COMPARATIVE DIFFERENCES:
TJC, CMS & NCQA MEDICAL
STAFF and CREDENTIALING
STANDARDS
Debra R. Green, MPA, CPMSM, CPCS
Director, Medical Staff Services and Pediatric Residency Program
Stanford University Medical Center
•Stanford Hospital & Clinics
•Lucile Packard Children’s Hospital
Objectives
• Overview of the 3 main regulatory bodies
– Who they are?
– What they do?
– Why they exist?
• Overview of Credentialing Standards
– Requirements
– Compliance
• Survey Process
The Joint Commission (TJC)
• Who are they?
– Private Organization
• What do they do?
- Unannounced Surveys
– Can Survey “For Cause”
• Why do they exist?
– To ensure patient care and quality
Center for Medicare/Medicaid
(CMS)
• Who are they?
– Government Organization
– Surveyors are typically State DOH employees
– Gives deeming authority to TJC, HFAP and DNV
• What do they do?
– Validate TJC
– Can Survey For Cause
• Why do they exist?
– To ensure patient care and quality
Authorities Deemed by CMS
• Healthcare Facilities
Accreditation Program
(HFAP)
– Over 200 hospital and
200 other HC facilities
and labs
– Existed for 60 yrs
• Det Norske Veritas
Healthcare, Inc (DNV)
– Certifies other
companies in
additional to
healthcare
– Existed since 1884
(began in Norway)
– World wide reputation
for quality and
integrity
National Committee for Quality
Assurance (NCQA)
• Who are they?
– Private Organization
• What do they do?
– Accredits: MCO’s, MBHO’s, PPO’s, NHP’s etc.
– Certifies: CVO’s
• Delegated Credentialing Agreements
– Hospital does the work for MCO
Overview of Standards
• Joint Commission
–
–
–
13 total MS Standards
Several Elements of Performance (EP’s)
Several changes to MS Standard – 2007, eff 1/2008
–
–
5 MS Standards
Evidence of Compliance
–
–
12 Standards (Credentialing)
Elements of Performance for each Standard
• CMS Conditions of Participation (CoP’s)
• NCQA
MEDICAL EDUCATION
• TJC Requirement
• (I) Primary Source
verification from
Medical School
• NCQA Requirement
• (I) Primary source
•
• Alternate sources:
AMA, AOA, ECFMG
•
verification from
Medical School
Not required if board
certified or if
residency has been
verified
Alternate sources:
AMA, AOA, ECFMG
(after 1986), state
licensing agency
POST GRADUATE TRAINING
• TJC Requirement
• (I) Primary source
verification from
training program
• Alternate sources:
AMA, AOA
• NCQA Requirement
• (I) Primary source
verification from
training program
• Alternate sources:
AMA, AOA, state
licensing agency
• Not required if board
certified (n/a for
dentists)
PEER REFERENCES
• TJC Requirements
• (I&R) Required
• NCQA Requirements
• Peer must be within
• (I&R) Peer Review
same professional
discipline (advisable to
utilize peer in same
specialty)
• Recommendations
should address training
or experience, clinical
competence and ability
to perform privileges
• 6 General Competencies
through Credentials
Committee with
representation from
similar types and
degrees of expertise
WORK HISTORY
• TJC Requirement
• NCQA Requirement
• (I) Doctor must provide
• (I) Doctor must provide
•
• No verification required
chronological history of
his education, training
and experience
Determination of
“significant” clinical
performance
five year work history on
application or CV
but must explain gaps of
6 months or more
HOSPITAL PRIVILEGES
• TJC Requirement
• “Ability to perform”
• Significant clinical
•
•
performance
Practice within scope
Grant or Deny must be
objective and evidence
based
• NCQA Requirement
• Application must include
•
attestation statement
from applicant regarding
history of limitation or
loss of clinical privileges
or other disciplinary
action
NOTE: NCQA does not
require doctors to have
clinical privileges at an
acute care facility
Performance Monitoring
• Required only by TJC
• Focused Professional Practice Evaluation
(FPPE)
– Proctoring – Chart Review or Observations
• Ongoing Professional Practice Evaluation
(OPPE)
– Ongoing data assessment for ALL
MEDICARE/MEDICAID
