THE PRACTITIONER APPRAISALPROCESS CREDENTIALING OF LICENSED INDEPENDENT PRACTITIONERSCredentialing and privileging (in provider organizations) are processes of confirming the clinical competence and professional performance of, at a minimum, all licensed independent practitioners
A licensed independent practitioner (LIP) is any individual who is professionally licensed by the state (U.S.) and permitted by the organization to provide patient care services without direction or supervision, within the scope of that license
Core Criteria for credentialing /privilegingFour core criteria that help validate the practitioners skills and physical and mental ability to discharge patient care responsibilities: 1-Current licensure 2-Relevant training and experience (professional schools, residencies, fellowships, postdoctoral programs, board certifications, clinical certifications)
3-Current competence (informed opinions from authoritative sources concerning current clinical judgment and technical skills, peer recommendations); 4-Ability to perform the privileges requested or essential functions of the position
General Competencies forCredentialing / Privileging Patient Care: "Provide patient care that is appropriate, and effective for the promotion of health, treatment of disease, and at the end of life"; Medical/Clinical Knowledge: "Demonstrate know/edge of established and evolving clinical, and social sciences and apply to patient care and education of others";
Practice-based Learning and Improvement: "Be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices"; Interpersonal and Communication Skills: "Demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of health care teams";
Professionalism: "Demonstrate behaviours that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession and society"; Systems-based Practice: "Demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care. "
Credentialing/Re-credentialing Process Definition: The verification of the practitioners right and competency to provide patient care in the appropriate setting.
Criteria of Credentialing / privileging Current, valid license to practice Current competence History of loss of license and, history of loss or limitation of privileges or disciplinary actions . Evidence of physical ability to perform the requested privilege (or) inability to perform essential functions of the position
CLINICAL PRIVILEGING/REPRIVILEGINGPROCESS Clinical privileging and re-privileging cannot be centralized. This process must always be setting-specific, based on services available, so it has to be accomplished at each provider site
Definition: "Privileging" means granting permission to provide specific medicalor other patient care services in the organization, within well-defined limits, based on the individuals professional license and his or her experience, competence, ability, and judgment and on the organizations ability to provide and support the service.
Delineation of privileges: Clinical privileges are granted individually, based on criteria established by the organization, usually using privilege control sheets that are specific to each department, section, service, or specialty. The criteria determine the level of competency appropriate for each privilege, e.g., the number of procedures that must be performed every two years for the practitioner to be considered currently competent and to retain the privilege
Privilege status Temporary: Temporary privileqe to practice until credentialing and individual privilege delineation has been processed and approved by the governing body. Approved: Delineated privileges approved for the time period specified by the institution, but never longer than two years Emergency: Any practitioner is permitted to do everything possible to save a life or protect a patient from further or serious harm within the scope of his/her license, regardless of membership status, credentialing status, or approval of specific privileges.
Proctoring As part of the process of granting initial privileges or a new privilege to a practitioner, proctoring by peers (observation and/or a review of cases) may occur within guidelines established in the medical/professional staff bylaws, rules and regulations, medical staff department.
PRACTITIONER PROFILING Represent a performance monitoring and analysis, helping to effectively communicate appropriate findings to those leaders who need to know. Profiles are practitioner-specific data and information summaries used in the reappraisal process, usually in conjunction with re- credentialing and re-privileging activities.
Ideally profiling should be as concurrent as possible, with review, analysis, and reporting at least quarterly, to identify better practices, as well as permit appropriate intervention in quality of care and patient safety issues.
Profiling in Hospital process All independent practitioners with delineated clinical privileges, whether or not they are medical staff members, are profiled, based on an ongoing measurement process. Department chairs, section chairs, medical/clinical directors, or chief medical officers, depending on the setting and structure, must review the profile data for both positive findings and any areas of concern.
