RECORD OF PROCEEDINGS - WIN/Staff



RECORD OF PROCEEDINGS

NATIONAL CREDENTIALING FORUM (NCF) 2005

LAGUNA BEACH, CA – HOTEL LAGUNA

11-12 FEBRUARY 2005

INTRODUCTION

All welcomed to NCF 2005 by Cris Mobley, of C. Mobley & Associates, LLC. Thanks to Lynn Stockton and Vicki Searcy for hosting and finding this conference site for NCF 2005, all welcomed to Laguna Beach, CA.

GENERAL INFORMATION/ANNOUNCEMENTS

This year to conserve time, the Round Table was limited to basic: Names and the Company that you represent at NCF. Kindly reminders of ground rules:

• All speak – no one dominates

• Open & forthright

• Put phones on vibrate/off (each offense will cost $5)

• No sidebars

Thanks to NAMSS for the CEUs that have been provided for participation in the Forum again this year.

CHECKPOINT – LYNN STOCKTON

Checkpoint is working with UT Health Information Network (UHIN) on an electronic application for credentialing to be built in Flash (moves fast, looks good, easy to use, intuitive and can be incorporated with existing Morrissey systems.) This will be created as a Data Collection tool only – no ownership of data (sent back to owners.) It will be used as a Credentialing OR Enrollment model. The basic elements (name, address, etc.) will be asked for enrollment, full credentialing process will include more information. This information that the practitioner enters will then be cued up and sent to the places that he designates. The doctor chooses enrollment vs. credentialing. However, they will still collect paper (attestations, ROI’s, licenses, malpractice.) No primary source verification will be done in Phase 1.

COUNCIL FOR AFFORDABLE QUALITY HEALTHCARE (CAQH) – RICHARD GALICA

The Committee on Operating Rules for Information Exchange (CORE) is a new industry-wide initiative launched by CAQH to facilitate the development of operating rules for eligibility and benefits transactions. Once implemented, the operating rules will enable a provider to submit a request, using the electronic system of their choice, to obtain a variety of coverage information for any patient and from any participating health plan.

Universal Credentialing DataSource Update as of 2/1/05:

• Fifty five (55) organizations are currently participating

• 155,000 participating providers with over 112, 000 complete credentialing applications

° Physican Applications – live in 49 states and DC (NV expected to go live May 05)

° Allied Health Applications deployed in 2004 – live in 40 states and DC (48 states by mid Feb 05)

° Because of only recent deployment of Allied Applications 95% of completed provider applications in the system are physician applications

° Use state mandated forms as required in some states

° Participation and complete provider numbers increase approximately 2,000/week

• In February 2005 CAQH is moving from a 90 day notification system to remind providers to update their application and time sensitive data, to a three (3) time a year notification (fax/e-mail) process

• Ongoing Sanction Monitoring module added as an option for interested organizations. Meets NCQA and URAC standards for the ongoing monitoring.

• Application is being revised to add new data elements requested by hospitals and others. Expect Mid-December 2005 rollout for Version 5.0.

• Currently planning for the possibility of data exchange functions with some popular software and system data portals. Target: Spring 2006 for system release at earliest.

PRACTITIONER HOSPITAL DATA BANK () – ANDY LOCK

Looking at clients needs, the internet is used extensively for PSV. There are two difficult pieces that cannot be garnered from the internet:

• Malpractice Insurance

• Medical Staff Affiliations

PHDB has set out to create a solution to Medical Staff affiliations to automate to make use as a PSV tool. This is being piloted in the Duke Health Raleigh Hospital and the Durham Hospitals in North Carolina. The appeal would be a central location that is updated by each hospital online, which would include an online attestation. Some hospitals would release a roster of the physician’s names, with an attestation attached that all information is PSV. There is no confidential information in the database, but enough for PSV. Doctors that are NOT in good standing will not be in the databank. Affiliation status is listed (Locum tenens, active staff, provisional, etc.) This is strictly a medium to distribute the approximately 80 to 90% of “good standing” practitioners on the hospital’s roster. If the physician has a sanction, the CVO will have to call the hospital for information. This service is free to the hospitals to post, there is a fee for outside entities to query. Hospitals would keep doctors who left in good standing on the roster for future PSV. But the doctors who leave in bad or other standing will not be on the roster/database.

