Joint Commission Update
National Credentialing Forum
Ron Wyatt MD, MHA, Merck IHI Fellow 2009-2010
Medical Director, Division of Health Care Improvement
Office of the Chief Medical Officer
The Joint Commission
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San Diego, California
January 31, 2013
Credentialing and Privileging
 CMS Conditions of Participation(CoPs)
www.ecfr.gov.
 §482.12 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
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– §482.11 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
Credentialing and Privileging
 §482.12 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
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 CoPs
Credentialing and Privileging
 §482.12 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
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 CoPs
Credentialing and Privileging
 CoPs
– §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
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 §482.22 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.
Credentialing and Privileging
 CoPs
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.
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 Recent revision from CMS:
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
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Joint Commission
Credentialing and Privileging
Credentialing and Privileging
– Six areas of “General Competencies”
–Patient care, medical/clinical knowledge,
practice-based learning and
improvement, interpersonal and
communication skills, professionalism
and systems-based practice
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Utilization of three concepts to allow
the organized medical staff to conduct
a more comprehensive evaluation of a
practitioner’s professional performance
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
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– Focused Professional Practice Evaluation
– Ongoing Professional Practice Evaluation
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
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– Focused Professional Practice Evaluation
– Ongoing Professional Practice Evaluation
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
– 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.
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 FPPE
Examples
of
Data
OPPE Expectations
• 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
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 Ongoing Chart Review
 Direct Observation
 Peer Evaluations
 Monitoring of diagnostic and treatment techniques
 Data collection must be completed for all
practitioners who are Medical or Professional Staff
MembersActive, 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
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Data Analysis
 Data collection must be completed for all
practitioners who are Medical or Professional Staff
MembersActive, 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
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Data Analysis
In Summary
FPPE is a brief period of looking at the basic
safety and competence in exercising ALL
privileges for new medical staff members
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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
For Standards/NPSG question:
– 630-792-5900, Option 6 or
– http://www.jointcommission.org/Standards/
OnlineQuestionForm/
Pat Adamski
Ron Wyatt
– 630-792-5922
– rwyatt@jointcommission.org
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– 630-792-5964
– padamski@jointcommission.org
The Joint Commission Disclaimer Statement
 These slides are only meant to be cue points, which
were expounded upon verbally by the original
presenter and are not meant to be comprehensive
statements of standards interpretation or represent
all the content of the presentation. Thus, care should
be exercised in interpreting Joint Commission
requirements based solely on the content of these
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 These slides are copyrighted and may not be further
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 These slides are current as of January 31, 2013.
The Joint Commission reserves the right to change
the content of the information, as appropriate.