Practitioner profilesUsed in : 1-Monitoring of clinical processes, e.g., mortality review findings; peer-reviewed events with rating below standard of care; performance on core measures. 2--Use of operative and other procedures placing patients at risk, e.g., unplanned return to operating room; --Use of medications, e.g., use of preoperative antibiotics; use of beta blockers post CABG --Use of blood and blood products, e.g., usage not meeting criteria after peer review (inpatient and outpatient )
3-Significant infection surveillance findings, 4--Utilization management findings, e.g., readmissions related to previous hospitalization w/in 31 days; total inpatient stays and average length of stay , total inpatient and outpatient procedures; 5--Pharmacy and therapeutics function
6-Patient safety findings, including adverse events, root cause analyses; --Risk management findings; 7---Medical record review. 8--Pertinent findings/successes resulting from QI Team activities;
9-Pertinent findings from external review, including the Quality Improvement Organization (QIO), State Department of Health, private review and case management companies. 10-Information concerning patient care activity in the organization, e.g., numbers of patients admitted or treated, numbers and types of procedures performed;
11-Outpatient activity, e.g., unscheduled inpatient admissions due to adverse outcome from outpatient procedure; 12--Information concerning fulfillment of administrative responsibilities, e.g., meeting attendance, committee membership, QI team participation, productivity, etc.;
Practitioner profiles must:-Be maintained in a strictly confidential environment, As part of a credentials file or In a separate locked file, stamped as "Confidential-Part of Credentials File.-Be released only in accordance with bylaws, rules and regulations, and/or policy, to authorized individuals or committees, within the limits of the law; Except for activity data, be comprised only of peer-reviewed findings; raw data is unacceptable, as it has not been validated
Be reviewed and signed off by:--Medical directors and/or peer review committee--Department chairs, at the time of reappraisal for reappointment to the medical staff and re-privileging in hospitals; or
APPOINTMENT/REAPPOINTMENT(Medical/Professional Staff Membership • Eligibilitv: The medical/professional staff includes fully licensed physicians and may include other licensed individuals permitted by law and the organization to provide independent patient care services (e.g., psychologists, podiatrists, dentists).
Initial appointment is provisional Initial appointment is provisional, with a time period consistent for all applicants, generally 6 months to 1 year, as determined by the medical staff bylaws. The full appointment period is also determined by the bylaws, but cannot exceed two years, as The Joint Commission accreditation standards require renewal of privileges at least every two years.
Initial Appointment Once the provisional time period has elapsed and required proctoring is completed, the practitioner is advanced to an active staff (depending on the categories available and the bylaws provisions)
Reappointment Reappointment includes reappraisal of:-Re-credentialing: Updated information concerning current activity, licensure and certifications/ registrations, liabilities/claims leading to judgments against the practitioner, and malpractice insurance coverage;-Current competency review (profile information): Quality management activities; peer review activities
Reappointment -Review of other reasonable indicators of continuing qualifications, sometimes including attendance at medical/ professional staff, department, and assignedcommittee and team meetings; -Peer and departmental recommendations; -Review and renewal of specific clinical privileges
Reappointment Compliance with continuing medical education requirements. Reappointment is granted for the time period specified in the bylaws or policies/procedures, but never for longer than two years, again based on Joint Commission accreditation standards requirement regarding renewal of privileges.
PATIENT/MEMBER ADVOCACY ANDFEEDBACK PROCESSESOne of the most exciting results of the emphasis on continuous quality improvement concepts is the renewed interest in the patient/member as: Integrally involved in, and controlling, his or her care; A "customer", with specific needs and expectations; A "processor" and "supplier" in the process of patient care; Having very specific rights, as well as responsibilities, within the process of care.
The Organizations Responsibilities to thePatient/Member Include:Respect for: -The patient/member as an individual with unique healthcare needs, including consideration of psychosocial, spiritual, and cultural variables influencing the perception of illness and accommodation of right to religious/spiritual services; -Personal dignity and the right to considerate and respectful care.
Reasonable responses to requests and needs for treatment or service (access), including pain management Information concerning the patients/members right, in collaboration with his or her physician and to the extent permitted by law, to make decisions regarding his or her care, treatment, and services, including providing informed consent and making the decision to refuse treatment.
