Board Responsibility for

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• Board Responsibility for
• Medical Staff Privileges
• and Credentialing

Web ConferenceApril 3, 200812 1 p.m.
For audio, call1-888-850-5066 code 222177
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• Sponsored by

Association of Washington Public Hospital
Districts
Significant funding provided by Office of Rural
Health Policy through the Washington State
Department of Health
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• Speakers

Greg Montgomery
Dana Livingstone Kenny
Robert J. Walerius
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• Board Responsibility for
• Medical Staff Privileges
• and Credentialing

• Robert J. Walerius

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• Credentialing confirming licensure, malpractice
  insurance, board certification if required,
  references, restrictions on practice, and
  background
• Privileging scope of training and current
  experience to hold clinical privileges requested

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• Medical Staff Office collects relevant
  information from applicant and others
• File containing application and information is
  forwarded to the Medical Staff for review and a
  recommendation to the Board

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• The Board has ultimate responsibility for
  approving who can practice in the hospital and
  what clinical privileges are held
• Delegation to the Medical Staff does not relieve
  the Board of responsibility

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• A direct correlation exists between the
  competence of the Medical Staff and quality and
  patient safety
• Quality and safety are core fiduciary
  responsibilities
• We are entering a new area of heightened focus on
  quality and patient safety

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Institute for Healthcare Improvement 5 Million
Lives Campaign

• Goal protect patients from 5 million incidents
  of harm over 24 months
• IHI estimates 15 million incidents of medical
  harm yearly in hospitals
• 40 to 50 incidents of harm for every 100 hospital
  admissions
• 40,000 incidents of harm daily

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5 Million Lives Campaign (contd)

• Prior 100,000 Lives Campaign had 3,100
  participating hospitals
• New campaign seeking 4,000 hospitals
• 12 interventions targeted to reduce harm
• One intervention is to enlist active governing
  board support to improve quality

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CMS new focus on quality

• Never Pay plan CMS will not reimburse for 8
  conditions CMS deems to have occurred because of
  mistakes October 1
• Pay for Performance value-based payment plan
• New federal protection rules for confidential
  reporting of mistakes

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Theories of Liability

• Board needs to understand theories of liability
  to evaluate potential risks to the hospital when
  deciding on privileging

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Theories of Liability (contd)

• Corporate negligence
• Independent duty to patients to exercise care in
  selecting, retaining, and supervising the
  performance of the Medical Staff
• Hospitals role is not just to furnish facilities
  and equipment for physicians to practice in
  isolation

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Theories of Liability (contd)

• Medically unnecessary services
• Patient is unnecessarily exposed to risks of
  medical procedure and CMS incurs needless costs
• CA case hospital paid 59.5 million to settle
  false claims allegations that hospital
  negligently credentialed and monitored
  cardiologists

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Theories of Liability (contd)

• Failure of Care
• Care provided is so deficient that it amounts to
  no care
• Liability for billing CMS for services not
  actually rendered

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• Board must understand performance goals that will
  allow the hospital to provide high quality and
  safe care
• Attention to credentialing and privileging is
  essential to drive increased quality and safety

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Suggested Board Questions

• Are the roles of the Board and medical staff
  clear, understood, and in writing?
• Are qualifications for staff membership and
  privileges in writing and followed?

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Board Questions (contd)

• What data on clinical competence is reviewed by
  the medical staff?
• Does the medical staff engage in meaningful peer
  review and corrective action?
• Is the Board involved?

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• Role of the Hospital Board

• Credentialing / Privileging

• Dana L. Kenny

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Legal Requirements

• Accreditation JCAHO Standards
• 60 WA hospitals JCAHO accredited 35 not
  accredited
• Governing Board Sets the framework for
  supporting quality patient care, treatment and
  services
• Surveys based upon accreditation cycle (every
  36-39 months)
• Washington hospital licensing laws (RCW 70.41 and
  WAC 246-320). Enforcement
• Surveys for compliance every 18 months (except
  for JCAHO accredited)
• Agreement with CMS for Medicare/Medicaid
  recertification survey

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Legal Requirements

• CMS Conditions of Participation (42 CFR 482.22)
• Hospitals 42 CFR.482.22. Governing Body shall
• Ensure that criteria for selection are individual
  character, competence, training, experience and
  judgment
• Ensure that the Medical Staff is accountable to
  the governing body for the quality of care
  provided to patients
• Enforcement generally delegated to Department
  of Health by Agreement
• Critical Access Hospitals 42 CFR 485.601
• Governing body assumes full legal responsibility
  for determining, implementing and monitoring
  policies governing hospitals total operation.

