Medical Staff: Credentialing, Core &

Special Privileges, Peer Review, &

Quality Improvement Program
November 8, 2014
11:30-12:30

Barbara Anderson, JD
Assistant Director, Professional Practice
Lorraine Jordan, CRNA, PhD
Senior Director, Research
Lynn Reede, CRNA, DNP, MBA
Senior Director, Professional Practice
www.aana.com

Learning: CMS &

Accreditation Basics
Discuss CMS Conditions of
Participation & Interpretive Guidelines.
Describe the relationship of the
accrediting organizations with CMS &
facility.

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Facility Accreditation

The Ins and Outs

How the AANA Can Help You

AANA Professional Practice

Division Role
Developing relationships with Accreditors
Continuously review standards to ensure CRNA
and patient interests are protected
Support individual CRNA/facility with resources
AANA action when there are policy
disagreements between AANA and the
accrediting organization

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AANA Accreditation Activities

Represent CRNA and patient interests
The Joint Commission (over 20,000
facilities)/AOAs HFAP
Hospitals/ASCs/Office-Based
Others: AAAHC, AAAASF (ambulatory)
New JC competitors in hospital market:

DNV (hospitals/CAHs)
CIHQ (hospitals/CAHs; Texas-based)
AAHHS (offshoot of AAAHC; small/rural)
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Centers for Medicare and

Medicaid Services

http://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs

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Accreditation Association for

Ambulatory Health Care, Inc.

http://www.aaahc.org/en/news/Health-Care-Resources/credentialsverification/

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Why Accreditation?
Voluntary process for facility
Evaluate for quality & meeting
standards
CMS Deemed Status Surveys:
Accreditation and
Medicare/Medicaid Certification to
be paid
www.aana.com

Why Accreditation?
Meet state regulatory requirements,
especially in the office-based
surgery/anesthesia area
Meet insurance requirements
Benchmark best practice with the
surveyor(s)

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Standards

Policy & Procedure

Leadership
Environment of Care
Medication
Management
Anesthesia/Sedation
Surgical Care

Medical Staff
Human Resources
Medical Records
Laboratory & Blood
Bank
Infection Control

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Continuous Survey Readiness

Meet and work with your facilitys accreditation
director & related departments
Address accreditation manual sections for staff
education and compliance
Periodically monitor compliance with policy in
your practice
Monitor the AANA Accreditation Resources
http://www.aana.com/myaana/ProfessionalPractice/Pages/Facility-Accreditation.aspx

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Continuous Readiness
Participate in facility policy, procedure and
practice review
Create and implement an action plan to maintain
continuous readiness
Education
Communication
Mock tracer or survey
Consider an accreditation consultant

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Before the Survey

Monitor your plans effectiveness
Policies, staff files up to date
Staff is following policy
Quality data is being analyzed and
practice improved
Questions? Contact the AANA

practice@aana.com
(847) 655-8370
www.aana.com

During the Survey

If an issue arises, first smile and listen
If the facility is cited, discuss possible solutions
with the surveyor
If the facility is cited (or about to be cited) and you
believe that the citation is a misinterpretation of
the standard,
Follow facility policy and procedure, and
consider possible responses :

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Issues Arising During Surveys

Ask surveyor for standard and any other
documentation of surveyors
interpretation
Professionally and politely explain your
interpretation using your anesthesia
expertise
If issue persists, contact the AANA for
consultation and provide
documentation.
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Post-Survey Actions
Follow up with the AANA call or email
practice@aana.com a summary of
anesthesia accreditation issues
Areas of survey focus
Highlights
Learning
Concerns
If cited, partner with facility team to develop
response. Practice improvement, not
bandage.
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Post-Survey Actions
Determine all deadlines for response,
including appealing, corrective action
plan submission
Assist in appeal response
Assess and determine corrective action
plan
Implement corrective action plan

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Medical Staff:
Quality Improvement Program

Learning: QAPI, Quality

Measures, PQRS & QCDR

Define the elements and documentation

of a continuous quality improvement
performance improvement program,
projects and quality measures.
Discuss changes in quality measure
reporting through PQRS/QCDR and
reimbursement in the future.