Development of policies regarding provision or withholding of resuscitation, life sustaining treatment, and decisions concerning end of life care and treatment; Policies and procedures to both protect and permit the exercise of patient/member rights, including mechanisms for the communication of needs, and resolution of patient/member complaints or grievances
Protection, within the limits of the law, of personal privacy, security, and confidentiality of information; appropriate consents obtained, including recording or filming for purposes other than identification, diagnosis, or treatment; Freedom from mental, physical, sexual, verbal abuse, neglect
Communication of information related to ethical issues or human experimentation or other research projects affecting his or her care or treatment; Protection as research subjects and respect of rights during research, investigation, and clinical trials;
Patient / Member Responsibilities to theProvider of Care Provide, to the extent possible, information that providers need to care for them Follow plans and instructions for care they have agreed on with their practitioners and Participate in understanding their health problems and developing mutually agreed upon treatment goals
Complaints , Grievances, and Appeals Complaint: An oral or written expression of dissatisfaction. A person "registers" a complaint, generally about the processes of care.
Grievance: A formal expression of dissatisfaction, usually written but may be oral. A person "files" a grievance, generally about quality of care or financial issues. Appeal: A request to change a previous decision made by the organization
PATIENT/MEMBER FEEDBACKPROCESSES Healthcare Quality and Customer Satisfaction-Consumers will evaluate quality based on such criteria as: Access to practitioners Geographical access Service Relationship/connectedness/affinity Cost
Collection of Patient/Member Feedback Feedback is based on perceptive quality and may take the form of complaints, positive or negative perceptions of care, or even innovative ideas for improvement
Patient/member satisfaction and riskmanagement Patient satisfaction is one of the key factors in quality management and performance improvement that provides perceptive quality information and helps measure outcomes of care and service. Patient dissatisfaction is one of the key factors in risk management that prompts patient/family action to file a claim.
Patient feedback systems in loss preventionand reduction To establish effective outcome databases; use of patient feedback in outcomes management There must be a system of distribution of aggregated patient feedback information to all who need to know in order for appropriate response to take place:
Patient / Member Feedback Processes -Surveys/questionnaires (written and Internet) --Patient perception of care/satisfaction --Health status -Telephone and face-to-face interviews -Focus group Internet e-mail communications (questions, comments, etc.) -Complaint and grievance processes
PATIENT AND FAMILY EDUCATIONPROCESS The educational assessment should: -Address the relevant healthcare needs, abilities, and readiness to learn; -Include cultural and religious beliefs, emotional barriers, desire and motivation, physical and / or cognitive limitations, and language barriers
The education should: -Be understandable; -Include instruction necessary to meet ongoing healthcare needs, including, if relevant:--Plan for care, treatment, and services--Basic safety health practices--Safe and effective use of medication--Safe and effective use of medical equipment and supplies --Education about pain management, including risk, assessment, and methods-for management --Potential drug-food interactions --Counseling on nutrition and modified diets
REPORTING MECHANISMSinformation for hospital governing body review may include : -Activity: Admissions, patient days, encounters, etc., as applicable -Unplanned admissions / readmissions as defined by the organization or the appropriate reference database; -Discharges against medical advice -Summaries of media stories; -Satisfaction survey trends: patient, staff (professional and organization);
REPRTING MECHANISM Complaints: patient, professional staff, organization staff; -Pattern analyses of --Occurrences --Claims --Mortalities Summary utilization data: --Average length of stay --Cost per case --Cost avoidance
REPORTING MECHANISM Rates: --C-sections --Mortalities, e.g., neonatal/maternal --Medication errors --Healthcare-associated infections, e.g., surgical site, outbreaks A balanced scorecard/dashboard is a good way to organize the data, with key performance measures supported by other department/service measures as relevant
EVALUTAION OF QM / PI FUNCTION Evaluation of QM/PI activities is critical to determine whether processes in the organization have really improved and whether strategic and operational goals and objectives have been met.
COMPONENTS OF EXCELLENCE Valid, reliable data and information about important functions and associated processes of care and service and patient safety; Collaboration for continuous improvement in organizational performance by all appropriate leaders, medical staff, departments/services, cross-functional teams, and committees;
Timely assessment of data to identify significant variations in processes and outcomes, both undesirable and best practices; Identification and prioritization of quality activities , performance measures, variances, and other opportunities to improve care and. services; Validated effectiveness of actions/strategies implemented to improve care processes;
Communication of clear information across and within all appropriate departments/services, organizations, etc.; Complete documentation and follow-up; Evidence of supportive QM structure and systems, including information management
Evidence of support and involvement of all key leaders; Integration with all other pertinent activities, including utilization management, risk management, and safety; Ongoing quality education efforts organization wide.