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Legal Requirements

• Conditions of Participation Quality Assessment
  and Performance Improvement 42 CFR 482 .21.
• Governing Body shall
• Ensure that program reflects complexity of
  hospital and services, involves all hospital
  departments and focuses on improved health
  outcomes and the prevention and reduction of
  medical errors

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Meeting Legal RequirementsJCAHO Standards

• Past general review based upon paper
  credentials
• Now recognition of active credentialing
• Credentialing/Privileging collection,
  verification and assessment of information
• More than paper credentials required
• Objective, evidence-based
• Purpose more comprehensive evaluation of a
  practitioners professional competence

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JCAHO Standards
General Competencies

• 1. Patient Care
• 2. Medical/Clinical Knowledge
• 3. Practice-based Learning and Improvement
• 4. Interpersonal and Communication Skills
• 5. Professionalism
• 6. Systems-Based Practice

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Privileging JCAHO Standards

• Process for evaluating requests for particular
  privileges
• Ensuring qualifications based upon ongoing review
• For surgeries developing and approving a
  procedures list
• Assessment of resources
• Recommendations to the governing body for
  applicant-specific privileges

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Expedited Credentialing/ Temporary Privileges

• Staggered cycles of renewal
• Expedited credentialing by Board when Board not
  scheduled to meet soon
• Cannot be approved by medical staff
• Initial appointment and reappointment
• Authority can be delegated to at least two voting
  members of Board. Otherwise, temporary
  privileges when
• Complete application awaiting approval (120 days)
  or
• Important patient care need (verification of
  licensure and current competence)
• Process for locums must meet standards for
  temporary privileges
• Medical staff develops criteria for expedited
  process for granting privileges

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Focused Professional Practice Evaluation ? Used
When

• 1. Practitioner has credentials to suggest
  competence, but additional information needed
  (initial appointment and anytime additional
  privileges are granted)
• 2. Questions arise about practice during course
  of ongoing practice evaluation

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Quality Improvement Programs and Ongoing
Professional Practice Evaluation (maintaining
privileges)

• Quality Improvement Programs Licensing
  Requirement. RCW 70.41.200
• Mechanism for periodic review of
• Credentials
• Physical and mental capacity
• Competence in delivery of health care services
• Evaluation of staff privileges

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JCAHO Standards

• Ongoing professional practice evaluation
• Identifying professional practice trends that
  impact quality of care and patient safety
• Focus on Continuous Quality Improvement

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Suggested Board Questions

• Does the Medical Staff have
• Process for temporary privileges? Expedited
  privileges?
• Processes for considering general competencies
  for credentialing/privileging?
• Process for focused review and ongoing
  professional practice evaluation?

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• Peer Review and

• Corrective Action

• Greg Montgomery

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Peer Review andCorrective Action Scope

• Clinical competence refers to judgment regarding
  the nature and timing of treatment and technical
  skills in executing the proper treatment

• Professional conduct refers to physician conduct
  when acting in a professional capacity including
  any impairment or behavior that interferes with
  the orderly operation of the hospital.

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Peer Review and Corrective ActionProfessional
Conduct

• Corrective action taken in response to multiple
  complaints about physician disruptive conduct
  involving abusive treatment of nurses,
  technicians, and fellow physicians was
  appropriate.  Clinical incompetence involving
  patient injury is not a necessary basis for
  corrective action.

• The disruptive physician is by definition
  contentious, threatening, unreachable, insulting
  and frequently litigious.  He will not, or cannot
  play by the rules, nor is he able to relate to or
  work well with others.

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Peer Review andCorrective Action Options

• Educational
• CME
• Physicians assistance programs
• Counseling
• Proctoring/Preceptoring
• Voluntary limitation of privileges
• Mandatory second opinion
• Suspension
• Revocation
• Restrictive

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Peer Review andCorrective ActionRoad to the
Board

• Request for corrective action
• Investigation and Recommendation to MEC
• MEC Recommendation to the Board
• Right to Hearing with Report and Recommendation
• Right to Appeal

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Peer Review andCorrective Action Boards Role

• Hearing Record
• Bylaws provide standard

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Peer Review andCorrective Action Boards Role

• Appellate Review Committee
• Appeal Statement
• Oral Presentation
• Decision

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Peer Review andCorrective Action Immunity

• Requirements for immunity for professional review
  action
• Reasonable belief that action was in furtherance
  of quality health care
• Following reasonable effort to obtain facts
• After adequate notice and hearing procedures
  afforded physician
• Reasonable belief that action warranted by facts
  known after reasonable effort to obtain and
  notice and hearing

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Peer Review andCorrective Action Investigation

• Physician entitled to a reasonable investigation,
  not a perfect investigation
• Facts so obviously mistaken or inadequate as to
  make reliance on them unreasonable
• Fabricating damaging evidence or purposefully
  overreacting is not part of legitimate peer
  review

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Peer Review and Corrective ActionNotice and
Hearing

• Inform physician of issues
• Issues can change during course of investigation
  as long as there is notice
• Opportunity to be heard at each step in process -
  Investigation Committee, MEC, Fair Hearing, Appeal

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Decision

• Process
• Facts
• Conflicts
• Conclusions

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Peer Review and Corrective Action Key Immunity
Question

• Was the action undertaken in the reasonable
  belief that it would further quality health care
  based on facts known at the time
• Courts will not substitute judgment of the
  medical staff or governing body or reweigh
  evidence

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Robert Walerius [phone] bob.walerius_at_mill
ernash.com Dana Kenny [phone] dana.kenny
_at_millernash.com Greg Montgomery (206)
622-8484 greg.montgomery_at_millernash.com