AMERICAN BOARD OF MEDICAL SPECIALTIES (ABMS) – ROB NELSON

Display Agent Program:

• Method of designating agents for PSV in response to JCAHO changes. Who is an agent, who is not? Processes are in place for integration of this data. Freshness, security and integrity of data is also at issue.

• Moving away from books: No longer valid for PSV after January 2005 (birthdays were removed from the books.) CD Roms will no longer be used for PSV after June 2005.

• Considers technology development (non-manipulative data) – entities must have guidelines that they follow and be audited for integrity of PSV Data

• Refer to the ABMS Official Display Agent List and the Credentialing Advisory Notice at

ABMS Direct Connect:

• Enhanced internal application at ABMS made available to credentialers

• Provide secure access to MD search and account management functioning

• Currently available through CertiFACTS On-Linesm (an Official ABMS Display Agent owned and operated by TMP Worldwide, a Division of Monster Worldwide.)

TOPIC II: What is Maintenance of Certification (MOC) for physician recertification – Six general areas of competencies: Medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice. This supports the continuous education and evaluation of specialists. The example of implementation of MOC program by the American Board of Plastic Surgery was cited as good example of meaningful competency assessment and improvement effort that involves data collection and peer comparison.

PANEL DISCUSSION: TELEMEDICINE – CHRIS GILES, FACILITATOR; DAVID HOOPER, FEDERATION OF STATE MEDICAL BOARDS (FSMB)

Chris Giles – Introduction of Telemedicine: Defined by American Telemedicine Association as “use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and for the purpose of improving patient care, treatment and services.” Chris discussed the relevant JCAHO medical staff standards including the requirement that hospitals/entities that participate in this process are charged with appropriate maintenance of the equipment and with having appropriate training. Privileging by proxy (distant site vs. originating site) as defined by JCAHO was also discussed.

There are many websites showing various ways that telemedicine is being used:

• The elderly for home health

• After surgery

• Dermatological Assessment and treatment

• Tele-psychiatry

• Robotics

Issues relevant to telemedicine that need to be considered and answered prior to an organization participating in telemedicine include:

• Possible liability for negligent credentialing, especially if privileging by proxy is utilized – is the organization covered for such a situation?

• Licensure – state licensure requirements must be fulfilled by all physicians participating in telemedicine.

• HIPAA compliance is key due to patient information being transported electronically.

David Hooper – Benefits of telemedicine:

• To increase speed of diagnosis and treatment.

• Increased availability of specialty expertise to outlying areas

• Thus, increasing efficiency and access to health care

Main points to remember:

• Practice of medicine occurs in the state where the patient is located

• The personal exam (H&P) cannot be exempted, must have “hands on” relationship

• A valid license must be held in each state that the physician is providing service

License portability: Four states in the Northeast are trying to facilitate licensure between them through a Regional Pilot program. If this is successful, it is quite possible other blocks of states in other regional areas will do the same. There is also a goal to have a “common license application form” to help streamline the process.

FSMB has changed the website based on feedback from last year’s encouragement of NCF participants to Tim Knettler. Differing elements can be used as resources. Can find specific states guidelines on telemedicine by clicking on individual state on the website.

NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) – FRANK STELLING

Interactive Survey System (ISS): Process was redesigned with a look at business rules to make sure they were the same. The major user of the ISS are the MCO’s (50%), with the majority of the users weighing in that they were very satisfied with streamlined preparation; easier documentation and submission, and an improved overall process.

2004-2005 changes:

• HIPDB as source for sanctions in credentialing standards

• Monitoring non-discrimination

• Appropriate ABMS sources

What is the ISS? Two components:

• Standards and guidelines is web-based and searchable (available in print or e-publication)

• The survey tool

1. allows the entities waiting for survey to complete question/answer tool for survey readiness/preparedness;

2. has available links that show supporting documentation to compliance rules; and

3. includes the standards and guidelines (in a drill-down format)

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS (JCAHO) – BOB WISE

This has been a busy year for JCAHO, things to be reflected in 2006:

Update on Credentialing and Privileging 2005: Matching rigor of Credentials/Privileging to quality needs. Safety is taking a front seat - Practitioners number one focus.

Matching Rigor of Privileging to Quality needs

• Access vs. safety/quality (changing access usually creates an inverse relationships with safety/quality issues)

An essential ingredient is to increase the rigor:

1. Credentialing/Privileging task force has been meeting for one year. One of the issues is putting an end to privileging by exception.