Any of these components can be prioritized as annual objectives for organization wide quality strategy improvement or as a checklist for annual evaluation of effectiveness of the function.
EVALUATION OF PI PROCESSES AND OUTCOMES Evaluation of quality management/performance improvement activities must address their relevance to the organizations mission, vision, and strategic plan
Process effectiveness: Viability of the Plan, given current resources, including the practicality of OM/PI activities; -Ability to measure patient outcomes and improvement in the quality of patient care (utilizing as many outcome parameters as possible); -Accurate communication of information to the appropriate persons, teams, committees, board, or other groups;
Documentation to support compliance with The Joint Commission, NCOA, and other standards and state and federal regulations, as applicable; -Cost-effectiveness and efficiency benefits of the activities; Patient and staff safety benefits of the activities; -Ability of all QM/PI activities to assess customer needs and expectations and to meet or surpass those needs.
Outcome effectiveness: -Degree to which Strategic Ouality Initiatives were met; -Degree to which outcome objectives for quality initiatives were met; -Comparison of current performance measures (indicators) with previous ratings
-Comparison of the current findings from patient and staff surveys/questionnaires with previous measures; -Evidence of improved clinical performance; Amount of new information available to leaders for the next planning period: --Strategic and quality goals; --Organizational objectives; --Strategic Ouality Initiatives.
Evaluate QM activities-Are strategic goals and objectives being met?-Are program strengths being maintained?-Are weaknesses being corrected?-Are quality objectives and activities meeting current standards, regulations, and other review requirements? -AreQM/PI activities comprehensive, including all relevant disciplines, teams and committee -Is OM/PI activity coordination efficient and effective?
Are QM/PI activities supported by the governing body, administration, and physicians/LIPs? Does each understand their role and responsibilities? -Are important and meaningful problems and issues identified, analyzed, and resolved? -Are all appropriate and available data sources being utilized to support teams and to measure and assess performance? -Are predetermined, valid performance measures used when appropriate?
Are data aggregated, displayed, analyzed, trended, and reported? -Are improvements recommended? Are they implemented? Are they evaluated for effectiveness? -Are all OM activities adequately and accurately documented? -Are reporting mechanisms adequate (frequent enough; to all appropriate persons, departments, teams, committees, settings; clear communication tools)?
• Methods of evaluation Review of patient processes and outcomes (data summaries, activity reports, critical events, claims information); -Review of perceptions and attitudes (observation, interview, questionnaires, complaints); Review of services (availability, timeliness, and quality based on critical events, adverse outcomes, patient satisfaction).
Infection Prevention and Control Infection: "The transmission of a pathogenic microorganism to a host, with subsequent invasion and multiplication, with or without resulting symptoms of disease." [The Joint Commission]
Healthcare-associated (nosocomial): Infections that patients acquire during the course of receiving treatment for other conditions or that healthcare workers acquire while performing their duties within a healthcare setting. [CDC] Iatrogenic: An infection or other complication of treatment induced in a patient by a physicians or other licensed independent practitioners activity, manner, or therapy
Epidemic infection: .~ higher than expected level of infection by a common agent in a defined population during a defined period.“ individuals with a healthcare-associated infectionThe ratio describing the number of individuals with a healthcare- associated infection [numerator] divided by the number of individuals at risk of developing healthcare-associated infections [denominator], for a specified group, e.g., surgical site infections, probably stratified by type of procedure, condition, location (geographic or body part), etc., based on the organizations population and experience
Goal and scope Goal: "...reduce the risk of acquisition and transmission of health care-associated infections Evidence of goal achievement: Reduced healthcare-associated infection rates.
Scope of the function: Coordination of all activities related to the surveillance, prevention, and control of healthcare associated infections; - Linkages with support systems to reduce the risks of infection from the environment, including food and water sources.
