WIN/Staff



National Credentialing Forum 2013January 31 – February 1Meeting Minutes Assuring Continuing Competence – View from the AccreditorsHFAP – Joe Cappiello , Chief Operating OfficerA Thought: Previous discussions about “greater stake-holder recognition” of medical staff professionals is reminiscent of? debates with my friend of many years, Dr. Al Buck about attempts to bring quality into the military healthcare system by elevating the stature of those who are accountable for this type of work. Over the years, working in the field as the quality director of a large university-based medical center, the issue still comes up time and again. The reality becomes that the importance of what you do doesn’t come from the outside. It cannot be mandated by a standard. It really is what you do to make yourself important. The quality of the profession, the professionalism that is displayed, is the key in how invaluable you make yourself. HFAP Background: Has been accrediting hospitals since 1945. Started as accreditor for Osteopathic Medical Centers when DOs were not allowed to practice in Allopathic Medical Centers. This has changed over the years and the medical staffs are now very integrated. HFAP was first accrediting body to achieve “deeming” status when the Medicare Law was passed in 1965. HFAP has had to demonstrate to CMS their compliance with the conditions of participation of Medicare in their standards for the last 47 years. Therefore, HFAP is very familiar with government requirements. Standards score: We score each of our standards as Compliant or Non-Compliant – either you are doing it or you are not. HFAP approach is very straight-forward: educative and consultative onsite. Accreditation is a risk-reduction strategy – there is a body of standards based in science and experience; so the idea is that compliance with the standards is not to achieve the goal to become accredited but compliance with the standards is important because they make sense, they improve the quality of care and they mitigate or support the reduction of risk. Data is collected on physicians to identify possible points of risk and to improve care. HFAP strategy is meticulous evaluation of every standard, every time – 100% of standards are reviewed onsite 100% of the time. There is no penalty for non-compliance with the standards, what HFAP is concerned about is identification of risk in the facility. Thus, nurturing an environment where there is no penalty for “discovery” of a deficiency. When a deficiency is found the facility will have to provide a “plan of action” of how they plan to become compliant. The action plan will be monitored to assure the deficiency is corrected. By design HFAP standards are written very clearly. Credentialing and Privileging Standards are straight-forward, no gray areas, no room to say “I wonder what HFAP means – what am I supposed to do…”At issue: Standards are necessarily dynamic. Hospitals are acquiring “medical groups” and employing physicians at an accelerated rate. Previously, credentialing and privileging occurred with the understanding that hospitals were simply workshops where the physicians practiced and we should only be concerned with what occurred under that roof. . What you do in the hospital is really important to us… we are going to monitor that, privilege you, and make sure that your credentials are adequate to allow you to perform under our roof. What you do outside in your private practice is your own business. But, when the hospital acquires your practice, you become “employees” of the hospital. The question is under this evolving scenario -- Where does the liability for the hospital begin and end? Does it extend into the physician’s office practice? Is the hospital and some of the data that is collected on the physician now begin to extend to what they do day-in-and-day-out at the office level? How do you bring those data sets together? How do we reconcile the two different care models (we care about what you do here, but not what you do there?) If we have “data” are we not obligated to do something about it? What is our legitimate responsibility if that data is available for analysis and translation into something meaningful for improving care and mitigating risks? What is the risk and liability of ignoring the data?Are there standards we can begin to think about as to how we can connect that data sources; the monitoring of the practice continuum, rather than an episodic approach – those events that happen only within the hospital walls. The previous President of The Joint Commission, Dennis O’Leary, stated: “When you see one Medical Center in the U.S., you have seen “one” Medical Center ...” You cannot take and lump everyone together and say what works for “A” is going to work for the rest of the alphabet. There is a delicate balance to be struck between what you require for one and regardless of the size and regardless of the resources that facility has, that standard must be applicable across the board. Use of data: It seems what we are trying to do with data is akin to looking up at contrails in the sky and attempting to identify the make of jet by looking at those contrails… How effective is it to look at an “after-event” (i.e. contrail) – as opposed to trying to be ahead of the events – to anticipate what is coming. There has been talk about forms and how data is collected. To me it is important to remember that it is not the form itself that is relevant… it is the data that is put onto the form that matters. Often times, we get “stuck” with the appearance of the form (contrails) rather than the elements that are being collected and how to use that data. NCQA – Frank Stelling (slides will be made available for website)Affordable Care Act: What NCQA is doing to meet standardsRequirement: Must be accredited to “play”Many “exchanges” will be brand newIn terms of Health Plans NCQA has Initial and Renewal SurveysInitial Survey: Friend organization coming through for the first timeRenewal Survey: Organization is already accredited and will be going through a “reaccreditation” process (completed every 3 years)Process has been changed – NCQA now has three evaluation options (differences being: a) requirements that must be met; b) scoring differences; c) statuses or what they are assigned when survey is completed - for example, for regular health plan