SANCTIONS
• TJC Requirements
• NCQA Requirement
• Not addressed in
• (I & R) Current or
standards
previous sanctions
must be verified
• Verify through NPDB,
OIG, CMS, FSMB,
state Medicaid agency
ONGOING MONITORING OF
SANCTIONS
• TJC Requirements
• NCQA Requirement
• Not addressed in
• P&P’s for the ongoing
standards
•
•
monitoring of sanctions
1) Medicare/Medicaid
2) License
3) Complaints
Documentation is
regularly obtained and
reviewed
Monitoring Adverse
Events
DEA/CDS
• TJC Requirement
• NCQA Requirement
• (I & R) Doctor must
• (I & R) Verify through
provide information
regarding previously
successful or currently
pending challenges or
relinquishment of
registrations
copy of certificates,
NTIS, AMA
CONTINUING MEDICAL
EDUCATION
• TJC Requirement
• NCQA Requirement
• (I & R) Participate in
• (I & R) Not Required
•
•
•
Continuing Education
Documented
Considered in Privilege
process
Should be relevant to
clinical privileges
requested
MALPRACTICE INSURANCE
• TJC Requirements
• NCQA Requirement
• Primary source
• Primary source
verification not required
unless required by
bylaws.
• (I & R) MS must evaluate
professional liability
actions
verification not required
• (I & R) Attestation by
doctor or copy of policy
showing dates and
amount of coverage or
Face Sheet
MALPRACTICE HISTORY
• TJC Requirement
• NCQA Requirement
• (I & R) evaluate
• (I&R) Doctor must
evidence of “unusual”
or “excessive”
number of actions
resulting in a final
judgment.
provide malpractice
history for past five
years.
• Verified through
carrier or NPDB
NATIONAL PRACTITIONER
DATA BANK
• TJC Requirement
• (I&R) Must query at
granting of initial,
renewal and when a
new privilege is
requested.
•
NCQA Requirement
•
(I&R) Query if you can’t
obtained last 5 years of
claims from Insurance
carriers.
•
Use as alternate source
for sanctions or
limitations on licensure
HISTORY OF FELONY
CONVICTIONS/Drug Use
• TJC Requirements
• NCQA Requirements
• Terminology is not
• (I&R) Application
used in Medical Staff
Standards
• Required under HR
Standards
must attest to his/her
history of loss of
license and felony
conviction and lack of
illegal drug use.
BOARD CERTIFICATION
• TJC Requirement
• (I) Verification not
required unless bylaws
require board certification
• (R) Organization Specific
• Verify through ABMS,
AOA or specialty board
• NCQA Requirement
• (I) Not required, but
•
•
verify through ABMS,
AMA, AOA, state licensing
agency if board certified
(R) Verify only if
certification has expired
(including lifetime)
Must document “lifetime”
in lieu of expiration date
LICENSE
• TJC Requirement
• (I & R)Primary source
•
verification required at
initial appointment,
reappointment, revision
of privileges and at time
of expiration
Current and Valid
• Verify through state
licensing board
• NCQA Requirement
• (I & R) Primary source
verification required
• Must be current and valid
• In effect at time of
credentialing decision
• Verify through state
licensing board
LICENSE SANCTIONS
• TJC Requirements
• NCQA Requirements
• (I & R) The doctor
• (I & R) Primary
must provide
information regarding
challenges or
relinquishment of
license (attestation
question)
source verification
• Verify through state
license board, NPDB,
or FSMB
ATTESTATION STATEMENT
• TJC Requirements
• NCQA Requirements
• Terminology Not Used • Applicant must
provide a current,
signed attestation
statement regarding
the correctness and
completeness of
application
TIME FRAME FOR COMPLETION
• TJC Requirement
• Structured procedure
•
must be defined in
bylaws
Complete applications
must be acted upon
within reasonable time
frame as specified in
bylaws
• NCQA Requirement
• Credentials
information must be
no more than 180
days old at the time
of credentialing
committee’s decision
LENGTH OF APPOINTMENT
PERIOD
• TJC Requirement
• NCQA Requirement
• May not exceed two
• Effective 7/1/01
years
credentialing period
may be for 36 months
NOW ABOUT CMS…..