Responsibilities of the QC ,team orcommittee Approval of the type and scope of surveillance activities, including data collection and analysis methodologies; -Approval of actions taken to prevent or control infections Documentation in minutes of conclusions, recommendations, actions, and person(s) responsible for implementation of action;
Responsibilities of the QC or Committee Communications to the medical executive committee, if applicable, CEO, nurse executive, persons responsible for organization wide quality management activities, and governing body; --Review and approval of all infection control policies and procedures;
Responsibilities of the infection controlprofessional-Development and management of policies/procedures/processes; -Participation in strategic and other organizational planning;-Participation in organization wide PI activities/strategic initiatives;-Quality control/monitoring/review of equipment and/or processes
Responsibilities of the infection controlprofessional Budgeting/management reporting (Infection control needs, occurrences, etc.); -Participation in safety inspections, emergency/disaster preparedness, drills; -Participation in space, resource, and service allocation; -Staff performance evaluation/competency review
Responsibility as a patient safety activity Preventive activities :Policies and procedures, education, and infection control measures Surveillance : case finding, investigation of significant infections, data analysis, and reporting-All of these processes and steps have as their goal a safe experience for the patient and should be integrated with the patient safety program
The Joint Commission states that a healthcare-associated infection involving a death or permanent disability should be considered a sentinel event, requiring intensive analysis and root cause analysis The key element is collaboration among infection control professionals, physicians, other clinical staff, administrative directors, and others as identified.
A typical hospital policy statement It might read: "Healthcare-associated infections are defined as those infections not present or incubating at the time of admission.
As a rule, an infection will be considered healthcare-associated if there is documentation of infection occurring 48 hours after the admission date, or if the physician indicates a diagnosis of healthcare-associated infection. Specific criteria will be used for identifying healthcare-associated infections by site, based on the guidelines established by the Centers for Disease Control and Prevention. These guidelines shall be approved by the [Infection Control] Committee and the [Medical Executive] Committee [or Quality Council]. "
Disease surveillance It is an epidemiological practice by which the spread of disease is monitored in order to establish patterns of progression. The main role of disease surveillance is to predict, observe, and minimize the harm caused by outbreak, epidemic, and pandemic situations, as well as increase our knowledge as to what factors might contribute to such circumstances. A key part of modern disease surveillance is the practice of disease case reporting.
The Surveillance/Control Cycle in infectioncontrol
Minimal Requirements for Surveillance Monitor infection patterns (sites, pathogens, risk factors, location within the facility) Detect changes in the patterns that may indicate an infection problem Direct the rapid implementation of control measures Monitor antibiotic use and resistance Provide the staff with exactly the information they need in order to improve infection prevention practices.
Types of surveillance approaches include: 100% surveillance--Detection and recording of all healthcare-associated infections occurring on every service in every area at every setting;--Calculation of infection rates to identify potential infection problems in specific areas;--Appropriate analyses include collection of denominators;--Continuous conduction (e.g., lab report screening) or periodically (e.g., 100% every 3 months for 1 month).
Types of surveillance approaches include Priority-directed, targeted surveillance --Specific services, e.g.:-All patients in surgical settings;-All patients in special care areas in hospitals
Priority-directed, targeted surveillance Targeted patient populations (disease-specific or based on adverse occurrence), e.g.:---All patients with Class I surgical wounds who develop infections;---All patients on ventilators who acquire pneumonia;---Patients developing infection from certain antibiotic-resistant bacteria.
Priority-directed, targeted surveillance Procedures, e.g.:--All ambulatory cardiac and orthopedic surgical procedures;---All Swan-Ganz catheter insertions in hospitals.
Types of surveillance approachesC-Problem-oriented or outbreak response surveillance --Conducted to measure the occurrence of specific infection problems; --Further evaluation as necessary, collecting comparable data from control groups to identify risk factors and appropriate control measures; --Continued surveillance to determine effectiveness of control measures
Standards for infection control• CDC guidelines as infection control standardsThe CDC has specific guidelines for prevention of healthcare-associated infections, e.g., pneumonia, surgical site, intravascular device, catheter associated urinary tract, isolation, environmental, hand hygiene, personnel safety, home care, long term care. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr521