1. Healthcare Facilities Accreditation Program (HFAP)
2007 Medical Staff Credentialing Standards
George A. Reuther
Director, HFAP

2. The HFAP Accreditation History
HFAP first began in 1945
Accrediting Hospitals and Other Health Care Facilities for over 60 years
Accrediting Hospitals Under Medicare for Over 40 years
Recognized by Managed Care Organizations and Insurance Companies

3. Current Areas of Accreditation
Hospitals
Clinical Laboratories
Ambulatory Care / Surgical Facilities
Mental Health & Substance Abuse Facilities
Physical Rehabilitation Facilities
Critical Access Hospitals

4. Government Recognition
Deeming Authority from the Centers for Medicare and Medicaid Services (CMS):
Medicare Conditions of Participation for Hospitals, CAHs, and ASCs.
Clinical Laboratory Improvement Amendments (CLIA)

5. Accreditation Survey Related Activities
Hospitals – Three (3) day survey
Three (3) member Survey Team reviews hospital compliance with HFAP accreditation requirements
Physician, RN, and Administrator

6. Patient Safety Initiatives
National Quality Forum (NQF)
30 Safe Practices (2003)
HFAP adopted 28 of the 30
Safe Practices

7. National Quality Forum 30 Safe Practices (2003)
For example:
#14 Operative Site Verification
#18 Anti-Thrombotic Therapy
#20 Prevent Central Venous Catheter
Infections
#21 Surgical Site Infections (SSI)
#22 Contrast Media

8. “The Organized Medical Staff”
The hospital must have an organized medical staff that operates under bylaws approved by the governing body and is responsible for the quality of medical care provided to patients by the hospital

9. Credentialing and Privileging Process
HFAP standards for credentialing and privileging provide for the periodic appraisals by the facility’s medical staff of its members.
The appraisal is to determine the suitability of individual members and all other credentialed providers for membership/continued membership on the medical staff, or

10. Credentialing and Privileging Process (cont’d)
credentialing / re-credentialing (for non-member credentialed providers), and to
determine if an individual practitioner’s clinical privileges should be approved, continued, discontinued, revised or otherwise changed. (HFAP hospital )

11. Credentialing and Privileging Process (cont’d)
The standards describe the responsibilities of credentialed professionals to the facility in which they work, to the patients which they treat, and to the Governing Body of the facility. (HFAP hospital , , and )

12. Medical Staff Membership
The standards identify the selection criteria for membership on the medical staff.
These criteria must include: licensure, training / education, current competence, health status, experience, character, and judgment. (HFAP hospital )

13. Required Application Information
The standards identify the required application/reapplication information to be provided for review.
This information includes: 1. licensure history, 2. medical education and post graduate training,

14. Required Application Information (cont’d)
3. malpractice insurance and history, 4. specialty board status, 5. sanctions or disciplinary actions, 6. criminal history, 7. healthcare employment history, 8. professional references, and 9. clinical activity.

15. Required Application Information (cont’d)
10. All information provided by the applicant/re-applicant is to be compared against verified information (HFAP hospital )

16. Quality Assessment and Performance Improvement
The facility’s quality assessment and performance improvement (QAPI) function involve: A. clinical assessments by Medical Staff and other providers for all service types of patients,

17. QAPI (cont’d)
B. diagnostic procedures – including invasive and non-invasive procedures from clinical laboratory, imaging, cardiorespiratory, physical or behavioral medicine, etc., for patients of all service types; and

18. QAPI (cont’d)
C. therapeutic interventions – including those processes and outcomes as appropriate to Medical Staff functions (HFAP hospital )

19. QAPI Information Used in Review of Candidates
Information derived from the facility’s QAPI functions is used in the review of candidates for appointment and privileging and addresses: 1. medication therapy, 2. infection control, 3. surgical / invasive and manipulative procedures,

20. QAPI Information Used in Review of Candidates (cont’d)
4. blood product usage, 5. data management (with emphasis on medical record pertinence and timeliness), 6. discharge planning, 7. utilization management,

21. QAPI Information Used in Review of Candidates (cont’d)
8. complaints from patients and families or from hospital staff, 9. restraint / seclusion usage, and 10. mortality review. (HFAP hospital )

22. Medical Staff Accountability
The Medical Staff is accountable to the Governing Body for the quality of medical care provided to patients by all credentialed practitioners and for
aggregating their QAPI finding from the departments, services, committees or other structural components to:

23. Medical Staff Accountability (cont’d)
A. develop plans for continuing the education of its members and all credentialed staff; B. provide annual evaluations of improvements in the clinical care provided;

24. Medical Staff Accountability (cont’d)
C. utilize as information in the process of evaluating Medical Staff for all membership categories including associate (provisional), active, consulting, and hospital-based membership categories;

25. Medical Staff Accountability (cont’d)
D. utilize as information in the process of evaluating and acting upon reappointment and reprivileging requests from its members and all other credentialed staff; and

26. Medical Staff Accountability (cont’d)
E. utilize as information in an ongoing process of evaluating the members of the medical staff. (HFAP hospital )

27. 03.00.04 Demonstrated Competencies
To include:
Current work / practice
Special training
Quality of specific work
Patient outcomes
Education
Maintenance of CME (continued)

28. 03.00.04 Demonstrated Competencies (cont’d)
Adherence to Medical Staff guidelines
Certifications
Appropriate licensure
Currency of compliance with licensure requirements to perform each task, activity, privilege requested for the category of practitioner.