• Expected implementation 1/2006

• Creation of transitional period for new providers – currently there is either a yes or a no, nothing in between

• Improve inter-cycle monitoring and triggers

• Greater expectation of oversight of new privileges especially ones connected to high risk procedures

• Oversight after triggers

2. Suggest methods of oversight

• Data review

• Proctoring (passive and active involvement)

• Data collection on someone presenting themselves for the first time to confirm impressions

• Trigger with closer looks: what does it mean? (i.e. looking at charts, aggregate data)

• Intracycle monitoring – should be on going vs. last minute rush (maybe the 2-year cycle will change when valid intracycle monitoring is implemented and done well)

3. Primary Source Verification (PSV) for Non-LIP – there is a huge hole (the next three requirements are being considered for 2006, but have not been completely vetted.)

• All programs

• Whenever license/certificate required by law or organization

4. Organizational responsibility of clinicians under direct supervision of LIP

(someone not employed by hospital for example: PA, OR Tech, or a surgeon’s private first assistant.) They have to be put through some sort of process to verify competency, same criteria as an employee

5. Credentials/Privileging require for ambulatory organization acting as a proxy to hospitals (i.e. teleradiology.)

Decreasing the Rigor:

1. Disaster planning

• Currently only LIP in hospitals

• LIPs – extended to all programs

• Non-LIPs all programs, including all who volunteer to help

2. Coverage of LIP by LIP (Long Term Care)

Certification of Staffing Agencies

1. Market Research

2. Launched 9/2004

3. Eligibility – Clinical staff provide care and under supervision of supervisor of organization’s staff

4. Major areas of review:

• Leadership

• HR (credentialing and assessing competency)

• Performance improvement

• Information Management

HR Management

• Credentialing

• Assessing competency (goes beyond credentialing)

• Match staff to assignment

• Improving competency (is there active participation in company to get feedback?)

Current Discussions: Can a hospital reduce its burden by using accredited organizations? Not yet but stay tuned.

Discussion on reportable events:

• observation of another practitioner (not reportable)

• stepping in (restrictige) or requiring someone to be there at time of care (reportable)

• many organizations define differently – need to standardize

AMA PHYSICIAN PROFILE (PATRICK MCDONAL)

Profile will include corresponding schedules and expiration date

PANEL DISCUSSION: USE OF CORE PRIVILEGES - VICKI SEARCY, FACILITATOR; CAROL CAIRNS; BOB WISE, JCAHO

Carol Cairns – CMS position (paper)

CMS drafted document about Core related to the privileging system. Criteria based privileging is imperative:

• Starts with competence (have to establish)

• Defines what competence is

• Special training

• Quality outcomes

• Patient outcomes, etc.

Core is an “approach” not a format of privileging

Individually assessed competencies, then come to consensus on what quality looks like – this will raise the bar.

Concerns: Privileging systems are becoming a source for plaintiff attorneys to discover for Negligent Credentialing. Where is the criteria? Cases being lost to these attorneys due to that missing piece not being defined.

Bob Wise – Issue has to do with whatever group you are dealing with. There has to be a reason that you are putting all these competencies together. Creating these groups is an art, and thus has to be done in an individualized process.

Example: The colonoscopy – differing folks fighting over same turf (Surgeon, GI, Family Practice, Internal Medicine.) Who will define standards/competencies?

PANEL DISCUSSION: ASSESSING COMPETENCY – LYNN STOCKTON, FACILITOR; ANNETTE VAN VEEN GIPPE, AOA; ALFRED BUCK, CHRIS GILES

Christine Giles – Definition of competence is variable, depending on who is doing the defining. Does the locale of practice impact the definition? The ABMS, ACGME and AOA have presented six general competencies for which they are developing definitions. The ACGME is using these competencies to develop assessment and measurements of physicians in training programs; the ABMS and AOA and their various specialty boards are utilizing these competencies to develop maintenance of certification programs:

• Patient care

• Medical knowledge

• Practice-based learning and improvement

• Interpersonal and communication skills

• Professionalism

• System-based practice

Healthcare professionals are challenged to try to define measurements for these competencies. The ACGME has posted on their website the “Outcomes” project which provides their definitions for the general competencies and includes a tool box of various measurement tools that have been developed and are in use in various types of residencies. The work at ACGME should be observed and consideration given to how some of their tools might be utilized in the measurement of physicians out in practice.

