HFAP Flashcards
HFAP time frame for reappointment is not to exceed…
two years
What two accreditors state a hospital may not rely solely on board certification when considering practitioner for medical staff membership?
HFAP, CMS
According to JC & HFAP name four approved PSV sources for medical education?
Medical School, AMA, ECFMG, AOA
Who requires criminal background checks?
HFAP
Who requires background checks?
HFAP (the only organization that requires)
What is the HFAP appointment timeframe?
not to exceed 2 years
Professional reference must include health status?
HFAP
Can HFAP use credentialing committee to make recommendations?
Yes
According to HFAP standards temporary privileges may be granted in what cases?
1) for time of emergency or disaster 2) locum tenens 3) during review and consideration of application 4) for care of specific patients
HFAP application requests information regarding the following
Disciplinary actions taken or investigations pending by hospitals or other healthcare facilities, specialty boards, Medicare/Medicaid actions against DEA, Actions listed in the NPDB, information regarding criminal history.
Nondiscrimination according to HFAP
membership criteria cannot include sex, race, creed, national origin or handicap cannot impact the applicants ability to discharge privileges for which were applied.
Medicare/Medicaid Sanctions/Exclusions Requirement by HFAP
Sanctions or disciplinary actions must be reviewed at initial & reappointment. The application requests information regarding disciplinary actions taken or investigations pending by Medicare/Medicaid.
Current competence is determined by HFAP how?
information obtained from residency or facilities where the applicant has been practicing low volume may require review of procedure logs and competency from other facilities.
Complaints - HFAP Hospital 2015
Data collected regarding patient grievances and complaints that are not defined as grievances are reviewed through the QAPI functions. At a minimum, the hospital must review and send information to the distant-site telemedicine entity on all adverse events that result from a physician or practitioner’s provision of telemedicine services and on all complaints it has received about a telemedicine physician or practitioner.
Compliance with Law - HFAP Hospital 2015
Standards require compliance with applicable law and regulations.
Continuing Medical Education - HFAP Hospital 2015
Components of practitioner qualifications and demonstrated competencies include maintenance of continuing education. Evidence of continuing educational activities every two years may be requested.
CVO’s/Delegation: HFAP Hospital 2015
A professional credentialing organization, such as a CVO can be used to perform PSV, but the process for credentialing by the organization must reflect the requirements as stated in the standards.
Criminal Background Checks: HFAP Hospital 2015
The medical staff application must request information regarding any criminal history for 7 to 10 years. This facility conducts criminal background investigation based on information provided in the application or as required by federal and state regulations.
Current Competence: HFAP Hospital 2015
Criteria for membership and privileges must include current competence. Evaluation and granting of clinical privileges must be commensurate with the individual’s documented training, experience, and current competence. Applicants must provide clinical activity documentation and competency to be used in consideration of privileges requested. This can come from residency or from facilities where the applicant has been practicing. They must also provide procedure logs with outcomes to support privilege requests for procedures not attested to in postgraduate references. Reapplicants provide departmental recommendations low volume may require review of procedure logs and competency from other facilities including recent experience and recommendations from QA committee and/or other committees based upon peer review findings. Ongoing professional practice evaluation (OPPE) information is factored into the decision to maintain existing privileges, to revise existing privileges and/or to revoke an existing privilege prior to or at the time of renewal. Data is collected on an ongoing basis and summarized at least three times during each two year appointment cycle. (effective 1/2015); The organized medical staff defines the circumstances requiring additional, focused monitoring and evaluation of a practitioner’s professional performance. (effective 1/2015)
What is HFAP?
HFAP was established in 1943 by the American Osteopathic Association (AOA), and began surveying hospitals in 1945.[3] Initially, HFAP provided osteopathic hospitals with accreditation ensuring osteopathic residents received appropriate training. In the mid-1960s the United States Congress decided that accredited hospitals would meet conditions set for participation, and thus automatically participated in newly established Medicare and Medicaid programs. HFAP quickly applied for and was granted said status[4] in 1965.[5] By 2012, HFAP accredited about 214 hospitals in the US.[5] In 2015, ownership of HFAP moved from the AOA to the Accreditation Association for Hospitals/Health Systems (AAHHS).[6] Stands for: Healthcare Facilities Accreditation Program (HFAP) - from wikipedia
Designated Equivalent Sources: HFAP Hospital 2015
FSMB or fraud and abuse control information systems (FACIS) for actions against a physician’s medical license - AMA Physician’s Profile, AOA Official Osteopathic Physician Profile, for verification of medical education and postgraduate training. - ECFMG for verification of foreign medical education. - NPDB query for professional liability actions resulting in final settlements or judgements within the past five years. - If certified by a member of board ABMS, verify board certification with ABMS; if certified by a specialty board of AOA, verify with AOA Ostepathic Physician Profile.
Disaster or Emergency Management Plan Privileges: HFAP Hospital 2015
The medical staff bylaws provider for a medical staff chief and/or the CEO to grant emergency privileges to a practitioner to accomplish lifesaving procedures, within the scope of his/her license during such times that reasonably suggest that a staff member who is a credentialed practitioner with appropriate privileges is not available. Temporary privileges can be used in time of emergency and/or disaster. The hospital has a plan for dealing with clinical volunteers during emergency disaster. This plan should provide for primary source ID from the volunteers hospital/ A documented phone call is acceptable. The hospital should use volunteers as appropriate within the scope of their license/certification.
Drug Enforcement Agency Certificate (DEA) or State Controlled Dangerous Substances Certificate HFAP Hospital 2015
Application includes actions against DEA certificate or state CDS certificate
Education: HFAP Hospital 2015
PSV is required and includes AMA Physicians Profile, AOA Official osteopathic phsyician profile, and educational commission for foreign medical graduates (ecfmg) documentation regarding training and education must be sufficient to support requested privileges.
Felony Convictions: HFAP Hospital 2015
The application requests information regarding any criminal history and a criminal background investigation is conducted based on information provided in the application or as required by federal and state regulations.