the statuses are: excellent, commendable, accredited, provisional; and d) length of accreditation or how long this process lasts):Interim Survey– generally organizations with no members nor practitioners yet. On survey the only outcome they can get is of 18 months duration and measure reporting (HEDIS and CAPS – the AHRQ consumer satisfaction measures). The only two outcomes are: Interim or Denied because there are no HEDIS measures. The way NCQA is set up, there is a 100 point scale. For 2013, 50% of those come from HEDIS/CAPS measures and 50% comes from Standards and Guidelines.First Survey is like an Initial Survey. They can become accredited or provisional for 36 months. HEDIS/CAPS measurements are required after the second year. The biggest changes made by NCQA for 2013 are changing the First Survey options. The organization can do one of three things:Come through for standards onlyCan come through First and CAPS, orCome through for HEDIS and CAPSRenewal Survey – same accreditation process already in useDiscussion: CVO may see some of the organizations, exchanges especially that may be seeking help to find out what the new standards mean. Again, this is the biggest change that NCQA has made. There will be an effect on credentialing in that it will include the three survey types. Major change: Look-back periods – how far back from the date of the survey do the surveyors go back to review the organization? It has been changed for Initial Survey to six months and for Renewal Surveys it is 24 months. This will be changing, for Interim it is essentially “wet ink” – their procedures and policies could have been written the day before sending in survey information. For First Survey evaluation option, six months and Renewal Survey it remains the same at 24 months. The rationale for this is Interim has not been in operation very long, just seeking their standards and for First, they have not been in place for any length of time. Changes in Credentialing Standard: CR2 – merging of two elements (no changes in requirements for 2013). Still using the same credentialing committee decision day as the start of the timeframe backwards.Another major change: Combining all the verification requirements into one standard. There is no longer initial verification credentialing standards and recredentialing verification standards. They will now all be under the same standard. Big change: there will only be one file review. This will hopefully reduce the number of files reviewed in an attempt to streamline process. However, Interim Surveys do not have a file review – goal is preparing the organization (as it is only an 18 month accreditation) for the follow-up First Survey when there will be a file review. The Interim Survey is offsite and only structural (policies and procedures). CR4: No change in requirements CR5: Frank’s hope that in 2015 we will see as a result of “Ongoing Monitoring” that there will not need to be a separate standard and CR5 will be removed.File Review Change: There will be one file review – NCQA essentially wants to see initial files and recredential files. NCQA will pick the files; the organization will choose diverse files. For example, if it is a recred file, these files do not require education and training petency: HEDIS and CAPS measures are important to NCQA. The information is garnered from the actual files of practitioners. There are 22 criterion monitored that show individual report cards on how the provider is fairing. The healthplans are able to get these measures and use them for their own statistical and metrics keeping. NCQA believes in transparency and sees it helping outcomes, as no healthplan wants to be last on the list. With providers, there is ongoing monitoring with sanctions and review of any type of quality issue. Changes in Standards Effective 01July2013:Physician Directory: changes to physician statuses must be updated within 30 days of verificationInformation in Physician Directory has to be verified by the credentialing department – which is a problem because the credentialing departments generally have nothing to do with Physician Directories – it is generally a Marketing Department function. (This is going to NCQA’s Standard’s Committee next week as there has been a lot of push back regarding Board Certification timelines)The Joint Commission – Dr. Ron Wyatt TJC Standards for FFPE/OPPE do not require Board Certification Mid-Level and Other Practitioners: Are now eligible based on Medical Staff Board to be credentialed by organizations (NPs, PAs, Pharmacist, Clinical Social Workers, Clinical Nutritionist, etc.) as approved by governing board. Process involves evaluation and verification data relevant to professional performance – and making sure medical staff is using evidence-based decisions when granting, denying or revoking privileges. Three Components of Credentialing and Surveying:? ACGME six areas of competency - Role of Professionalism (looking back to training level) and how it impacts patient safety. Driven to make an organization safer for its patients at the same time protecting the organization. FFPE/OPPE FFPE – (focused) a process requires evaluation of competence on all practitioners by an approved governing body. OPPE – (ongoing) is completed every 2 years on all practitioners – TJC recommendation is not to wait every two years, but a schedule that is every 3, 6, or 9 months – before the two years is up, there should be some documentation on at least 3 data points. Where does TJC see FPPE/OPPE going? More than a checklist to be used for performance improvement. Must be a tool to look at data and to be used not just for credentialing and privileging, but for improvement purposes. This will allow leadership to direct resources to the most appropriate places. It is also an opportunity to increase medical staff engagement in improvement. FFPE/OPPE Process needs to be improved on both sides. Patients should be brought into process. Should be used to predict areas of improvement. Day Two: Physician Performance Data – How do we use it? Dr. Mark Smith Problem: Getting the Data – what are the basic problems? Start with observation about physician performance. In past ideas have been “cherry-picked” related to measurable performance and is used as representation – the fallback being “case review”. Safety looks at “rates of harm”. From a medical staff perspective there are four buckets of data: Initial Application – what we collect for someone just being hired? Focused Evaluation – most organizations do this informally historically but now need to do this formally for initial applicants if JC accredited Ongoing Evaluation – monitoring someone who is actively participating on medical staff? Reappointment Evaluation – amalgamation of information to base decision on, recreating initial decision “are you currently competent for privileges?”Data needs to serve two masters: What is acceptable?