NAMSS Grid Flashcards
Which Organizations Require Ongoing Professional Performance Evaluation of Privileged Practitioners?
A) JC & DNV B) JC & CMS C) JC & HFAP D) DNV & CMS
Answer: C
Who requires peer references?
JC, HFAP, AAAHC
Who reappoints?
JC, HFAP, NCQA, URAC
Who requires an attestation?
NCQA, URAC, AAAHC
Who requires education verification?
JC, HFAP, URAC and AAAHC
Who requires statement regarding felony convictions?
HFAP, NCQA, AAAHC
Attestation must state that the information submitted is complete and correct?
NCQA, AAAHC
Who requires a malpractice history for applicants?
JC, HFAP, NCQA, URAC and AAAHC
Who must have a process in place to address complaints?
JC, HFAP, NCQA, URAC
Who requires board certification?
None
Who requires current competence?
JC, HFAP, CMS
Who requires a malpractice history for applicants?
JC, HFAP, NCQA, URAC, AAAHC
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
Attestation must state that the information submitted is complete and accurate?
URAC
Time limited credential must be verified by the CVO within how many days prior to submission to the client?
120 days
Under HCQIA, a hospital failure to report an adverse privilege action lasting longer than 30 days may cause the organization to lose HCQIA immunity for how many years?
3 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 Who? Medical School, AMA, ECFMG, AOA are approves sources of medical education?
JC, HFAP
Name an essential source when developing a peer review policy?
HCQIA
The HCQIA was passed into law in what year?
1986
HCQIA peer review protections apply to peer review of
Physicians, Dentists
Who recommends appraisal at least every 24 months if state law does not establish?
CMS
Who requires an attestation statement?
URAC, HFAP, NCQA
Who requires current competence?
TJC, HFAP, AAAHC
Who says if state law requires background checks than they are required?
CMS
Does CMS address sanctions?
No
Who allows FSMB to verify license sanctions?
JC, NCQA, HFAP
Malpractice coverage is necessary for what accreditation systems?
NCQA, HFAP, URAC
Who uses five year history for evaluation of malpractice?
NCQA, HFAP
Who has provisional credentialing?
NCQA, URAC
Who has temporary privileges?
JC, HFAP
Who requires peer recommendations?
JC, HFAP, AAAHC
What are the CMS criteria for selection to the medical staff?
Competency, Character, Judgement, Experience, Training
CCJET
Competence; Character; Judgement; Experience; Training
CMS conditions of participation for hospitals require that criteria for selection to the medical staff include evaluation of five areas
character, competence, training, experience, judgement
Name the six general competencies according to the ACGME & ABMS?
1) patient care 2) medical/clinical knowledge 3) practice based learning & improvement 4) interpersonal & communication skills 5) professionalism 6) system based practice
Which accreditation bodies have standards for medical record documentation and confidentiality?
JC, NCQA
Which of the following specifically require an attestation?
1) NCQA 2) URAC 3) AAAHC
Which accrediting bodies require CE process to address complaints?
JC, NCQA, HFAP, URAC, CMS
The Medicare Conditions of Participation are contained in which/what federal regulation?
code of federal regulations
Who specifically requires peer references?
1) JC 2) HFAP 3) AAAHC
Who requires a statement by the applicant regarding felony convictions?
1) NCQA 2) HFAP 3) AAAHC
Why was the HIPDB created?
to combat fraud and abuse in health insurance and healthcare delivery and to promote quality care
Ability to Perform Clinical Privileges Requested (Health Status)
the applicant’s ability to perform privileges requested must be evaluated and this evaluation documented in the credentials file. The applicant must submit a statement that no health problems exist that could affect the exercise of clinical privileges’. On initial appointment this statement should be confirmed by a director of a training program, the chief of services, or the chief of staff at another hospital where the applicant holds privileges, or an MD or DO approved by the medical staff. If there is doubt about an applicant’s ability to perform privileges requested, the medical staff can require an evaluation by an external and/or internal source. Health status is evaluated prior to recommending privileges.
