1. North Carolina Association Medical Staff Services MAY 15, 2008
Renee Aird Dengler, RN, MS, CPMSM, CPCS
Advocate Health Care
Director, Medical & Professional Affairs

2. The Joint Commission History 1910 – Ernest Codman, MD
1951 – American College of Physicians, American Hospital
Association, American Medical Association, Canadian
Medical Association
Social Security Amendments of 1965 – Deemed Status
– accredited hospitals are in compliance with most of the
Medicare Conditions of Participation for Hospitals

3. Centers for Medicare and Medicaid Services (CMS)
History
1965 – Medicare and Medicaid enacted under Social Security Act
1973 – HMO Act
1977 – Health Care Financing Authority (HCFA)\
1982 – PROs
1983 – Prospective Payment System
1985 – EMTALA

4. Centers for Medicare and Medicaid Services (CMS)
1996 – Health Insurance Portability and Accountability Act
(HIPPA)
2001 – HCFA is renamed CMS
- Center for Medicare Management
- Center for Beneficiary Choice
- Center for Medicaid and State Operations
2003 – Medicare Prescription Drug Improvement and
Modernization Act

5. Centers for Medicare and Medicaid Services (CMS)
State Operations Manual
Conditions of Participation
Regulations and Interpretive Guidelines

6. Centers for Medicare and Medicaid Services (CMS)
Deemed Status
TJC
AOA - HFAP
DNV - NIAHO

7. Centers for Medicare and Medicaid Services (CMS)
Survey Process
Validation Survey
Web Sites
State Operation Manual / Interpretive Guidelines
updates

8. Centers for Medicare and Medicaid Services (CMS)
“Familiar” Standards
Review of Conditions of Participation, Standards & Interpretive Guidelines

9. The Joint Commission & CMS
August 2008 Letter
Re: Deeming Authority

10. The Joint Commission & CMS
Revised 2009 Accreditation Requirements as of March 26, 2009 MS MS MS MS MS MS

11. Clarifying Standards Core Privileges Telemedicine
H&Ps – APRNs, PA, Medical Students

12. Clarifying Standards Expedited Credentialing
Health Care Industry Representatives (HCIR)
LIP Health Screening

13. Clarifying Standards Ongoing Professional Practice Evaluation (OPPE)
Focused Professional Practice Evaluation (FPPE)

14. National Committee on Quality Assurance (NCQA)
Credentialing Standards
NPDB – Proactive Disclosure Service (PDS)
Verification of “lifetime” board certification

15. National Committee on Quality Assurance (NCQA)
Verification of CDS and DEA
Verification of Education & Training for Expired Board Certification
Pen or Pencil?