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Continuous Compliance Series- It’s not JUST an OSV Prep
COMPLIATRIC WEBINAR SERIES
Presented by: Michelle Layton BSN, MBA
michellel@infidiumhs.com
Chapter 5 – Clinical Staffing
ThankYou For Providing Care
Disclaimers
 This presentation is not endorsed by Management Strategists
Consulting Group (MSCG)
 This presentation is not endorsed by Health Resources
Services Administration (HRSA) or the Bureau of Primary
Health Care (BPHC).
 Not employed by MSCG or BPHC
 Independent Consultant who is contracted to conduct
Operational Site Visits (OSV), provide Technical Assistance
and assist health centers with preparation for their OSV
 This information should not be considered legal advice
Confidentiality Notice: This document is confidential and contains proprietary information and intellectual property
of Infidium Healthcare Solutions. Neither this document nor any of the information contained herein may be
reproduced or disclosed under any circumstances without the express written permission of the aforementioned
party.
Purpose of the Compliatric Series
 Virtual Operational Site Visits (VOSVs) are here to stay
◦ Time frames for notification can be short
 Compliance = HRSA funding
◦ Non-compliance can affect other Federal Programs (i.e.,
FTCA)
 Continuous Compliance = High performing health
center
◦ Eliminates the chaos of having to “prepare”
Agenda
 Requirements for Compliance
 Evaluation of Compliance
 Fundamentals of Credentialing and Privileging/Peer Review
 Maintaining Continuous Compliance – Factors to Consider
 Clinical Reviewer Insight
 Question and Answer Session
Requirements for Compliance
Requirements for Compliance
 Health center must have adequate clinical staffing
to carry out the required and additional services on
Form 5A
◦ Can be provided either directly or through formal written
contracts/referral arrangements
 Health center must have the appropriate number
and mix of staff to ensure reasonable patient
access to health center services
◦ Must be appropriate for the health center’s patient
population
◦ Must consider the size, demographics and health needs
Requirements for Compliance
 Health center must have operating procedures for the initial
and recurring review of credentials for all clinical staff
 Health center must have operating procedures for the initial
granting and renewal of privileges for all clinical staff
 This applies to all health center employees, individual
contractors and volunteers:
◦ Licensed Independent Practitioners (LIP)
◦ Other Licensed and Certified Practitioners (OLCPs)
◦ Other Clinical Staff (OCS)
Requirements for Compliance
 Health center must maintain secure files for all categories of
clinical staff
 Files must contain up to date documentation of all
credentialing and privileging elements
 Health center must ensure all contracted or referral providers
are appropriately credentialed and privileged
 How is this accomplished??
◦ Language in the formal written contract or referral arrangement
◦ Documentation of the credentialing and privileging procedures
utilized by the organization you are contracting with or referring to
Evaluation of Compliance
Evaluation of Compliance
 Review of Documentation
◦ Current staffing profile with name, position, hire date, FTE
status, specialty and translation capability (spreadsheet)
◦ Policy/procedures for credentialing and privileging of LIPs,
OLCPs and if applicable, other clinical staff
◦ Sample credentialing and privileging files (SVP, page 17)
◦ Credentials Verification Organization (CVO) contract
◦ Sample of the formal contracts/referral arrangements
reviewed under Required and Additional Health Services
Evaluation of Compliance
 Staff Interviews
◦ Verification of process with Clinical Leadership and staff
responsible for credentialing and privileging
 Site Tours
◦ Tour of two sites, one where the majority of services are
provided
◦ If a Column I service can not be observed during a site
tour, documentation of the service in the patient’s medical
record must be provided (Refer to Required and Additional
Health Services)
Fundamentals of Credentialing
and Privileging
Back to Basics
Credentialing and
privileging…
Oh… I thought they were
the same thing?