– this is needed by medical staff leaders and organization In helping the physician’s achievement of excellence – this is desired by physicians?? Outline of major problems to collection of performance data:? Primary data that is old (coming in six months after the fact) – how to make real time? Physician and Advanced Practice attribution is a problem in the area of aggregate rates (problem that you cannot track APPs through most organizations)? Hospital IT systems were not set up to handle multiple provider types?makes attribution difficult Outpatient/ambulatory driven data has remained outside of data collection purview Lack of common definition and standardization Problematic EHR – data collection?? Inappropriate diagnosis coding and documentation (which leads to coding)? Non-value versus value-added variation in quality (e.g. Diabetes guidelines physician use flexibility)? Quality would demand getting rid of non-value added variation but maintaining the value added variationForcing proper documentation with case reviews by peers Sharing the data within a given organization and between organizaationsCredibility of data (dirty or tainted) Small/Low-end data – getting significance from numbers Data collection systems residing in silos that don’t talk to each other Why is data collected: to show physician quality care – dilemma is physician care goes across a broad swath, so how do we measure enough to know that a correct conclusion can be made?Thinking about collection of data we think in three parts: Case Review – hard to do, but easy data to collect because each case generates its outcome and can be tracked Aggregate Rates – tougher collection of data challenges due to: By nature they have numerators and denominators; they have number of events that occurred over the total number of potential events that occurred (e.g. number of endoscopies with perforation over number of endoscopies performed) Difficulty capturing all of the numerator events and denominator events; this measurement could get into the ambulatory versus inpatient cases Rules (tend to be more administrative in nature, i.e. “did you do your medical records charting?”) are more reactive and are measured by “rule breaks” (going out and monitoring hand washing techniques) Solutions: A structure that works well for aggregate data rates is medical staff stating from a peer review stance – “you need to own this process”. You can only complain about the credibility of the data when you are a part of the solution. In other words, you are involved in collection of data and making sure the data is adequate. A structure that works in organizations is the Data Integrity Council whose job isn’t to evaluate and say what the data means, but to assure data collected is accurate: accurate numerators and denominators; accurate attributions; and collaboration with quality personnel to assess measurements, processes, and audits for validation. Physician attribution solutions: ?Assign case attribution to whoever did discharge summary. Objective assigning of attribution – preponderance of care (amount of care given during case) Decentralization of data: audits of where data is collected organization-wide and centralizing reports (data warehouses) Turning data into information by creating context defined by baseline acceptable and excellence (will allow for understanding of acceptable complication rates, pushing physicians to drive their report cards to excellent).Maintenance of Certification / Maintenance of Licensure UpdateABMS – Mike Coyne ABMS Currently has greater than 800,000 registered physicians that are certified by one or more of ABMS’ boards. There are over 375,000 participants in the MOC (which was stood up in 2006). Trending: 65% of certified providers are in Time-Limited Diplomates, ABMS is projecting that by 2020 the number should be closer to 93% in the continuous certification model. Certification consist of four parts:1.?????? Professional Standing (Licensure): Hold a valid, unrestricted medical license2.?????? Lifelong Learning and Self-assessment activity3.?????? Cognitive Expertise (Examination)4.?????? Quality ImprovementABMS background: Organization has been around for 75 years. Initially there were lifetime certification holders. In 1970, The American Board of Family Medicine first introduced concept of time-limited certifications with start and end dates. Fast-forward to 2006, all the boards approved their MOC programs. With MOC there is always some type of activity – one of the four parts that the physician has to partake in to meet requirements of MOC. In 2011, 7 Member Boards displayed their MOC certification. In 2012 ABMS is displaying whether or not the physician is meeting the requirements for their MOC for 11 additional Member Boards. ABIM the largest board, for a variety of reasons will not be displaying MOC until 2014. Must remember this is an evolving display of information. Display: MOC is separate and distinct from Board Certification. New Policy Board Eligibility – no less than 3 no greater than 7 years does a physician have the ability to achieve board certification from their individual member board in their specific specialty. “Eligibility” is now a recognized term. (see chart showing each individual board and what their eligibility period is). One caveat to Board Eligibility: the official policy reads that its physicians who need to become board certified in the time of completion of their residency program – there is an outlier: The American Board of Family Medicine – their term is that you are Board Eligible even if you have let your certification lapse.? ABMS has heard the need for development of Evidence-based back-up for MOC. What are the outcomes, how does it impact quality of care? MOC / Board Certification fork in the road: Some boards