SDS Accreditation Update
Credentialing is a problem Here's how to comply
In the first half of this year, almost half (48%) of ambulatory organizations and 68% of office-based surgical practices accredited by The Joint Commission were not in compliance with HR.02.01.03: The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
There are concrete steps providers can take to "get compliance right," says Beverly A. Kirchner, RN, BSN, CNOR, CASC, president of Genesee Associates in Dallas, which develops, manages, and consults with freestanding surgery centers. Consider her suggestions:
Read and understand the standards you need to follow for the accrediting agency. "Do not be afraid to ask questions from the accrediting agency before they visit you," Kirchner says. Also, network with other surgery centers to see what they have done to meet the goals. "Never reinvent the wheel if you can help it," Kirchner says.
Also, read and understand the regulations from the Center for Medicaid and Medicare Services (CMS). Those regulations are available on the Ambulatory Surgery Center Association web site (www.ascassociation.org) under the "Medicare" tab.
Know the governing body has legal responsible for the credentialing process and the granting of privileges, Kirchner says.
Create policies and procedures for the credentialing process (new and reappointment). "Most of the centers have the policies and procedures for credentialing and granting privileges defined in the medical staff bylaws," she says.
Create appointment and reappointment applications. "A lot of states have standardized forms on the web site for the medical association," Kirchner says.
Develop a privilege list for each service line that will be offered at your center.
"Create the list to reflect what the center can safely perform and has the equipment and supplies to perform," Kirchner says.
The privilege list must be detailed, she emphasizes. "Some places create the privilege list using the services' CPT codes," Kirchner says. Other facilities create them to designate that procedures such as a knee arthroscopy include diagnostic, anterior cruciate ligament (ACL), meniscus tear repair, and debridement. "The key is they must be detailed," Kirchner says.
Know the definitions of the process, including privilege, credentialing, primary source verification, legally qualified (according to the Centers for Medicare and Medicaid Services), and professionally qualified.
Know the rules of granting privileges to allied health practitioners such as physician assistants, nurse practitioners, certified registered nurse anesthetists, and registered nurse first assistants. "They must include but not be limited to written policies and procedures and establishing a system to oversee work and evaluate the quality of work performed," Kirchner says.
Competence is the key word in every organization's standards and regulations. Other important factors are peer review and creating an annual report card based on performance.
The minimum information you must collect is the minimum training you accept and if the applicant has met your criteria for training, e.g., whether the applicant is board certified or eligible.
A process must be developed to describe how the facility will review, assess, and validate qualifications of the practitioner that includes education, training, experience, certification, licensure, and competence, Kirchner says. Primary source verification must be completed on every applicant, she says. A health history must be verified and completed on every applicant. Also, peer review and recommendations from peers must be completed, reviewed, and on file. A picture of the practitioner must be in the file. There must be verification from at least one source that the person in the picture is in fact the person he/she claims to be.
Establish an orientation program for the practitioners for whom you grant privileges.
The orientation program should include, but not be limited to, key safety content such as fire safety and emergency carts available, relevant policies and procedures such as safety, Quality Assessment Performance Improvement (QAPI), infection control and prevention, medical records responsibilities, safety goals, the risk management program, managing of pain, culture diversity, and reporting structure of the center (organizational chart).
The center must have fair hearing policies and procedures. "Most of us have this policy and procedure in our medical staff bylaws," Kirchner says.
Make sure all physicians and allied health providers have a copy of the medical staff bylaws and rules and regulations that govern the center. "If the documents are updated, make sure the practitioners on staff get updated copies of the documents," Kirchner says.
Create your peer review policies and privileges. "Create the forms you will use for peer review," Kirchner says. "Create your annual report card for each type of service you have in the center."
The governing board must approve every policy and procedure and form created, she points out.
"Small centers with one or two physicians should probably outsource the credentialing process to a CVO [credentials verification organization] so a second set of eyes is doing the review," Kirchner says. "Large centers may want to outsource credentialing and privileging verification to a CVO simply due to the amount of work and time it takes to keep the files up to date."
Small practices also might need an outside peer review of their work, sources suggest.
Keeping files current is one of the most difficult parts of the credentialing process for the center, she acknowledges. "Files must always have current license, DEA [Drug Enforcement Administration], and other license, certifications, malpractice insurance, etc."
In the first half of this year, almost half (48%) of ambulatory organizations and 68% of office-based surgical practices accredited by The Joint Commission were not in compliance with HR.02.01.03: The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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