Patient Care: A recent change in the US Medical Licensing Examination for physicians preparing for licensure is the inclusion of a clinical skills test where the physicians will be observed performing 11-12 patient interviews and will be assessed on their ability to establish rapport with the patient, elicit a pertinent H&P, obtain accurate impressions and make an appropriate diagnosis and record the interview in a medically pertinent progress note.

Practice-based Learning and Improvement: There is still a push back against evidence based medicine from some physicians, but many organizations have established clinical pathways as guidelines for measurement and more and more physicians are participating on PI teams trying to identify root causes of problems, thus, demonstrating a willingness to learn from errors.

Systems-Based Practice: The physician must be the patient’s advocate. Access to the various resources in the community must be understood by the physician so that he can utilize them effectively for his patient.

In maintenance of competence, CME is not enough. It is a lifelong process of improvement of practice. Can these learning techniques be measured?

ABMS and AOA Maintenance of Certification (MOC) programs are being established by all the specialty boards. They are designed to document that their physicians have maintained the competence that they were originally certified for over the years through continual training and practice in that area of specialty.

Patient satisfaction – there are a host of criteria that patients use to evaluate hospital and practitioner quality:

• Time spent with physician

• Explanation of diagnosis and treatment

• Technical skills of physician

• Personal manner of physician

• Use of latest technology

• Focus on prevention

• Concerns for emotional well being of patient and family

This being said, it cannot be under-emphasized: Evaluation of the physician’s performance must be an ongoing process that takes place not just at reappointment, but at every juncture that the physician interacts with the hospital and its clients. Along with this evaluation of the physician, the facilities expectations must be communicated, as well as meaningful feedback relating to expected competencies.

Al Buck – In the great minds think alike arena, two questions are asked about competency:

1. Could/should credentialing process and its product (the credentials file) support the determination of competency?

2. Could/should the credentials file be used to establish or communicate competency (for instance in response to legitimate outcome question?) Yes, to both.

Definition suggestion: I current day discussion much use of “competency” in a marketing sense – but how about this: Successful performance in a specified site(s) over time through assessable results, knowledge, skills and commitment (professionalism, compassion and so forth.)

Things keeping us from going forward: lack of consensus about definition, policy needs (such as file utilization, data standards) and relative ignorance of success stories (best practices) in credentials management and utilization – but NOT by lack of available technology. Specific example - impediments to performance measurement incorporation: Reference data: policy/standards about data base linkage (among practice sites or organizations), case risk adjustment methodology, aggregation rules, analytical processes and reporting. Pertinent law: policy resolution of medical-legal concerns such as discover and use of arbitration as a constructive adjunct to tort reform.

New challenges/potential developments: non-physician LIPS/non-LIP, (emergency technicians, RN’s, NP’s, pharmacists, etc.); expanded scope of competence of ACGME (e.g., interpersonal skills, communication, professionalism, system based practice), career evolution/management; license renewal, and GME selection/support.

At a more system level, new use might involve or relate to: GME/CME management (planning, budgeting), distribution of providers (skills), integration of oversight for healthcare sites (especially for the small isolated organizations), comprehensive (more inclusive) peer review, comprehensive mentoring, and transportability.

Comment: Your organization and emphasis can offer a heightened level of summary so accept the above as “grist for the mill.”

Annette Gippe – AOA developed in 2000 a pilot program in Family Practice Residency, denoting that clinical assessment starts here. As a result of this success the CAP (Clinical Assessment Program) was started, thus it was further implemented. In 2003 FP requires all residency programs to do this for accreditation. By 2005 Internal Medicine residency program will have to adopt as well for their accreditation.

Other measures in the quality arena:

• Electronic patient records – endorse docket system

• Created new special college for Medical Informatics to get DO’s educated to use technology to help their practices

• CMS has a pilot project in CA, MO with quality questions

• Accredited hospitals are required to report to CMS

AOA would like to redesign their profile, requesting input. It will probably be launched in 2005.

Membership committee voted to weed out physicians that are less than ethical. AOA voted to proactively go after these DO’s and to work with the State Boards and FSMB to pull out these licenses.