are already trying to move MOC into the board certification flow. There is a continuous cycle with a start date for certification but no end date. Physicians are always trying to be involved in some type of activity whether it’s a self-assessment or quality improvement of their practice or studying for examinations. These boards are instituting a concept called the annual reverification date. It is a periodic “check-in” to verify the physicians are still in good standing. MOC working group has been formed to help with consistency across the boards. Goal is to standardize and clarify across the 24 various boards. AOA – Annette Gippe???AOA launched Osteopathic Continuous Certification (OCC) January 1, 2013. Some benefits of OCC are: Continual knowledge and skills improvement Quality assurance for the public Five components of OCC: Unrestricted Licensure – board certified physicians must have a valid, unrestricted license to practice medicine in one of the 50 states and adhere to AOA’s Code of Ethics.Lifelong Learning/Continuing Medical Education (CME) – all board certified physicians must fulfill a minimum of 120 hours of CME during each three-year CME cycle.Cognitive Assessment – Diplomates must successfully complete examinations developed by their specialty certifying board assessing specialty medical knowledge and core competencies in the provision of health care. New component Practice Performance Assessment and Improvement this requires a physician to assess their current practices performance against established benchmarks. Continuous AOA Membership: Is a requirementCME has always been the heart of lifelong learning and required for maintaining certification; however, CME has changed – the historic Ski trips offering CME don’t count any more. CME has to show assess practice improvement. More needs to be said about lifelong learning to the public – that the physician does not just have a certification on the wall. The concept is a whole lot different than it used to be. The boards have various learning modules offering meaningful CME. As a result board certification means a lot more because of the underlying lifelong learning and training required. ???????????CME challenges: Must show evidence-based reasons why the CME is being offered. It won’t be long before CME programs will require follow-up over time to find out what the education program did to improve a physician’s practice. ?AOA wants to make sure this process does not become a burden for physicians but more of assurance of quality care for the public. There are so many things physicians have to keep up with now: EMR, PQRS, OCC, MOL, MOC … how much time do they need to spend proving that they are practicing good medicine? It does not hurt to raise the bar but the question needs to be asked: is value added??The AOIA Official Osteopathic Physician Profile Report is being upgraded. The plan is to launch April 1, 2013??????????????? AOA will notify everyone who has ordered a profile within 18 months after initial order of changes In Board certification or education status. It will report if the physician is participating/compliant with OCC and MOC.???????????? The physician who has a lifetime certification will not be required to participate in OCC at this time. They will be strongly encouraged to participate as more states begin to require MOL, MOC or OCC in order to maintain licensure.? FSMB – Michael Dugan, MBA Four Points to the MLL Team in terms of update – there has been substantial pushback with a lot of “confusion” that people tie the two together that MOL = MOC = OCC – that is not the case. They are distinct as MOC and OCC are further down the path and aim to achieve/ensure a different (higher) standard than MOL. The concept the FSMB has recommended to state medical boards for their licensees is “you are not required to participate in MOC/OCC in a MOL program; however, if you are, that is substantially/wholly compliant and would meet any requirement of MOL. If you are not there are other activities that are being identified/looked for (e.g. criterion based privileging, common competency framework, privileging sort of standards intended to meet MOL.) The FSMB does not recommend a high-stakes exam requirement for MOL. Nine active pilot boards – however for implementation there are no dates. Approximately two dozen different pilots have been developed, with three currently underway: State readiness inventory (so state boards can see what issues would need to be addressed as they consider steps for implementing MOL – and determine how they would work with the recommended framework) Physician acceptability survey (What are physician learning practices, preferences, and needs?)? License renewal pilot (how would MOL fit impact a state’s license renewal processes/procedures?) Reporting (if all of this were in place, what would the reporting look like?) (this pilot is a bit down the road…maybe not until the end of this year. This could say something like “a further pilot will consider how reporting of compliance with MOL requirements will occur at the state medical board level”).AAPA/NCCPA – Tricia Marriott, PA-C, MPAS, DFAAPAThe big “buzz” for PAs is the new certification maintenance (they are not allowed to say maintenance of certification –apparently trademarked by ABMS) requirements coming in 2014. There are four organizations (separate entities) working closely together for education and certification of PAs: ? ARC-PA’s (Accreditation Review Commission on Education for the Physician Assistant) handles the 170 programs. Each program has the same accreditation standards which allows for the competencies coming out of each program to be comparable. PA competency-based training mirrors physician-based training. PAEA (Physician Assistant Education Association) is the education organization. The program directors belong to this association and help develop the standards for educators. ?NCCPA (National Commission on Certification of Physician Assistants) is a completely separate organization that has many physician organizations on their board. NCCPA’s function is to help develop the standards for the certification and maintenance of certification for PAs. AAPA (American Academy of Physician Assistants) is there to help PAs in their practice, and is the Advocacy organization for the profession. After graduating from PA