29. …the list of privileges is modified for that practitioner.
If the practitioner is not competent
to perform one or more task/ activity/
privilege…
…the list of privileges is modified for that practitioner.

30. 03.01.04 Bylaws – Categories of Medical Staff
Include a statement of the duties, responsibilities, and privileges for each category of medical staff.
Categories must include all practitioners who provide a “medical-related” level of care, such as…

31. 03.01.04 Bylaws – Categories of Medical Staff
Physicians
Dentists
Allied Health Practitioners, e.g.,
RN First Assistants,
Surgical Assistants,
Anesthesia Assistants,
CRNAs,
Midwives

32. 03.01.15 Re-application References – Re-applicants
Must have Clinical Competence Review
Must have peer review reports, e.g.,
Clinical peer review,
Medical record review,
Credentials Committee/Function , and / or
Medical Executive Committee review

33. Re-application
Clinical Activity – Application & Re-applications
Must have QAPI clinical / objective data with signature of department chairperson
# Cardiac Stents
# Complications
Must have recommendation from department in which privileges are sought
Lack of Physician Participation:
Citation would be against the Medical Staff / Department of Medicine (not the individual physician.)

34. 03.01.15 Re-application Clinical Activity – Re-applicants
Examples of QAPI clinical / objective data
Timeliness of H&P
Content of Discharge Summary
# Patient Complaints
# Surgical Complications
# Re-intubations

35. Medical Staff Bylaws provide granting of emergency privileges.
Within scope of license
For life saving procedures
During times that a staff member who is a credentialed practitioner with appropriate privileges is not available.

36. Temporary Privileges
Bylaws provide for the granting of temporary privileges while a file is waiting to go to MEC and Board for final approval.
Application must be complete.
Credentialing Committee has reviewed file.
Applicable for:
For specific patients
For locum tenens
For times of emergency and / or disaster

37. Disaster – Clinical Volunteers:
Temporary Privileges
Disaster – Clinical Volunteers:
A plan is in place for clinical volunteers
The plan provides for primary source identification from the volunteer’s hospital, e.g., a documented telephone call
Volunteers function within their scope of license / certification

38. Chapter 2 – Allied Health Professionals
Allied Healthcare Practitioner (AHP) Categories
The governing body with the medical staff will determine which allied health practitioner disciplines will function under each category.

39. Chapter 2 – Allied Health Professionals
Credentialing Procedures
Appointed using privilege lists or a defined scope of practice.
Privileges that require physician supervision are identified.
Privileges that require direct or indirect supervision are identified.

40. Practitioners that provide a Medical – Related Level of Care…
or Conduct Surgical Procedures:
Must be individually credentialed
based on their own individual qualifications.
Regardless if care is provided directly or
under supervision,
Whether employed by the hospital, a physician
or other entity, or a contracted provider

41. Chapter 2 – Allied Health Professionals
Credentialing Procedures
The privileging process for AHP is the same process as used for the Medical Staff

42. Allied Health Professionals - Employed by Hospital
Credentialing Procedures
If the AHP functions in an education or leadership role,
This individual would not usually be privileged by the medical staff.
Files would be maintained in the HR department or as defined by hospital.

43. Professional Credentialing Organizations (PCO)
Definition:
“An independent contractor who has no clinical or financial affiliation with the people on whom data is being collected. There can be no evidence of any relationship that could raise the question of a conflict of interest.”
Facilities may use PCOs to assist in data collection for the credentialing and re-credentialing process, but the responsibility for granting privileges always remains with the facility.

44. Professional Credentialing Organizations (PCO)
The PCO may perform:
Personal reference checks
Verification of privileges at all facilities where the candidate maintains privileges
Verification of education and certification, etc.

45. Professional Credentialing Organizations (PCO)
Minimally, the facility granting privileges
MUST :
Verify State licensure
Query the National Practitioner Data Bank, and
Perform verification immediately prior to appointment.

46. CMS Conditions of Participation Final Rules (2006)
November 27, 2006:
H & P within 30 days / 24 hours of admission (before surgery)
Verbal Orders: Authenticate and time order within 48 hours
Final Rule –
December 8, 2006:
Restraint or Seclusion

47. The Healthcare Facilities Accreditation Program (HFAP)
George A. Reuther,
Director
142 East Ontario Street
Chicago, IL