Cris Giles – Example of North Shore Long Island Jewish Health System: study included office practice sites (they have to offer value)

• Mentorings

• Quality assessment of referrals

• Joint partnership for automation of offices

• Makes practitioner feel that they are a part of a larger entity (that they’re not alone in this)

Makes note of inadequacy of peer review.

Wendy Crimp – there’s agency on policy and research that has 44 physician competencies. Maybe we should look at this. Leapfrog provided funds. Frank Stelling knows about agency and can get information. Should have update next year. Ask a CMS regional person to attend.

PANEL DISCUSSION: CREDENTIALING CONSENSUS ALLIANCE (CCA) – CRIS MOBLEY, FACILITATOR; RICHARD GALICA, CAQH, ANNETTE VAN VEEN GIPPE, AOA; ROB NELSON, ABMS

NAMSS vision in the beginning for the CCA was “to establish the simplest set of consistent requirements for credentialing that meets the needs of the community.” To develop best practices – but the big question ends up being: What do you do with this information? Questions asked: what else can we do as a credentialing industry?

Summary of expectations brought out some issues of concern:

• Trust-share of data (why everyone is always re-PSVing information, trust is lacking)

• Redundancy – can it be reduced

• Best practice has to be defined

• Turf wars, as there are many competitors in this field, and along with them the “special interest” groups

Bottom line is that we basically all do the same sort of work (Obtain, Verify, some Assess, some Review.) Can this process be streamlined and identified so that there is in the future some identification of best practice for verification of information. (This would include the sites that we now hold as Primary Verification Sources, such as ABMS, AMA, FSMB, ECFMG, NPDB, etc.)

NAMSS is considering a white paper on the needs of the various organizations and what is the credentialing core data elements that should be included on an application.

Finally, the CCA should not disband, they need to reorganize and re-energize in future innovation for the industry.

Annette Gippe – Discussion CCA

• ACGME: 6 competencies were discussed. Documentation of competencies is a good place to start. (e.g. How did they handle their residencies?)

• Redundancy of PSV, AMA collects ABMS material, why are Primary Sources overlapping data if there is collaboration. (Politics/money aside – develop central repository for this information. If we did this, would the industry accept it?)

Dick Galica – Discussion CCA

Dick reported CAQH is adding additional data elements identified by NAMSS and NCF, the revised application will be released 12/2005. The lengthy development release date relates to data conversion of current information, which requires extraordinary effort to ensure accuracy. He felt that CCA members recognized that credentialing can become more efficient and that during the morning, there was a great deal of interest and energy to move forward and find solutions. He suggested the energy was experienced as frustration in the afternoon because there was no clear consensus of a stepwise plan to move forward. He suggested that time may have been more productive by focusing on building a plan to address some of the inefficiencies in credentialing rather than tring to move in a direction the group was not prepared for. He is fairly optimistic there is energy and desire of participants to find a solution, but believes a number of individuals felt deflated and will need to be re-energized with a clear goal before progress will be made. NAMSS was encouraged to rethink their focus, but that there was a lot to do.

Betsy Ranslow – Discussion CCA

The VA is considering a request from Indian Health Services to have access to Vetpro for their hospitals. They will be an interesting organization to watch and see how they progress.

Rob Nelson – Discussion CCA

Need agreement on Data elements. He was impressed with expertise and passion in that room. He further commends those individuals (NAMSS) for getting them together. A large problem was the move to gain the CCA participants to endorse any product. Some of the organizations (Federal agencies and others) would not have the ability to endorse and was not appropriate for that group. Five issues:

• Cost-efficiency

• Pre PSV data element collection vs. PSV Verifications

• PSV redundancy (1.8 billion dollar cost to the industry)

• Who’s going to touch this from an industry perspective?

• How do you acquire data elements effectively, efficiently, securely?

NCF general comments:

• A centralized Mother-load database is not the answer (ATM technology for PSV) to allow real-time connection to the primary source for data elements is possible via technology. This reduces many of the data integrity and quality concerns as well as avoids some of the entrenched turf issues.

• NAMSS should force the industry to find solutions.

• NAMSS should considering working with AHA on legislation that would allow hospitals to access HIPDB.