school, the student has to sit for the NCCPA certification exam. This exam must be passed in order to be licensed in any U.S. state. This certification does not necessarily need to be maintained for licensure in 19 states. However, 95% of the PAs choose to maintain this certification.? What does that mean today? Every two years the certified PA must achieve (for recertification purposes) 100 hours of CME, 50 of which must be Category I (AMA, AAPA, ACGME). Some states have specific CME requirements such as HIV and Domestic Violence. If the PA does not submit 100 hours of CME they are allowing their certification to lapse. This CME process for PAs essentially amounts to maintenance of certification. In the PA’s sixth year, not only do the 100 hours of CME have to be submitted, the PA must sit for the examination again. What is changing: NCCPA is moving to a 10 year cycle (consistent with physicians) and has adopted the Certification Maintenance activities consistent with physicians. It requires, beginning in the 2014 cycle: Self-Assessment and ? Performance Improvement CME. The every two year CME requirement will continue. Most PAs are happy because they do not like taking the test every six years. The test will remain “generalist” in nature. An additional note is that the “Competencies for the PA Profession” mirror those of the ABMS. “Six Core Competencies for Quality Patient Care”. Document available upon request.Current Initiatives to Streamline Process and DiscussionLicensing Boards: Oklahoma – Reji T. Varghese, CPPB, CPOOklahoma Board of Medicine licenses medical doctors and 13 different allied health professionals. This includes just over 22,000 total licensees. One of the reasons OK Board of Medicine is on the map is due to some of their technology practices in use. Goal here today is to show the group what the Board does. The Board deals with staff members from over 100 hospitals in Oklahoma and the local NAMSS affiliate.OKMedBrd data is used in day-to-day jobs of medical staff offices. A 45 minute webinar is offered once or twice a month to introduce what the Board’s data is all about to newcomers. The Board caters to many stakeholders: Credentialing Staff; Insurance Companies; Pharmaceutical Companies; Third Party Providers; Health Departments and other Local and State Agencies. Data Sharing in Real Time: Avoid duplication of tasks????????????? Speed up process of credentialing (and staffing)Placement of healthcare workers into the fieldRecredentialingImmediate real-time notification of disciplinary actions, andLicense status changesOKMedBrd is a good repository of data. All state boards have moved away from the paper application and renewal process. This allows the Board to collect more data online.? The application process/status for licensees can be viewed in “real-time” the site is updated three times a day. Website allows for crosschecking of supervisor/supervisee (e.g. Physician Assistants and their supervising Physician)Real-time license renewal information is available with the availability of pre-license expiration notification. Board sends out seven day advance notice to subscribers (hospital credentialing pool) a list of that hospital’s practitioners whose license will expire in seven days. An email will be sent to the credentialing staff one-half hour after the license expires. As well, a texting service is available if that mode of communication is preferred. This service is provided 24/7. The Board sent out 6, 259 real-time email notifications (license expiration or disciplinary actions) in 2012. Another use the Board allows: Download database in flat text file to manage as needed. Each subscriber can designate what they need to be exported to build a customized download. Some subscribers are downloading the data so the initial credentialing applications basic profile is pre-populated. Just Added: Plastic License cards now have a Q-R code that when scanned will take the scanner to the OKMedBrd website. Thus, if a provider shows up at an emergency scene, any SmartPhone can scan the code which takes them to the physician’s profile on the OKMedBrd website. If there are restrictions, they will be visible.FSMB – Michael DuganGetting rid of paper/signature; Entity-connectMedEd/GME (auto verify)2012 56% of licensure included an FCVS credential Proactive reporting to FCVS disciplinary / licensure alert serviceCAQH – Sorin Davis2000 payersAHIP; BC/BSAdministrative simplificationCore Operating rules for information exchangeFor payers (eligibility)EFT/ERAHealthcare is a transaction business so goal is common set of operating rulesUniversal Provider Data Source1,100,000 licensed practitioners using the systemSelf-reported dataUpdated three times per yearProviders own data and attest to it675 participating organizations (mostly payers)Closed system – practitioner is invited to participateWhere is CAQH going?ACA – payorsTrend – wholesale to retailNow selling to employerLegal Updates – Brian Betner, JDTheme on “collaboration” in healthcare facilities: Collaboration follows money. By 2017 6% of hospital DRG income will be at risk for quality. Most non-profit health systems run on single-digit margins. When an entity pushes quality for that 6% reimbursement, collaboration will be a part of the dialogue. It will impact credentialing and privileging as much of this will be “membership” driven. Staff invitations to participate will be driven on the premise that the provider will be chosen based on his or her quality “numbers.” C-Suite is interested in your “numbers” not your “harm rate”. Confidentiality: Accreditation, Business Models, and Payor requirements are a few of the drivers of for what we do collectively from a credentialing and privileging perspective. These requirements tell the business to go forth and “do it”; but they do not necessarily make the entity stay in compliance with their state peer review laws. There is only one Federal Law privilege for confidentiality and this relates to patient safety organization activities. Each state has its own peer review statute; however, there is no state peer review law that has a “we know what you meant” element. Why are we seeing more requests for confidential information? Because we invite scrutiny. More than 31 states recognize the tort of negligent credentialing – it is not the same thing as medical malpractice (you created