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Embracing Quality Improvement and

Quality Improvement Systems

Use of HCAHPS datasets

Health Grades
www.data.medicare.gov
Hospital Compare
Physician Compare (to be released)
Use of quality dashboards in facilities
Using critical incident report for quality
improvement
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Quality in AnesthesiaPatient Safety

It is a process of systematic
methods to improve patient
safety while minimizing
losses both financial and
emotional

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Why does quality matter?

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CMS
National Health Expenditure Data
*Projected

%GDP

HealthCareSpendingPercentofGDP
20
18
16
14
12
10
8
6
4
2
0
1960

1970

1980

1990
2000
Year

2010

2014*

2020*

Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/NationalHealthExpendData/downloads/proj2012.pdf

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What are we getting for our money?

The U.S. health system is the most
expensive in the world, but comparative
analyses consistently show the United States
underperforms relative to other countries on
most dimensions of performance.
From: Mirror, Mirror on the Wall: How the Performance of
the U.S. Health Care System Compares Internationally,
2014 Update

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Ranking-Higher is Not Better

Rank

Overall

Ranking of 11 Countries for Quality Care

Ranking of based
11 Countries
Quality
Care
(Calculated
on 2011for
and
2013 Data)
(Calculated based on 2011 and 2013 Data)
Effectiveness
Safety
Coordination
PatientCenteredness

11
10
9
8
7
6
5
4
3
2
1
0
US

UK

Swiz

SWE

NOR

NZ
NETH
Countries

GER

FRA

CAN

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Source: http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

AUS

www.aana.com

Institute of Medicine Report

Reducing medical errors:
Establish national focus on patient safety
Identify and learn from medical errors through

mandatory and voluntary reporting systems

Raise standards and expectations for
improvement through oversight, group
purchasers, professional groups
Implement safe practices at the delivery level*
Healthcare System Patient
PARTNERSHIP!
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www.aana.com

www.aana.com

www.aana.com

Theoretical Frameworks to
Measure Quality

Deming cycle
Six Sigma
Baldrige Criteria
Hoshin
ISO 9000
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Process for QI Study

1.

2.

3.

A statement of the purpose of the QI activity

that includes a description of the known or
suspected problem, and explains why it is
significant to the organization.
Identification of the performance goal against
which the organization will compare its current
performance in the area of study.
Description of the data that will be collected in
order to determine the organization's current
performance.
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Process for QI Study

4.
5.

6.

Evidence of data collection.

Data analysis that describes findings about
the frequency, severity and source(s) of the
problem(s).
A comparison of the organization's current
performance in the area of study against the
previously identified performance goal.

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Process for QI Study

7. Implementation of corrective action(s) to
resolve identified problem(s).
8. Re-measurement (a second round of data
collection and `analysis) to objectively
determine whether the corrective actions have
achieved and sustained demonstrable
improvement.

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Process for QI Study

9. If the initial corrective action(s) did not achieve
and/or sustain the desired improved
performance, implementation of additional
corrective action(s) and continued remeasurement until the problem is resolved
or is no longer relevant.
10.Communication of the findings of the quality
improvement activities to the governing body
and throughout the organization, as
appropriate, and incorporation of such findings
into the organization's educational activities
("closing the QI loop").
www.aana.com

Embracing Quality Improvement and

Quality Improvement Systems

Use of HCAHPS datasets

Health Grades
www.data.medicare.gov
Hospital Compare
Physician Compare (to be released)
Use of quality dashboards in facilities
Using critical incident report for quality
improvement
www.aana.com

Additional Reading
Original Research
A Patient-Centered Primary Care Practice Approach Using Evidence-Based Quality
Improvement: Rationale, Methods, and Early Assessment of Implementation
Lisa V. Rubenstein MD, MSPH, Susan E. Stockdale PhDPages 589-597
Download PDF (980KB) View Article
OriginalPaper
The Anatomy of Primary Care and Mental Health Clinician Communication: A Quality
Improvement Case Study
Evelyn T. Chang MD, MSHS, Kenneth B. Wells MD, MPHPages 598-606
Download PDF (312KB) View Article
Original Research
Getting Performance Metrics Right: A Qualitative Study of Staff Experiences
Implementing and Measuring Practice Transformation
Devan Kansagara MD, MCR, Anas Tuepker PhD, MPHPages 607-613
Download PDF (313KB) View Article
Original Research
Examining Clinical Performance Feedback in Patient-Aligned Care Teams
Sylvia J. Hysong PhD, Melissa K. Knox RDPages 667-674
Download PDF (196KB) View Article