LEGISLATIVE UPDATE: DAVID HOOPER, FSMB

Internet Pharmacy consumer protection bill went nowhere in the 108th Congress (to establish standards for internet pharmacy dispensing.) Other issues to watch:

• Emergency Preparedness/Bioterrorism

• Patient Safety/Medication Errors

• Credentialing

• J-1 Physicians bill – will allow each state to request 30 waivers per year for International Medical Graduates who complete a Residency program

•

Emergency Preparedness/Bioterrorism - Passed:

• AZ HB 2006 – allows Physician Assistants to provide medical care without supervision during natural disasters, accidents or any other emergency

• FL SB 532 – Good Samaritan Act, Florida Volunteer Protection Act

• IL HB 5164 – Illinois Emergency Management Act, allows licensure requirement waivers.

Patient Safety/Medical Errors – Passed:

• IL HB 1082

• NJ SB 557 – There are a number of organizations collecting information on Medical errors: have to have confidentiality. Some are trying to hide gross negligence.

• TN SB 2162 – Legible prescriptions

Credentialing:

• CO HB 1354 – the Healthcare Care Credentialing Uniform Application Act: requires insurers in the state to use a common credentialing application

• CO HB 1406

Worth Watching:

• FL – Three Strikes (judgments) Amendment

• Medical Liability Claimants Compensation Amendment – malpractice lawyers have limited amount they can be paid

• Patient’s Right to Know Amendment (access to Physician report cards)

UPDATE FROM THE PRACTITIONER DATA BANKS BRANCH: BETSY RANSLOW, HRSA, DHHS

The NPRM for Section 1921 of the Social Security Act as amended by Section 5(b) of the Medicare and Medicaid Patient and Program Protection Act of 1987 (Section 1921) is in the HHS clearance system. The intent of Section 1921 is to protect program beneficiaries from unfit health care practitioners and otherwise improve the anti-fraud provisions of the Medicare and State health care programs.

Section 1921 will require that:

• Licensing board for all health care practitioners and entities submit adverse actions reports;

• Accrediting bodies for all health care providers (entities) submit adverse action reports. In addition, it will give law enforcement agencies access to any reports submitted under Section 1921, only. Those entities authorized to query the NPDB will have access to both NPDB reports and section 1921 reports.

Consideration is underway for a Pro-Active Disclosure Service (PDS) where queriers would be notified of reports naming any of their registered subjects when reports are received by the Data Banks. There would be a requirement to query the NPDB and/or HIPDB when registering the subject with PDS (the entity could register for PDS with the NPDB, HIPDB or both). The entity would be responsible for maintaining and updating its practitioner roster as practitioners left its employ/roster or if the entity wanted to entroll additional practitioners with PDS. (The penalty for breach of confidentiality $11,000.) The database would enable the entity to generate a summary of their registered practitioners. NCQA has included the PDS as usable for five of their standards for credentialing.

In an ongoing effort to increase reporting compliance the Practitioner Data Banks Branch continues to review media publications for reportable actions taken against specific practitioners and cross checking the information with Data Bank reports. The data bank has numerous outreach activities and educational endeavors that involve both national and international organizations. When questioned why hospital entities could not query the HIPDB, it was explained that staff did not know the reason with any certainty. However, it may have been that there was a lobbying effort made to keep hospitals from being required to query the HIPDB presumably because of concerns that it would be too burdensome since hospitals are required by law to query the NPDB. It was reiterated that HIPDB is owned by the Office of Inspector General (OIG), not by HRSA which owns the NPDB.

NCF WEB SITE UPDATE: ANDY LOCK –Website is alive and well. Next year it will be used to post the handouts for the conference, as well as:

• Updates

• Notes to website

• Updated pictures

FUTURE MEETING: An email evaluation form will be sent out. We may consider a Thursday and Friday combination, 2 full days next year. Regional CMS rep should be invited; also, AMA-OMSS, URAC.

MEETING CRITIQUE:

Would anyone like to be the facilitator next year?

Requests were made for thoughts, ideas and suggestions for next years agenda.

We have penciled in tentatively either Thursday/Friday 9-10 February 2006, or Friday/Saturday 10-11 February 2006.

Suggestions for locations/hosts – Palm Springs, CA, Napa, CA, South Carolina. Gino Conconi will check on Palm Springs location, Vicki Searcy will check with a hotel in Napa, and Carol Walker on South Carolina.

Submitted by Susan Freeburn, RN

Director Credentials Verification, AFIP

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