Definitions
Credentialing
The process of assessing and confirming the
qualifications of a licensed or certified health care
practitioner
Privileging/Competency
The process of authorizing a licensed or certified
health practitioner’s specific scope and content of
patient care services
Definitions
Licensed Independent Practitioner (LIP)
Physician, Dentist, Nurse Practitioner and Nurse
Midwife, or “ any other individual permitted by law and
the organization to provide care and services without
supervision, within the scope of the individual’s
license and consistent with individually granted
clinical privileges
Definitions
Other Licensed or Certified Health Care
Practitioner (OLCP)
An individual who is licensed, registered or certified but is not
permitted by law to provide patient care services without
direction or supervision. Examples include:
• Laboratory Technicians
• Medical Assistants
• Registered Nurses
• Dental Hygienists
Definitions
Other Clinical Staff
A clinical staff member that performs services in a state,
territory or other jurisdiction that does not require licensure or
certification. Examples include:
• Medical Assistants
• Dental Assistants
• Community Health Workers
Definitions
Primary Source Verification
Verification by the original source of a specific
credential to determine the accuracy of a qualification
reported by an individual health care practitioner.
Examples include:
• Internet verification (i.e., state database)
• Direct correspondence
• Reports from Credentials Verification Organization
Definitions
Primary Source Verification
Possible sources for PSV of education and residency
for physicians include:
• American Medical Association (AMA) Masterfile
• American Board of Medical Specialties
• American Osteopathic Association Physician
Profiles
• Education Commission for Foreign Medical
Graduates (ECFMG) – International graduates
licensed after 1986
Definitions
Primary Source Verification
Possible sources for PSV of certifications for other
LIPs (i.e., PA, NP, etc.) include:
• American Nurses Credentialing Center
• American Midwifery Certifying Board
• National Commission on Certification of Physician
Assistants
Definitions
Secondary Source Verification
Methods of verifying a credential that are not
considered an acceptable form of primary source
verification. Examples include:
• Notarized copy of the credential
• Copy of the credential that is made from an
original by approved staff
Definitions
Reappointment
The process of verifying expired credentials and re-
privileging of a licensed or certified health care
practitioner on a recurring basis
Credentialing and Privileging Activities
Credentialing and Recredentialing activities for
LIPs include:
• Verification of identity – Initial only
• Verification of current licensure, registration or
certification – Primary source
• Verification of education and training – Primary source,
initial only
• National Practitioner Data Bank Query
• Verification of DEA Registration
• Verification of basic life support training
Credentialing and Privileging Activities
Privileging and Reprivileging activities for LIPs
include:
• Verification of fitness for duty
• Verification of immunization and communicable disease
status
• Verification of current clinical competence
• Initial – Verification via training, education, reference reviews
• Renewal – Verification via peer review, performance improvement
activities
Credentialing and Privileging Activities
Credentialing and Recredentialing activities for
OLCPs include:
• Verification of identity – Initial only
• Verification of current licensure, registration or
certification – Primary Source
• Verification of education and training – Primary or
Secondary Source, initial only
• National Practitioner Data Bank Query
• Verification of DEA Registration (if applicable)
• Verification of basic life support training
Credentialing and Privileging Activities
Privileging and Reprivileging activities for OLCPs
include:
• Verification of fitness for duty
• Verification of immunization and communicable disease
status
• Verification of current clinical competence
• Based on Supervisory evaluation of clinical
competence per the job description
Temporary Privileges
• Privileges SHOULD:
• Be granted in accordance with FTCA Guidelines
• Be approved by the CEO upon the recommendation of
appropriate department head
• Privileges SHOULD NOT:
• Exceed more than 90 days
• Be renewed
• Be granted in lieu of expired credentials
Credentialing and Privileging Activities
Initial Privileging and Reappointment
 Privileging is completed after the health center has verified all
necessary credentials for a practitioner
 Re-appointment is completed on a recurring basis (i.e., every
two years), as determined by the health center
 Re-appointment involves the verification of expired
credentials and re-privileging of practitioners
 The health center determines who has approval authority for
credentialing and privileging
Credentialing and Privileging Activities
Delineation of Privileges (Clinical Services)
• Subsequent to credentials verification, the practitioner
submits a request for clinical privileges, which includes
completion of a Delineation of Clinical Services Form.