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Performance Assessment

http://www.businessnewsdaily.com/images/i/000/005/152/iFF/performanceevaluation.jpg?1389973661

Learning: Privileges, Peer Review

& Competency

Review the elements of core and

comprehensive privileges.
Discuss request for new privileges,
evaluating initial and ongoing
competency, and peer review. (OPPE,
FPPE).

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Definitions
Advanced Practice Professional (APP)
Allied Health Professional (AHP)
Independent
Dependent, physician direction,
supervision, collaboration
Credential, Privilege
Appointment, Reappointment

Safeek, Y. Credentialing & Privileging for

Accountable Care: A prescription
www.aana.com
for the ailing stethoscope and the dull scalpel. ACPE Publication. 2012

Considerations for Credentialing,

Privileging & Peer Review
Centers for Medicare & Medicaid Services
Accrediting Organization, State Health Department
State licensure
Scope of practice
Collaborative agreement, standardized
procedure, protocols, supervision/direction
Core/special privileges

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Credentialing & Reappointment

What does your facility require
Bylaws, Policy & Procedure
How often is reappointment
Develop
Letter of information
Application
Checklist
Who reviews
Student credentialing
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Core and Special Clinical

Privileges
Core
Specialty/subspecialty
Privilege based on training, education
&/or experience
Special
beyond what is required for procedures
in the core privileges

Coler, M. Determining which clinical privileges are special, or outside the core.
www.aana.com
Credentialing Resource Center Insider, April 2, 2009

APP Asked to Practice Outside of

Role
Held to higher standard
Knowledge, skills and current
competency
Role confusion
Loss of primary focus

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Assessment of Competency

Regularly evaluate performance and quality data

Activity and volume reports
Peer review information
Chart monitoring
Patient complaints
Variance reports
Incident reports
Patient satisfaction surveys
Any other obtainable data relevant to the
practitioners performance
Ensure appropriate competency assessment for AHPs. HCPro Credentialing Resource Center. August 2008
http://credentialingresourcecenter.com/content.cfm?content_id=214985

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Value of Peer Review

Practice improvement
Professional development
Addition of new skills
Accreditation
Reimbursement
Patient satisfaction
Practice improvement

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Who can provide peer review?

Same or similar privilege
Different specialty, understands
skills
Outside specialty peer

Casey, A., Is your ASC governing board in compliance with Medicare rules?
SurgiStrategies. July 25, 2012 http://www.surgistrategies.com

www.aana.com

Elements of Peer Review

Ongoing Professional Practice
Evaluation (OPPE) one model
Documentation
Portfolio of cases, chart review
Outcome data

Meets accepted standards of care

rendering clinical (medical) services
TJC. Ongoing Professional Practice Evaluation (OPPE) Standards
FAQ Detail. March 2010.

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ConfidentialPeerReviewDocument

DEPARTMENT OF ANESTHESIA
CRNA Ongoing Professional Practice Evaluation 2011
CRNA

Trigger

February

TOTALS

COMMENTS

PERFORMANCE MEASURES

SentinelEvents
AntibioticTiming
Normothermia
Failuretorespondtovariance

1
1
1
1

0
0
0
0

1
Legible>3
Attend75%
incomplete

0
0
0
0

1PILetter
1verified

0
0

ONGOING EDUCATION

Pagingresponse/Inabilitytocontact
Legibility
Committee/MeetingAttendance
AnnualCompetency
INTERPERSONAL COMMUNICATION

