevant training or experience Current competence Ability to perform the privileges requested Other criteria required by medical staff bylaws NPDB In all cases verify –education (AMA/AOA Profile OK –current competence –primary verification of State professional licenses –professional references (including current competence) –Database profiles from AMA, AOA, NPDB, and OIG Medicare/Medicaid Exclusions

14. 14 Allied Health Professionals TJC NIAHO LIPs through MS process Non-LIP APRNs and PAs HR or MS if not providing a medical level of care If State law allows, MS may include DPM, OD, DC, PA, CRNA, NM, APRN, DMD, PHD or other designated professionals approved by MS and Board and eligible for appointment

15. 15 Executive Committee TJC NIAHO 10 EPs outlining responsibilities, structure, function If MS has an executive committee, a majority of the members of the committee shall be doctors of medicine or osteopathy CEO and the nurse executive of the organization or designee shall attend each meeting on an ex-officio basis, with or without vote

16. 16 Notifications TJC NIAHO The decision to grant, deny, revise, or revoke privilege(s) is disseminated and made available to all appropriate internal and external persons or entities, as defined by the hospital and applicable law A current roster listing each practitioner’s specific surgical privileges must be available in the surgical suite and scheduling area Include surgeons with suspended surgical privileges or whose surgical privileges have been restricted

17. 17 Surgical Privileges TJC NIAHO Included in general category for privileges All practitioners performing surgery have surgical privileges established by the department of surgery and medical staff and approved by the governing body Privileges for general surgery and surgical subspecialties defined with established criteria approved by MS Privileges correspond with established competencies of each practitioner

18. 18 Automatic Suspension TJC NIAHO The medical staff bylaws include –description of indications for automatic suspension or summary suspension of a practitioner’s medical staff membership or clinical privileges –description of when automatic suspension or summary suspension procedures are implemented The medical staff will define the criteria and have a mechanism for consideration of automatic suspension of clinical privileges of a practitioner at a minimum when: –revocation/restriction of professional license –DEA certificate has been revoked, suspended or on probation –Failure to maintain the minimum specified amount of professional liability insurance –non-compliance with written medical record delinquency or deficiency requirements Mechanism for immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioner’s Medicare or Medicaid status

19. 19 QA/PI Data TJC NIAHO FPPE OPPE Medical Assessment –Blood –Medication –Operative and other procedure(s) –Appropriateness of clinical practice patterns –Significant departures from established patterns of clinical practice –Use of criteria for autopsies –Sentinel event data –Patient safety data Practitioner specific performance data is required and must be rate- based with comparative peer or national data available for comparison. –Blood use –Prescribing of medications –Surgical Case Review –Specific departmental indicators –Moderate Sedation Outcomes –Anesthesia events –Appropriateness of care for non- invasive procedures/interventions –Utilization data –Significant deviations from established standards of practice –Timely and legible completion of patients’ medical records Variants analyzed for statistical significance

20. 20 Addressed by TJC, Not NIAHO Verification of applicant identity Use of CVO (DNV does allow – is addressed under telemedicine) Health status (DNV only under surgical privileges) Applicant required to provide info re: previously successful or currently pending challenges to licensure or voluntary relinquishment, felony convictions Leadership standards place additional responsibilities on MS Residency program requirements

21. 21 Addressed by NIAHO, not TJC Receipt of database profile from OIG - Medicare/Medicaid Exclusions initial/reappointment/temporary privileges

22. 22 Resources Standards: NIAHO® Standards, Interpretive Guidelines, or Accreditation Process www.dnvaccreditation.com www.dnvaccreditation.com Jointcomission.org

23. Questions to Consider… Will our reputation in the community suffer if we change? (Are minimal standards sufficient in today’s healthcare climate?) Contracts with insurers may require certain accreditation and may need renegotiation Will there be a saving in direct and indirect accreditation costs? 23

24. 24 Questions