1. CREDENTIALING Where does the Board fit in? Robert P. Redwine President, Board of Directors Blount Memorial Hospital Maryville, Tennessee

2. At the top of a hospital’s organization is a governing board. The legal status of the board of any American corporation is relatively clear in that the board functions as the owner of the entity. So the board functions as the owner and is accountable to the community and/or the patients that are treated at the hospital.

3. Joint Commission Leadership Standard LD.01.03.01 The governing body is ultimately accountable for the safety and quality of care, treatment, and services. The governing body is ultimately accountable for the safety and quality of care, treatment, and services.

4. The governing board delegates credentialing of the physicians and allied health professionals to the Medical Staff.

5. What is credentialing? Credentialing makes sure that the healthcare provider is who they say they are, they have been trained to do the privileges they are requesting, and they are physically able and competent to do those privileges.

6. BOTTOM LINE: Primary reason for credentialing—Patient Safety

7. MS.4.10 Credentialing Process Designed to ensure that patients receive care, treatment, and services from qualified providers Designed to ensure that patients receive care, treatment, and services from qualified providers Follows the steps outlined in the bylaws or other documents as previously approved by the governing body Follows the steps outlined in the bylaws or other documents as previously approved by the governing body Includes a mechanism to ensure that the individual requesting approval is the same individual identified in the credentialing documents by viewing current picture hospital ID, valid state or federal ID Includes a mechanism to ensure that the individual requesting approval is the same individual identified in the credentialing documents by viewing current picture hospital ID, valid state or federal ID

8. MS.4.10 Credentialing Process (Cont.) Requires that the hospital verifies in writing from the primary source whenever feasible Requires that the hospital verifies in writing from the primary source whenever feasible Current licensure at the time of granting and renewal of privileges, and at the time of expiration/renewal Current licensure at the time of granting and renewal of privileges, and at the time of expiration/renewal Relevant training Relevant training Current competence Current competence

9. MS.4.15 Clinical Privileges Privileges: “Authorization granted by the appropriate authority (for example, the governing body) to a practitioner to provide specific care, treatment, and services in an organization within well-defined limits, based on the following factors, as applicable: license, education, training, experience, competence, health status, and judgment.” Privileges: “Authorization granted by the appropriate authority (for example, the governing body) to a practitioner to provide specific care, treatment, and services in an organization within well-defined limits, based on the following factors, as applicable: license, education, training, experience, competence, health status, and judgment.” The decision to grant or deny a privilege(s), and/or renew an existing privilege(s), is an objective evidenced-based process The decision to grant or deny a privilege(s), and/or renew an existing privilege(s), is an objective evidenced-based process

10. MS.4.15 Clinical Privileges (Cont.) The process for granting privileges includes: Clearly defined procedure approved by the organized medical staff for the processing of applications for granting, renewal, or revision of privileges Clearly defined procedure approved by the organized medical staff for the processing of applications for granting, renewal, or revision of privileges The procedure is approved by the organized medical staff The procedure is approved by the organized medical staff Applicant submits information that no health problems exist that could affect his or her ability to perform the privileges requested Applicant submits information that no health problems exist that could affect his or her ability to perform the privileges requested

11. MS.4.15 Clinical Privileges (Cont.) The process for granting privileges includes: National Practitioner Data Bank (NPDB) query (initially granted, renewal of privileges, and when a new privilege is requested) National Practitioner Data Bank (NPDB) query (initially granted, renewal of privileges, and when a new privilege is requested) Peer recommendations Peer recommendations

12. MS.4.15 Clinical Privileges (Cont.) Before recommending to the governing board that privileges be granted, the Medical Staff Evaluates: Challenges to any licensure or regulation Challenges to any licensure or regulation Voluntary and involuntary relinquishment of any license or registration Voluntary and involuntary relinquishment of any license or registration Voluntary and involuntary limitation, reduction, or loss of clinical privileges Voluntary and involuntary limitation, reduction, or loss of clinical privileges Any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant Any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant

13. MS.4.15 Clinical Privileges (Cont.) Before recommending to the governing board that privileges be granted, the Medical Staff evaluates: Documentation as to the applicant’s health status Documentation as to the applicant’s health status Relevant practitioner-specific data as compared to aggregate data, when available Relevant practitioner-specific data as compared to aggregate data, when available

14. MS.4.70 Peer Recommendations Obtained from a practitioner in the same professional discipline as the applicant with personal knowledge of the applicant’s ability to practice Obtained from a practitioner in the same professional discipline as the applicant with personal knowledge of the applicant’s ability to practice Obtained/evaluated for all new applicants for privileges Obtained/evaluated for all new applicants for privileges On renewal of privileges, when insufficient practitioner- specific data are available must be able to comment on: On renewal of privileges, when insufficient practitioner- specific data are available must be able to comment on: Medical/clinical knowledge Medical/clinical knowledge Technical and clinical skills Technical and clinical skills Clinical judgment Clinical judgment Interpersonal skills Interpersonal skills Communication skills Communication skills Professionalism Professionalism

15. The governing board needs: a Medical Executive Committee that is dedicated to quality patient care

16. A Credentials Committee that is dedicated to quality patient care

17. Medical Staff Services personnel that are dedicated to quality patient care BECAUSE:

19. Blount Memorial’s Credentialing Process Pre-application to the Medical Staff Services Office Pre-application to the Medical Staff Services Office Full application packet to the Medical Staff Services Office Full application packet to the Medical Staff Services Office Verifications and competency reviewed by Medical Staff Services personnel Verifications and competency reviewed by Medical Staff Services personnel Review of the complete file and signature by the Department Chair Review of the complete file and signature by the Department Chair

20. Blount Memorial’s Credentialing Process (Continued) Review of the complete file and signature by the Credentials Committee Review of the complete file and signature by the Credentials Committee Review of a summary of the complete file and signature by the Medical Executive Committee Review of a summary of the complete file and signature by the Medical Executive Committee Review of a summary of the complete file and signature by the Board of Directors Review of a summary of the complete file and signature by the Board of Directors

21. Blount Memorial’s Credentialing Process (Continued) Temporary Privileges may be granted if the file is complete, it fulfills the criteria set forth in the Bylaws, and the chair of the Department and the chairs of the above Committees and the President of the Board reviews and gives their signatures for approval. The file must still go thru the above process, but the applicant will have temporary privileges until the Board grants the applicant membership and privileges.