a hostile work environment, you created a negligent environment, you retained someone you should have fired.) Because much of the quality information that is gathered in hospitals today is not done methodically and in strict compliance with what States require for confidentiality. Most states have a specifically defined Peer Review Committee (speaking broadly: Privileging, Credentialing, and Evaluating). You have to prove that you methodically followed all of the requirements. In cases of Negligent Credentialing the document stamped “Confidential and Privileged” attempting to make it a protected document not to be disclosed in court, is being questioned by the Plaintiff’s Bar, especially when these are the very documents that will prove the charge of Negligent Credentialing. There is a consistent attempt to get access to this information. Aggregate data may not be viewed as “privileged” because you are not at the provider level. If you can get ahold of aggregate data and know that only four people can do hand surgery, this may be all that a plaintiff needs. When information is crossing your desk ask the question: “Who collected it?? Why is it collected?” Be comfortable that this was collected in a process that the State recognizes as privileged, “not we feel it should be privileged because it relates to quality. Laws are very prescriptive and not intent driven. Bigger case on confidentiality this year: Illinois Professional Regulation versus Walgreens – it was a reinforcement of the confidentiality provided by the Patient Safety Act for the use of a Patient Safety Organization (PSO). This is the first state level appellate case stating: if clearly done within the process that federal law allows, information submitted to a PSO will be protected under Federal Law. The point to this is not how you feel about it, or that you came close, or that you were well intentioned; it is did you cross your t’s and dot your i’s on how you generated the information and who you shared it with (within the confines of your state peer review.) Some states are very prescriptive about with whom you can share this information. Enforcement of the Healthcare Quality Improvement Act (HCQIA) and Federal Immunity only applies to the court in which you are being tried. State level immunity generally does not apply in Federal Court. So parallel processes – would recommend when a medical staff is doing something, that it be done within the context of Federal Law, reasonable investigation, etc. Want to satisfy both State and Federal requirements.? HCQIA immunity is generally upheld at the State level. False Claims Act Case: Brought by a physician whistleblower terminated from a recruitment agreement in Tennessee alleged that the patient contacts requirements of the hospital “agreement states provider must be an active staff member, requiring referral of 32 patients per year”. Physician claims this provision was a “kick-back” by “requiring” physician to refer patients. This was a good case because it reinforced that CMS and the Federal Courts were okay with this traditional and common requirement when based on quality or medical staff classification.? Cases like this strengthen the issue of “patient contacts” as long as they are defensible in relation to the meaningful measurement of a provider’s pliance: We have not generally thought about compliance as being closely related to credentialing. A lot of quality data is generated in the confines of a reporting process. Going back to the 6% of DRG payments that are at risk by 2017 -- quality data is becoming claims data. When claims and quality data are becoming one and the same, submitting that data to Medicare opens you up to false claims act. The better your data, the more likely it is going to affect your reimbursement. You either meet the medical necessity and evaluation management requirements or you don’t. It is not so clear in the quality gathering side of the hospital because quality gathering internally does not have the same level of scrutiny that is done with claims processing. In the black and white world of claims processing you are either eligible for reimbursement or not. All of the quality data gathering may cause compliance concerns for reimbursement. Credentialing is coming a lot closer to compliance in terms of being subject to fraud and abuse law oversight. E.???? Update from the VA – Kate Enchelmayera.??Federal Supremacy for Nurse Practitioners within VA (Licensed Practitioners Practicing Independently or LPPIs): This has been an “imminent policy for two years, however, not sure how it will fall out as there is still a lot of discussion on both sides. Some clinical leaders are all for this change. There is a mixed bag of reactions from practitioners. Some of the NPs are happy in collaborative situations they are in some would like to work in the more independent role. VA will still have to follow state law in prescribing controlled substances since that is Federal regulation that gives the states authority to decide who is going to prescribe controlled substances. Currently there are 22 states that allow total independence for LIPs. The Pearson Report comes out every year and explains what the NPs are allowed to do and not do. ?Just search your web browser for Pearson Report to find the most current report. b.?? Biggest changes/issues in VA: Reporting data on how VA measures wait time for individuals to initially access a mental health appointment. As the large battalion returns to the continental US, called surge, everyone is screened and required to go through follow-up, particularly in mental health issues. A lot of reservists come to the VA for their follow-up care as they are entitled to it for 4 years after they leave active duty. The VA got caught with bad data about how long it was taking them to get these individuals in to mental health appointments.? On June 1, 2012 the VA was committed to hiring in a four month period, 5,000 mental health professionals. This goal was not met. Only 1,800 residents finish psychiatry programs per year. This group has been tapped out and all of them do not want to join VA and see the adult patients suffering from PTSD possibly even with a dual diagnosis. Most of the psychologists are also tapped out. VA is continuing to recruit psychiatrists, psychologists and social workers, but also are looking at