1. 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)
© 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

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

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

4. 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

5. CMS Regulations and Interpretative Guidelines for Hospital

6. Medicare CoP Privileging Criteria
Character
Competence
Judgement
Experience
Training
Criteria

7. 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

8. 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

9. Joint Commission Hospital Standards for documenting competency

10. Morbidity and mortality data, when available
MS – 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

11. Clinical Privileges

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

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

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

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

16. 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

17. 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

18. Monitoring/Proctoring
FPPE/OPPE/QAPI

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

20. See Sample FPPE Plan page 12

21. 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

22. 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

23. 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

24. 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!

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

26. Dealing with Low or No Volume Practitioners

27. 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

28. 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

29. Questions ?
Comments!