Variances
Grievances/Complaints

DEPARTMENTAL PEER REVIEW of CLINICAL PRACTICE EVALUATIONS

Acceptable
Nonacceptable

Score>3
Score<2

Operations Manager
Department Chairman

CRNA

Yes

Date
________________

____________________________________

Date

______________

Date _________________

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CNP OPPE
Provider:

Performance Measures
Sentinel Events
Prescribing Variances

Dept. Anesthesia

Indicator/
Trigger
1

July 2010 - December 2011

July 2011July 2010January 2011December
December 2010
June 2011
2011
0

Total > 5

Total > 2
Quality of Care Issues
variances
Explanation of Performance Measures

0
0

Sentinel event with identified APN issues

Prescribing variances greater than 5 variances
Quality of Care issues identified by more than 2 variance reports related to care issues

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New Privileges
Request for special privileges
Education
Proctoring
Temporary/permanent

Review of core privileges

Focused Professional Practice
Evaluation, proctoring
TJC. Focused Professional Practice Evaluation (FPPE) Standards FAQ Detail.
October 2008

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Practitioner Proctoring
Proctoring
Practitioner to provide clinical teaching or monitor
clinical performance
When: initial appointment, reappointment, quality
improvement, new privilege, FPPE, or corrective
action

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Focused Professional Practice

Evaluation (FPPE)
When
Initial appointment
When a new privilege is requested
Question arises during periodic
evaluation/OPPE

Communicate
Cause for focused monitoring
Anticipated duration
Specific mechanism for monitoring
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FPPE Monitoring Mechanisms

Chart reviews, both concurrent and
retrospective
Simulation
Discussion with practitioner and those
involved in same care event
Direct observation/proctoring
Internal or external peer review
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References
Safeek, Y. Credentialing & Privileging for Accountable Care: A prescription for the ailing
stethoscope and the dull scalpel. ACPE Publication. 2012
Accrediting Organizations: CMS http://www.cms.gov/, TJC
http://www.jointcommission.org/, AAAHC http://www.aaahc.org/, AAAASF
http://www.aaaasf.org/, HFAP http://www.hfap.org/
AAAHC Resources for Credentials Verification http://www.aaahc.org/en/news/HealthCare-Resources/credentials-verification/
AAAHC Accreditation Handbook for Ambulatory Health Care 14. 2014
ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE , INC.
Accreditation Association for Ambulatory Health Care. The credentialing and privileging
issue. Connection. May 2013. http://www.aaahc.org
Coler, M. Determining which clinical privileges are special, or outside the core.
Credentialing Resource Center Insider, April 2, 2009 http://www.hcpro.com/CRD-230896863/Determining-which-clinical-privileges-are-special-or-outside-the-core.html
Casey, A., Is your ASC governing board in compliance with Medicare rules?
SurgiStrategies. July 25, 2012 http://www.surgistrategies.com

www.aana.com

References
Centers for Medicare & Medicaid Services. Quality Assurance & Performance Improvement Tools.
February 2014 http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/QAPI/downloads/qapifiveelements.pdf
The HRSA quality toolkit, quality improvement methodology. Health Resources and Services
Administration. April 2011. http://www.hrsa.gov
Institute for Healthcare Improvement. Develop a culture of safety.
http://www.ihi.org/resources/Pages/Changes/DevelopaCultureofSafety.aspx
The Institute of Medicine of the National Academics
Institute of Medicine. The future of nursing: leading change, advancing health. October 2010
http://www.iom.edu/reports/2010/the-future-of-nursing-leading-change-advancing-health.aspx
Ensure appropriate competency assessment for AHPs. HCPro Credentialing Resource Center. August
2008 http://credentialingresourcecenter.com/content.cfm?content_id=214985
TJC. Ongoing Professional Practice Evaluation (OPPE) Standards FAQ Detail. March 2010.
http://www.jointcommission.org/mobile/standards_information/jcfaqdetails.aspx?StandardsFAQId=213
&StandardsFAQChapterId=74
TJC. Focused Professional Practice Evaluation (FPPE) Standards FAQ Detail. October 2008
http://www.jointcommission.org/mobile/standards_information/jcfaqdetails.aspx?StandardsFAQId=76&
StandardsFAQChapterId=74

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