other categories: Social Workers, Licensed Counselors, Family and Marriage Therapists – there is a lot of pressure for the Credentialer in the medical staff process because the VA credentials everyone who is required to have a license, registration, or certification. c.????VA Credentialing Policies: All are available on their internet site: ()d.???Strengthening Partnerships: A lot of activity with Department of Defense because of the large shared caseload. The biggest push is the integrated electronic health record (EHR). DoD has a health record, VA has a health record there is some data exchange built within the two, but it is not the integrated EHR. When someone enlists as an officer, the EHR should follow throughout the career to VA and beyond. There are also two separate electronic credentialing systems.? VA was hoping to expand their electronic credentials system to incorporate/include privileges; however they have not been funded for it.? In the process of this, there has been much discussion on medical staff processes and how VA and DoD relate to each other and share providers between the Agencies. In the next two to five years there will most likely be a common platform built for the credentialing between the two agencies. We already collaborate on other topics.? For example, there are approximately 35 Practice guidelines that have been completed with DoD and external partners that are also available on VA website. They can be found at and some examples are cardiac and mild TBI. e.???Development of Standardized Physician Position Descriptions: ?These were posted three years ago. Human Resources collaborated on this project. These were classified in Washington, DC. If they are used, they are not supposed to be changed. VA captured for two different levels the medical staff coordinators responsibility. Word of warning: HR does not understand the medical staff process. They still view it as an administrative task that a clerk can perform and have actually used them against some personnel. f.????Review of six months of 72 IG reports: VA has a cycle that is similar to Joint Commission where they go in and review IG reports every three years under a combined assessment protocol. Medical staff is one of the elements under QM. The major finding was that the FPPEs are not being sent back to the medical staff to close out (4 out of 48 facilities). They are not looking at the quality of the data yet – just trying to make sure they are in place. Where they are looking at quality is the department chair: what are they documenting in their recommendations for granting privileges? What have they looked at and what do they view as competency.g.???Adverse Action Process: VA has markedly increased at least the review process – they have flow-mapped out the process, because the at-wills (contractors and part-timers) are all managed one way (terminate provider and then given them due process for reporting to the NPDB). Those on probation get an HR process that is not sufficient to meet the due process so their due process for reporting to the NPDB is after they are terminated. The fulltime permanents are harder because they have employee rights. These employees must be given an opportunity to improve (can be blended with FFPE process.) The FFPE is used to hopefully bring the person back whole, not to usher them out the door. h.???Hiring more Physicians as employees?: VA has been using a performance-based pay process since 2006 (mandated by statute.) They will go out and survey country by physician specialty. There are very complicated pay bands that sets the base pay of a practitioner. However, the market difference in New York City versus Kansas City, Missouri for an urologist is great – so the pay panel can do a market survey to take the base pay up. The third piece is performance pay. This is negotiated with each physician. NPDB Compliance Update – Judith Roberts, MHA (HRSA)Four key system enhancements this year:Report forwarding – made it easier for hospitals and other reporting entities to send reports to the appropriate state licensure boards. Now have electronically enabled licensure boards to receive reports from reporting entities. To work licensing boards have to agree to accept reports. Currently, 77% of licensing boards have agreed to accept provider reporting mechanism. Related Query Response – to assist those who query to get information from NPDB that is easier to digest. Feedback has been that the reports are disparate in nature (e.g. are all reports tied to one action, etc.)Going Green – require registration to the databank every two years. In past it was an onerous paper process. Paper is only required now if the registering entity has some significant change to their registration. Routine registration is now completely paperless. Paperless Self-Query – Provider will go online, answer questions specific to them, which allows package of materials to be sent electronically to provider immediately. Merging of two databanks (NPDB/HIPDB) – Same legislative authorities behind databanks, just now the one combined bank called NPDB. Hopeful timeframe is March/April 2013. Question about OIG reporting and verification – does the NPDB query satisfy the OIG query? Research Bank of NPDBRecent effort: comparing databank information with AMA Masterfile database (which has information on 1.2 million providers). Comparison with Medical Malpractice data in NPDB – learned a few interesting issues:15% of physicians in AMA Masterfile have had a least one report to databank; of these 87% were male; 50% are for physicians specializing in Internal Medicine, Family Practice and OB/GYN. Reports related to women show: Fewer reports, but higher payments. 