Ability to perform clinical privileges requested (health status); JC 1/10/2017 CAMH; NCQA 2015 Health Plan Accreditation & 2013 CVO with updates
there is a current, signed attestation statement from the applicant regarding the reasons for any inability to perform the essential functions of the position, with or without accommodation, and the lack of present illegal drug use.
Ability to perform clinical privileges requested (health status) - HFAP Hospital 2015
Information regarding ability to perform privileges requested (health status is considered for each applicant and reapplicant during the review and approval process. For reapplicant, this can come from peers familiar with their practice; peer review activities; or reviews by the credentials committee, department chain, or medical executive committee. References should include a statement regarding the physician’s physical and mental health in relation to privileges requested.
Ability to Perform Clinical Privileges Requested (Health Status); DNV-GL NIAHO Acute Care 07/2014 Revision II
Although not specifically addressed in the standards, the surveyor guidance section regarding surgical surveyors, instructs surveyors to validate the hospital’s method for reviewing practitioner’s surgical privileges to determine if the process includes require verification of practitioner training, experience, health status, and performance. Surgical privileges shall correspond with the established competencies of each practitioner.
Ability to Perform Clinical Privileges Requested (Health Status) - URAC Health Plan; Accreditation Guide Version 7.2; 4.2014
Application includes disclosure of any physical, mental, or substance abuse problems that could without reasonable accommodation, impede the practitioner’s ability to provide care according to accepted standards of professional performance or pose a threat to the health or safety of patients.
Ability to perform clinical privileges requested (health status) - AAAHC 2015 Accreditation Handbook for AHC
The organization requires and reviews pertinent information concerning the applicant’s current physical, mental, health or chemical dependency problems that would interfere with the ability to provide high-quality patient care or services.
Ability to Perform Clinical Privileges Requested (health status) - Medicare Hospital COPs and Interpretive Guidelines - Rev. 141, 07-10-15
Although not specifically addressed in the regulations, the interpretive guidelines for 482.51 regarding surgical services, instruct surveyors as follows: “Review the hospital’s method for reviewing the surgical privileges of practitioners. This method should require a written assessment of the practitioner’s training, experience, health status and performance.”
Allied Health Professionals/Non Physician Practitioners: The Joint Commission 1/10/2017 CAMH
The Joint commission does not use the term “allied health professionals”. Rather, it refers to LIPs and Non-LIPs. The Joint Commission defines a licensed independent practitioner as “any individual permitted by law and by the organization to provide care, treatment, and services, without direction or supervision.” for staff other than PAs and APRNs: Human Resource standards require that before providing care, treatment or services, the qualifications and competence of a non-employee individual, brought into the hospital by an LIP are assessed by the hospital and are determined to be commensurate with the qualifications and competence required if the individual were to be employed by the hospital to perform the same or similar services. the organization reviews the qualifications, performance, and competence of each non-employee individual brought into the organization by a licensed independent practitioner to provide care, treatment, or services at the same frequency as individuals employed by the organization. For PAs and APRNs: All LIP PAs and APRNs who are providing a medical level of care (making medical diagnosis and treatment decisions) are credentialed and privileged through the medical staff process. PAs and APRNs who are not providing a medical level of care can be credentialed, privileged, and re-privileged through the medical staff process or an equivalent process that has been approved by the governing body. An Equivalent process at a minimum: evaluates the applicants credentials, evaluates the applicants current competence, includes peer recommendations and involves communication with and input from individuals and committees, including the MEC, in order to make an informed decision regarding the applicants request for privileges.
Allied Health Professionals - Non physician practitioners/NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
non-physician practitioners who have an independent relationship with the organization and provide care under the organization’s medical benefits must be credentialed.
Allied Health Professionals - Non physician practitioners HFAP Hospital 2015
HFAP standards do not refer to “allied health professionals”. Rather, they use the term “non-physician practitioners.” Standards regarding non-physician practitioners are a direct quote of CMS 42 CFR 482.22 (a) and 482.12. The following additional comments are included: the governing body must ensure that any privileges granted to non-physician practitioners are in accordance with state law, regulations, and scope of practice. Medical staff rules delineate the “qualification” process for non-physician first assistants. The Credentials Committee (function) is responsible for credentialing the medical staff as well as non-physician practitioners who provide a medical level of care, as applicable.
