1. Joint Commission Update National Credentialing Forum San Diego, California January 31, 2013
Ron Wyatt MD, MHA, Merck IHI Fellow
Medical Director, Division of Health Care Improvement
Office of the Chief Medical Officer
The Joint Commission

2. Credentialing and Privileging
CMS Conditions of Participation(CoPs)
§ Condition of Participation: Compliance with Federal, State and Local Laws
§482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. TAG: A—0023
§ Condition of Participation: Governing Body
§482.12(a) Standard: Medical Staff. The governing body must:
§482.12(a)(1) Determine, in accordance with State law, which categories of practitioners are eligible candidates for appointment to the medical staff; TAG: A—0045

3. Credentialing and Privileging
CoPs
§ Condition of Participation: Governing Body
§482.12(a) Standard: Medical Staff. The governing body must:
§482.12(a)(2) Appoint members of the medical staff after considering the recommendations of the existing members of the medical staff; TAG: A—0046
§482.12(a)(6) Ensure the criteria for selection are individual character, competence, training, experience, and judgment; and TAG: A—0050
§482.12(a)(7) Ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship or membership in a specialty body or society. TAG: A--0051

4. Credentialing and Privileging
CoPs
§ Condition of Participation: Governing Body
§482.12(a) Standard: Medical Staff. The governing body must:
§482.12(a)(2) Appoint members of the medical staff after considering the recommendations of the existing members of the medical staff; TAG: A—0046
§482.12(a)(6) Ensure the criteria for selection are individual character, competence, training, experience, and judgment; and TAG: A—0050
§482.12(a)(7) Ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship or membership in a specialty body or society. TAG: A--0051

5. Credentialing and Privileging
CoPs
§ Condition of Participation: 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.
§482.22(a) Standard: Composition of the Medical Staff
The medical staff must be composed of doctors of medicine or osteopathy and, in accordance with State law, may also be composed of other practitioners appointed by the governing body. TAG A: 0339
§482.22(a)(1) - The medical staff must periodically conduct appraisals of its members. TAG: A—0340
§482.22(a)(2) - The medical staff must examine credentials of candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates. TAG: A—0341

6. Credentialing and Privileging
CoPs
Recent revision from CMS:
Role of other practitioners on the Medical Staff: We have broadened the concept of “medical staff” and have allowed hospitals the flexibility to include other practitioners as eligible candidates for the medical staff with hospital privileges to practice in the hospital in accordance with State law. All practitioners will function under the rules of the medical staff. This change will clearly permit hospitals to allow other practitioners (e.g. APRNs, PAs, pharmacists) to perform all functions within their scope of practice. We have required that the medical staff must examine the credentials of all eligible candidates (as defined by the governing body) and then make recommendations for privileges and medical staff membership to the governing body.

7. Joint Commission Credentialing and Privileging
Process involving a series of activities designed to collect, verify, and evaluate data relevant to a practitioner’s professional performance
Serves as a foundation for objective, evidence-based decisions regarding appointment to the medical staff, and recommendations to grant or deny initial and renewed privileges

8. Credentialing and Privileging
Utilization of three concepts to allow the organized medical staff to conduct a more comprehensive evaluation of a practitioner’s professional performance
Six areas of “General Competencies”
Patient care, medical/clinical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice

9. Credentialing and Privileging
Utilization of three concepts to allow the organized medical staff to conduct a more comprehensive evaluation of a practitioner’s professional performance
Focused Professional Practice Evaluation
Ongoing Professional Practice Evaluation

10. Credentialing and Privileging
Utilization of three concepts to allow the organized medical staff to conduct a more comprehensive evaluation of a practitioner’s professional performance
Focused Professional Practice Evaluation
Ongoing Professional Practice Evaluation

11. Purpose
Align competency expectations to those used by ACGME training programs
OPPE
Require organizations to review performance data for all practitioners with privileges on an ongoing basis rather than the two year reappointment process and thus allow them to take the appropriate steps to improve performance on a more timely basis
FPPE
Require organizations to establish a process to evaluate the specific competence of all practitioners who do not have documented evidence of competency performing the privileges at the organization (e.g. new appointees, new privileges for current staff)
Process to evaluate a current privileged practitioner’s ability to provide safe, high quality patient care.

12. Examples of Data OPPE Expectations Ongoing Chart Review
Direct Observation
Peer Evaluations
Monitoring of diagnostic and treatment techniques
Internal: Infection rate; Complication rate; Blood use; Return to OR; Readmission rate; Return to the ED; LOS; Cultural Linguistic Competency; Patient satisfaction/complaints; Professionalism; Compliance with Rules/Regulations; Medical Records; Requests for tests; Morbidity and mortality; Use of consultants
External: Core measures; Professional data repository –STS, ACC; ACS National Surgical Quality Improvement Program; Commercial Vendors
Discussion with other individuals involved in the care of each patient - other practitioners, NP, PA, Surgical Assistants, Nursing, Ancillary Support Staff
Prospective Analysis – treatment conferences

13. Data Analysis
Data collection must be completed for all practitioners who are Medical or Professional Staff Members-
Active, Courtesy, Consulting, Allied Health, etc.
Zero data are in fact data – a zero rate may be good for complications but not good in that the practitioner has not performed a procedure in the last two years
There is no requirement that the data must be provided to the practitioner, and ….
The data and analysis does not need to be contained in the credential file

14. Data Analysis
Data collection must be completed for all practitioners who are Medical or Professional Staff Members-
Active, Courtesy, Consulting, Allied Health, etc.
Zero data are in fact data – a zero rate may be good for complications but not good in that the practitioner has not performed a procedure in the last two years
There is no requirement that the data must be provided to the practitioner, and ….
The data and analysis does not need to be contained in the credential file

15. In Summary
FPPE is a brief period of looking at the basic safety and competence in exercising ALL privileges for new medical staff members
OPPE is an ongoing period of looking at just a few indicators of quality for EACH practitioner – it touches on something he/she does, but not everything

16. For Standards/NPSG question:
, Option 6 or
Pat Adamski
Ron Wyatt

17. The Joint Commission Disclaimer Statement
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