2013: Satisfaction Survey will be conducted across reporters and querying entities. Results will be used to improve customer service (timeliness, usefulness, accuracy of information received).Hospital Compliance Efforts: Started with licensure – now have robust program in place where all licensure boards reporting data actions are compared to databank disclosures from those licensing boards. If actions are not reported to databank, boards are being reminded to submit those outstanding actions. Users can go into NPDB website, click on a map of the U.S. and pick a state, profession or board to see if that board is compliant with databank reporting requirements. This effort began in 2010 – the data does not go back earlier than this timeframe.Now the effort will turn to hospital compliance. Databank has partnered with the AHA who provided a file with the list of all of their members and non-members (n=6,268). This list was compared with the registered hospitals in the databank and a 90% match was discovered. Databank researchers are trying to sort out what the 10% is all about. Another problem revealed during this process was that there are some registered hospitals that have never queried the databank. Learned themes:Problem around hospital reporting is exacerbated by the fact that hospitals do not function in the same manner when the regulations were written 20 years ago (e.g. locum tenens, contracted physicians, etc.) Employed physicians are terminated through the HR path (no medical staff involvement, thus no professional review action and no databank report.) Joint Commission standards are silent appropriateness of automatic termination of clinical privileges without professional review process. Silos within hospitals (HR, Medical Staff) – there needs to be more exchange of information and complianceCompliance Officers in hospitals do a better job than medical staff services in education board leadership Tensions between medical staff office and administration that could be related to databank reporting requirementsStrong credentialing processes – hospital credentialing offices are more robust and selective in physician hiring process. Many hospitals use the pre-application process before formal application is submitted. Hospitals will advise candidates to withdraw applications if they see a problem (to avoid databank reportability)Hospital reporting infrequency – staff forgets procedure for reporting. Confusion around what is reportable (e.g. when to report a summary suspension). Some hospitals suspend practitioners for 29 days so they do not have to be reported to databank. Hospitals addressing issues on a system level: not going after individual practitioners so you do not see a report in databank Institution of an annual Attestation Process for hospital by CEOs to state they have reported all required events (allows CEOs to be made aware of the databank reporting requirements). Along with this there will be development of some targeted education materials for executive committees, human resources, hospital attorneys, and medical staff services. Other discussion: partnership with Joint Commission so they will ask questions in their survey process – looking at adverse actions and check to see if they were reported to databank.Single pathway to accreditation of Graduate Medical Education - Annette GippeUpdate from the AOA on the unified accreditation system with the ACGME. For the latest details and FAQ’s go to: ? on the PA CAQ - Tricia Marriott, PA-C, MPAS, DFAAPACertifying body (NCCPA) came up with certifications of added qualifications because of desire/need for individuals to be recognized for their experience in a specialty. So eligibility to sit for CAQ was designed with qualifications:Two years of experience with procedural logs (effectively eliminates new graduates) Cardio-vascular surgery Orthopedics?Nephrology??Emergency Medicine? Psychiatry Not sure whether CAQ adds any value at this point – Concern from a profession standpoint, the AAPA has not agreed with the NCCPA on the value or validity of “added value” to quality and safety or competency. Remains to be seen and is only in its first year. Other concern is the flexibility of the PA profession, which historically has shown the ability to train and move from one specialty to another. This may compromise the ability to change from one practice setting or clinical department to another. Generally in past PAs have gone into markets, settings, and specialties where a need was identified. Requiring a CAQ may eliminate a huge workforce. Currently less than 300 PAs across the specialties combined have taken the CAQ exam. (Less than 0.3% of the current PA workforce nationally)Sidebar Commentary on assessing PA Competency: There is a trend and opportunity for hospitals to add a?PA to the credentialing peer review committee, for the purpose of making decisions about PAs being granted?privileges?or re-appointed. (As physician privileges are expanding, so too are those of Pas (for example, in nephrology running the DaVinci robots, bedside ultrasound use in the ED and the critical care areas, etc.)? PAs should serve on the credentialing committee for FPPE and OPPE as well.National and Local Initiatives, Health Care Reform and other Hot topicsIllinois licensing board – all physicians licensed in Illinois received a letter in January 2013 that states because of funding issues, they had cut their personnel from 26 to eight. It will take 12 to 18 months for a new license to be issued. All licenses come out for renewal in January 2014, there is an expectation this will take 12-18 months to accomplish. At risk are the 6,000 resident license that will be issued by July 1st. The Physicians Association and Hospital Association did not support raising the fees (which had not been raised since 1987). Primary Source offices (Ohio as an example) are receiving calls from State Medicaid Agencies want to verify whether there is an incentive for practicing Primary Care Board Certified physicians. The law says (from Washington staff) all they have to have is an attestation. It has been found that the requirement for PSV of Board Certification has been struck down by several states: self-attestation was approved source of verification. ECFMG: Upstream from most of the verification organizations. Twenty-five percent of physicians in practice in U.S. are International Medical Graduates; 26% of doctors in residency training are IMGs. A quarter of these IMGs are U.S. citizens. ECFMG has been issuing approximately 10,000 certificates annually to IMGs. U.S. medical schools are increasing enrollment, so supply of medical graduates is starting to inch closer to the number of first year residents. It used to be 6,000 IMGs would start residency programs every year; it is quite possible that over the years the IMGs will start to get squeezed out of pipeline to licensure. Only 53% of IMGs who start certification process complete it. ................
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