Allied Health Professionals/Non-Physician Practitioners DNV-GL NIAHO Acute Care; 07/2014 Revision II
The governing body shall determine, in accordance with state law, which categories of practitioners are eligible candidates for appointment to the medical staff. The medical staff must include MDs and DOs. If allowed by state law, including scope of practice laws, other categories of non-physician practitioners may be appointed to the medical staff as determined by the governing body. In accordance with state law, the medical staff may include non-physician practitioners such as PAs, CRNAs, advance practice registered nurses, midwives, psychologists, or other professionals approved by the medical staff and governing body and eligible for appointment. All patients must be under the care of a member of the medical staff or under the care of a practitioner who is directly under the supervision of a member of the medical staff. All patient care is provided by or in accordance with the orders of a practitioner who meets the medical staff criteria and procedures for the privileges granted, who has been granted privileges in accordance with those criteria by the governing body, and who’s working within the scope of those granted privileges.
Allied Health Professionals/Non-Physician Practitioners; URAC Health Plan Accreditation Guide, Version 7.2 4/2014
All practitioners who are participating providers and who provide covered health care services to consumers and those who appear in the organization’s provider directory are credentialed. The organization verifies the qualifications of all AHPs that may provide clinical services to consumers through a written agreement with the organization.
Allied Health Professionals/Non Physician Practitioners AAAHC 2015 Accreditation Handbook for AHC
If allowed by the organization, the board must provide a process for the initial appointment, reappointment, assignment or curtailment of privileges and practice for AHPs (based on state law and evidence of Education, training, experience, and competency.) If the ASC assigns patient care responsibilities to practitioners other than physicians, it must have established policies and procedure, approved by the governing body for overseeing and evaluating their clinical activities.
Allied Health Professionals/Non-Physician Practitioners Medicare Hospital COPs and Interpretive Guidelines Rev. 141, 07-10-15
Interpretive Guidelines 482.12 (a) (1) and 482.22 (a) The governing body must determine, in accordance with State Law, which categories of practitioners are eligible for appointment to the medical staff. Furthermore, the governing body has the authority, in accordance with State law, to grant medical staff privileges and membership to non-physician practitioners. The corresponding regulation at CFR 482.22 (a) allows hospitals and their medical staffs to take advantage of the expertise and skills of all types of practitioners who practice at the hospital when making decisions concerning medical stafff privileges and membership. Granting medical staff privileges and membership to non-physician practitioners is an option available to the governing body; it is not a requirement. For non-physician practitioners granted privileges only, the hospitals’ governing body and its medical staff must exercise oversight, such as through credentialing and competency review, of those non-physician practitioners to whom it grants privileges, just as it would for those practitioners appointed to its medical staff practitioners are described in section 1842 (b) 18 (c) of the Act as any of the following:
Physician assistant (as defined in Section 1861 (aa) (5) of the Act;
Nurse Practitioner (as defined in Section 1861 (aa) (5) of the Act;
Clinical Nurse Specialist (as defined in Section 1861 (aa) (5) of the Act;
Certified Registered Nurse Anesthetist (as defined in Section 1861 (bb) (2) of the Act;
Certified Nurse Midwife (as defined in Section 1861 (hh) (1) of the Act;
Clinical Social Worker (as defined in Section 1861 (hh) (1) of the Act;
Clinical Psychologist (as defined in 42 CFR 410.71 for purposes of Section 1861 (ii) of the Act;
Anesthesiologists Assistant (as defined at 410.69); or registered dietician or nutrition professional. Other types of licensed healthcare professionals have a more limited scope of practice and usually are not eligible for hospital Medicare staff privileges unless their permitted scope of practice in their state makes them more comparable to the above listed types of non-physician practitioners. Some examples of types of such licensed healthcare professionals who might be eligible for medical staff privileges depending on state law and medical staff bylaws rules and regulations include but are not limited to:
Physical Therapist (as defined at 410.60 and 484.4);
Occupational Therapist (as defined at 410.59 and 484.4) and;
Speech Language Therapist (as defined at 410.62 and 484.4)
Furthermore, some states have established a scope of practice for certain licensed pharmacists who are permitted to provide patient care, services that make them more like the above type of non-physician practitioners, including the monitoring and assessing of patients and ordering medications and laboratory tests. In such states, a hospital may grant medical staff privileges to such pharmacists and/or appoint them as members of the medical staff. There is no standard term for such pharmacist, although they are sometimes referred to as “clinical pharmacists”.