Medical Staff Organization
• Regulation:
– Organized medical staff ; operates under
bylaws that are approved by governing body;
responsible for quality of care.
• Compliance:
– Bylaws, R&R’s, Cred files, Quality Reports,
Meeting minutes
MS Composition (a)
• Regulation:
– MS composed of MD’s, DO’s according to state
law; may also include others appointed by
Governing Body.
• Compliance:
– MS Rosters, Cred Files, Minutes or approved
Bylaws categories.
MS Composition (a)(1)
• Regulation:
– MS must conduct periodic appraisals
• Compliance:
– Cred Files, Profiles, Summary Reports of
Credentialing activity, Board minutes
documenting last 2 appraisals
MS Composition (a)(2)
• Regulation:
– MS must examine credentials of applicants for
membership and make recommendation to
Board.
• Compliance:
– Definition of Creds Review Process in the
Bylaws; any MS or Dept minutes that
document review and recommendations.
MS Organization & Accountability
• Regulation:
– MS must be well organized and accountable
to Governing Body for quality of Medical Care
provided.
• Compliance:
– MS Org Chart, Bylaws Description, Board
Minutes, definition of MS Composition in
Bylaws, Bylaws approval by Board
Medical Staff Bylaws
• Requirement:
– MS must adopt & enforce.
– Must be approved by Board; include category
descriptions, H&P requirement and criteria for
privileges to be granted; describe MS
Organization and applicant qualifications;
• Compliance:
– Bylaws, R&R, Minutes, Medical Records
(H&Ps), Quality reports (H&P timelines data)
Autopsies
• Requirement:
– Secure in all cases of unusual deaths and for
med/legal educational interests.
• Compliance:
– R&R, Autopsy Policy, QA or PI reports;
Medical Record Review.
History & Physicals (H&P)
• New Requirement as of 2007:
– No more than 30 days before or 24 hrs after
admission
• Old Requirement:
– No more than 7 days before and 48 hrs after
Success Tips for Compliance
• Continuous Readiness
• File Audits
• Database Audits (Appendix A)
• Increased Staff Knowledge (Appendix B)
• Employee Motivators/Incentives
Appendix A
Educational and Motivational Tool
Fun Quiz
Temporary Privileges
(Answer Sheet)
1.
2.
3.
4.
5,
Appendix B
Under certain circumstances, temporary clinical privileges may be granted for a limited period of time.
TRUE
When temporary privileges are granted to meet an important care need, the organized medical staff verifies only
current licensure and current competence before the provider can begin seeing patients.
TRUE
Temporary privileges for new applicants are granted for no more than 90 Bylaws/120 TJC days.
All temporary privileges are granted by the chief executive officer or authorized designee.
TRUE
Under which circumstances does the Joint Commission allow temporary privileges to be granted?
a.
To fulfill an important patient care, treatment, and service need.
b.
When a new applicant with a complete application that raises no concerns
is awaiting review and approval of the medical staff executive committee
and the governing body.
Bonus Question:
Temporary privileges for new applicants may be granted while awaiting review and approval by the organized medical staff
upon verification of……? List 5 items
- Current licensure.
- Relevant training or experience.
- Current competence.
- Ability to perform the privileges requested.
- Other criteria required by the organized medical staff bylaws.
- A query and evaluation of the National Practitioner Data Bank (NPDB) information.
- A complete application.
- No current or previously successful challenge to licensure or registration.
- No subjection to involuntary termination of medical staff membership at another organization.
- No subjection to involuntary limitation, reduction, denial, or loss of clinical privileges.
All answers can be found in the Joint Commission Medical Staff Standards under
MS.06.01.13
Questions????
Contact information:
Email: DeGreen@stanfordmed.org
Phone: 650-497-8920