Applicant Identity: The Joint Commission 1/10/2017 CAMH
There must be a mechanism to determine the applicant is the individual identified in the credentialing documents by viewing either a current picture hospital ID card or a valid picture ID issued by a state or Federal Agencies, such as drivers license or passport.
Applicant Identity/NCQA 2015 Health Plan
Accreditation and 2013 CVO with updates; not specifically addressed.
Applicant Identity/HFAP Hospital 2015
Not specifically addressed.
Applicant Identity - DNV-GL NIAHO Acute Care 07/2014 Revision 11
Not specifically addressed.
Applicant Identity - URAC Health Plan Accreditation Guide, Version 7.2 4/2014
Not specifically addressed.
Applicant Identity - AAAHC 2015 Accreditation Handbook for AHC
Not specifically addressed.
Applicant Identity - Medicare Hospital COPs and Interpretive Guidelines - Rev 14b 07-10-15
Not specifically addressed.
Appointment Timeframe - The Joint Commission 1/10/2017 CAMH
Not to exceed two years (Now 3)
Appointment Timeframe - NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
Re credential at least every 3 years. NCQA counts the three year cycle to the month, not to the day. For example, if the organization credentials a practitioner on January 5, 2013, the practitioner must be recredentialed by the end of January 2016.
Appointment Timeframe - HFAP Hospital 2015
Standards are a direct quote from 482.22 (a) 1 which states that “CMS recommends that an appraisal be conducted at least every 24 months for each practitioner.”
Appointment Timeframe - DNV -GL NIAHO Acute Care 07/2014 Revision 11
As defined by state law, not to exceed three years.
Appointment Timeframe - URAC Health Plan Accreditation Guide, Version 7.2 04/2014
Re credential at least every three years. URAC counts the three year cycle to the month. For example; if the organization credentials a practitioner on January 3, 2013 the practitioner must be recredentialed by the end of January 2016.
Appointment Timeframe - AAAHC 2015 Accreditation Handbook for AHC
As defined by state law and organizational policy and not to exceed three years.
Appointment Timeframe/Medicare Hospital COPs and Interpretive Guidelines - Rev. 141, 07-10-15
Interpretive Guidelines 482.22 (a) (1) the medical staff must at regular intervals appraise the qualifications of all practitioners appointed to the medical staff granted medical staff privileges. In the abscense of a state law that establishes a timeframe for periodic reappraisal, a hospital’s medical staff must conduct a periodic appraisal of each practitioner. CMS recommends that an appraisal be conducted at least every 24 months for each practitioner. Interpretive Guidelines 482.51 (a) (4) surgical privileges should be reviewed and updated at least every two years.
Attestation Statement/The Joint Commission 01/10/2017 CAMH
Not Specifically Addressed.
Attestation Statement/NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
practitioners complete an application (and reapplication) that includes an inquiry, regarding illegal drug use and inability to perform essential functions, history of loss, or limitations of licensure or privileges or disciplinary actions, current malpractice coverage, and felony convictions. Attestation must indicate that the applicant personally attests that the application was correct and complete when they applied to the organization. If a copy of an application from an external entity is used, it must include an attestation to the correctness and completeness of the application. NCQA does not require the attestation to be received prior to the organization conducting credentialing verifications and queries required for other elements. Signature can be faxed, scanned, digital, electronic, or photo copied. Use of signature stamp is not allowed unless the practitioner is physically impaired and the disability is documented in the credentials file. If the application’s final approval exceeds 365 (305 CVO) days from the date of the signature, the applicant must re-attest to the information being correct and complete. If state regulations require an application not containing an attestation, an addendum to the application for the attestation must be used unless State regulations prohibit.
Attestation Statement/HFAP Hospital 2015
Responsibilities for credentialed practitioners must include: participating in medical staff functions, committee activity, educational activity, educational and QAPI activities, abiding by bylaws, rules and regulations; and adhering to ethical practice guidelines. Although not specifically addressed in the standards, the scoring procedure for regulation instructs surveyors to review a select sampling of files to verify practitioners attest to the above-listed responsibilities at appointment and reappointment.
Attestation Statement - DNV-GL NIAHO Acute Care 07/2014 Revision
Not specifically addressed.
Attestation Statement - URAC Health Plan - Accreditation Guide: Version 7.2 04/2014
The application includes a signed and dated statement attesting that the information submitted with the application is complete and accurate to the practitioner’s knowledge. Electronic signature is acceptable. Written policies and procedures should establish controls and manage risk for electronic signatures. Examples of acceptable signatures include faxed, digital, electronic, scanned, or photocopied signatures. Time limit is 180 days prior to the credentials committee review.
Attestation Statement - AAAHC 2015 Accreditation Handbook for AHC
The application/reapplication have a formal statement releasing the organization from any liability in connection with credentialing decisions. Includes the applicant’s attestation to the accuracy and completeness of the application and the information provided. Written attestation and information includes professional liability claims history information on licensure revocation suspension, voluntary relinquishment, licensure probationary status or other licensure conditions or limitations; complaints or adverse action reports filed against the applicant with a local, state or national professional society or licensure board; refusal or cancellation of professional liability coverage; denial, suspension, limitation, termination or non-renewal of privileges at any hospital, health plan, medical group, or other health care entity; DEA and state license action; disclosure of any Medicare/Medicaid sanctions; conviction of a criminal offense/other than minor traffic violations; current physical, mental health, or chemical dependency problems, that would interfere with an applicant’s ability to provide high-quality patient care and professional services.
Attestation Statement/Medicare Hospital COPs and Interpretive Guidelines - Rev. 141 07-10-15
Not specifically addressed.
Board Certification - The Joint Commission; CAMH 01/10/2017
Verification may be obtained directly from the specialty board. ABMS and its certified display agents are considered an equivalent primary source. The American Osteopathic Association (AOA) Physician Database can be used for verification of osteopathic specialty board certification. Standards do not address verification of board certification for reappointment/reappraisal. this would be an individual hospital decision dependent upon bylaws, rules and regulations.
Board Certification - NCQA 2015 Health Plan Accreditation and 2013 CVO with updates
Time limit; 180 days MCO and 120 days for CVO. If a practitioner claims to be board certified, the organization must verify it. Verification of board certification meets the requirement for verification of education and residency training. Verification of board certification meets the requirement for verification of education and residency training. Verification for physicians may be obtained through any of the following. ABMS, its members boards, and its approved Display Agents; AOA official osteopathic physician profile report; AOA/AMA Physician Masterfile; Confirmation from the specialty board; Confirmation from the state licensing agency if there is a confirmation that this agency conducts primary verification of board status; must document the expiration date of the board certification in the credentialing file. If it is a “lifetime” certification status with no certification date verify that certification is current and document date of verification. Must verify board certification at re credentialing. If the board does not provide the expiration date, the organization must verify that the board certification is current. Note: verification of board certification is not applicable to nurse practitioners or other health care professionals unless the organization communicates board certification to members. Other health care professionals: verification must come from the appropriate specialty board, state licensing agency or registry if there is documentation that primary source verification of education and training is performed. If not, the organization must also verify the highest level of education and training. If the organization uses confirmation from a NCQA approved source (such as the state licensing agency or registry), the organization must verify that the source performs PSV, and at least annually, the organization must obtain written confirmation from the approved source that it performs PSV.
Board Certification - HFAP Hospital 2015
The medical staff may not make its recommendation solely on the basis of the presence or abs cense of board certification, a hospital is not prohibited from requiring board certification, but this cannot be the only criteria used when considering a physician for medical staff membership. A hospital must also consider the request for clinical privileges, current licensure, training and professional education, experience, and supporting references of competence. Board certification must be reviewed for each applicant/reapplicant during the review and approval process. Verify with ABMS if physician is certified by a member of board ABMS. If certified by an AOA specialty board, verify with AOA official osteopathic physician profile.
Board Certification: DNV-GL NIAHO Acute Care 07/2014 Revision 11
A hospital may not rely solely on the fact that a physician is board certified in making a judgement on medical staff membership.
Board Certification: Medicare Hospital COPs and Interp. Guidelines - Rev. 141, 07-10-15, 482.12 (a) (7)
The governing body must 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. In making a judgement on medical staff membership, a hospital may not rely solely on the fact that a MD/DO is or is not, board-certified. This does not mean that a hospital is prohibited from requiring board certification when considering a MD/DO for medical staff membership, but only that such certification must not be the only factor that the hospital considers. In addition to matters of board certification, a hospital must also consider other criteria such as training, character , competence and judgement. After analysis of all of the criteria, if all criteria are met except for board certification, the hospital has the discretion to decide not to select that individual to the medical staff.
Complaints - DNV - GL NIAHO Acute Care 07/2014- Revision 11
The hospital must develop and implement a formal grievance procedure, which includes a referral process for quality of care issues to the utilization review, quality management, or peer review functions as appropriate.
Compliance with Law - DNV - GL NIAHO Acute Care 07/2014 Revision 11
Standards require compliance with all applicable federal, state, and local laws.
Continuing Medical Education - DNV - GL NIAHO Acute Care 07/2014 Revision 11
All individuals with delineated clinical privileges participate in continuing education that is at least in part related to their clinical privileges. CME considered in decisions about reappointment or renewal or revision of clinical privileges. Action on an individual’s application for appointment/reappointment or initial or subsequent clinical privileges is withheld until the information is available and verified.
CVO’s/Delegation: DNV: GL NIAHO Acute Care 07/2014 Revision 11
Notation under telemedicine states that hospitals may use third-party credentialing verification organizations to compile an d verify the credentials of practitioners applying for privileges, but the governing body is still legally responsible for all privileging decisions.
Criminal Background Checks: DNV-GL NIAHO Acute Care 07/2014 Revision 11
not specifically addressed. Required if state law
Current Competence DNV-GL NIAHO Acute Care 07/2014 Revision 11
MS bylaws describe the qualifications to be met by a candidate in order for the medical staff to recommend that the governing body appoint the candidate. Those qualifications shall include verification of current competence on initial appointment and reappointment. Verification required prior to granting temporary privileges. Surgical privileges correspond with the established competencies of each practitioner. Practitioner specific performance data is evaluated, analyzed and appropriate action taken as necessary when variation is present and/or standard of care has not been met as determined by the medical staff. Performance data collected periodically within the reappointment period or as required as a part of the peer review process. This may include comparative and/or national data if available.
Designated Equivalent Sources: DNV-GL NIAHO Acute Care 07/2014 Revision 11
Verification of education required on initial appointment. AMA profile and ECFMG accepted. AMA/AOA profile listed in temporary privileges standard.
Disaster or Emergency Plan Management Plan Privileges: DNV-GL NIAHO Acute Care 07/2014 Revision 11
Bylaws must include a process for approving practitioners for care of patients in the event of an emergency or disaster.
Drug Enforcement Agency Certificate (DEA) or State Controlled Dangerous Substances Certificate DNV-GL NIAHO Acute Care 07/2014 Revision 11
MS bylaws describe the qualifications to be met by a candidate in order for the medical staff to recommend that the governing body appoint the candidate.
Education: DNV-GL NIAHO Acute Care 07/2014 Revision 11
MS bylaws describe the qualifications to be met by a candidate in order for the medical staff to recommend that the governing body appoint the candidate. Those qualifications shall include verification of education on initial appointment. AMA profile and ECFMG acceptable.
Felony Convictions: DNV-GL NIAHO Acute Care 07/2014 Revision 11
Not specifically addressed.