• The Delineation of Clinical Services Form:
• Includes only services and sites listed in the health center’s
approved scope of project
• Is specific to each specialty within the health center (i.e., Dental,
Behavioral Health, Family Practice, Obstetrics)
• Outlines Requested Services, Non-Requested Services,
Approved Services and Non-Approved Services
Peer Review
Peer Review
Peer Review must be completed:
 On a “routine and regular basis”
◦ Considered a quarterly QI Assessment per the Site Visit Protocol
 Between providers within the same specialty who are similarly
credentialed
 In all clinical areas within the health center’s scope of project (Family
Medicine, Obstetrics, Dental, Behavioral Health)
 Using an industry standard tool that clearly evaluates the quality of
services provided and does not only perform administrative review
 Using a blinded methodology that ensures confidentiality of patient
information
Peer Review – Basic Concepts
The results of Peer Review must be part of the
health center’s Quality Improvement Program and
incorporated into the LIP reappointment process,
which is evidenced by documentation in:
• Credentialing and Privileging Policy
• Peer Review Policy
• Quality Improvement Plan
• Credentialing and Privileging Files
Maintaining Continuous
Compliance – Factors to
Consider
Factors to Consider
 The Credentialing and Privileging Policy does NOT
require board approval – Best Practice? No
 Credentialing and privileging of clinical staff
(including LIPs) does not require board approval –
Best Practice? No
 The health center determines who has approval
authority for credentialing and privileging
 If the health center does not have other clinical
staff, they do not need to be included in the
procedures
Factors to Consider
 The Compliance Manual is the minimum standard
for credentialing and privileging of clinical staff
 Federal Tort Claims Act (FTCA) regulations are the
highest standard for credentialing and privileging of
clinical staff
 Follow the guidelines and examples for primary
and secondary source verification outlined in the
HRSA Credentialing and Privileging File Review
Resource
Factors to Consider
 An NPDB Query is required for ALL categories of
clinical staff – No longer “as reportable”
 Health Centers must ensure contracted and
referral providers are appropriately credentialed
and privileged
◦ Contracts/referral arrangements must include provisions to
support credentialing and privileging of the
contracted/referral providers; or
◦ Review the contracted organization’s credentialing and
privileging process
Resources
Additional Resources
Compliatric
https://www.compliatric.com/
HRSA Health Center Compliance Manual
Health Center Program Compliance Manual | Bureau of Primary Health
Care (hrsa.gov)
HRSA SiteVisit Protocol
Health Center Program SiteVisit Protocol | Bureau of Primary Health
Care (hrsa.gov)
HRSA Credentialing and Privileging File Review Resource
Credentialing and Privileging File Review Resource (hrsa.gov)
Questions & Answers
Michelle Layton BSN, MBA
Infidium Healthcare Solutions, LLC
michellel@infidiumhs.com
Direct: 214-766-0333

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Compliatric continuous compliance series chapter 5

  • 1. www.compliantfqhc.com Continuous Compliance Series- It’s not JUST an OSV Prep COMPLIATRIC WEBINAR SERIES Presented by: Michelle Layton BSN, MBA michellel@infidiumhs.com
  • 2. Chapter 5 – Clinical Staffing
  • 4. Disclaimers  This presentation is not endorsed by Management Strategists Consulting Group (MSCG)  This presentation is not endorsed by Health Resources Services Administration (HRSA) or the Bureau of Primary Health Care (BPHC).  Not employed by MSCG or BPHC  Independent Consultant who is contracted to conduct Operational Site Visits (OSV), provide Technical Assistance and assist health centers with preparation for their OSV  This information should not be considered legal advice Confidentiality Notice: This document is confidential and contains proprietary information and intellectual property of Infidium Healthcare Solutions. Neither this document nor any of the information contained herein may be reproduced or disclosed under any circumstances without the express written permission of the aforementioned party.
  • 5. Purpose of the Compliatric Series  Virtual Operational Site Visits (VOSVs) are here to stay ◦ Time frames for notification can be short  Compliance = HRSA funding ◦ Non-compliance can affect other Federal Programs (i.e., FTCA)  Continuous Compliance = High performing health center ◦ Eliminates the chaos of having to “prepare”
  • 6. Agenda  Requirements for Compliance  Evaluation of Compliance  Fundamentals of Credentialing and Privileging/Peer Review  Maintaining Continuous Compliance – Factors to Consider  Clinical Reviewer Insight  Question and Answer Session
  • 8. Requirements for Compliance  Health center must have adequate clinical staffing to carry out the required and additional services on Form 5A ◦ Can be provided either directly or through formal written contracts/referral arrangements  Health center must have the appropriate number and mix of staff to ensure reasonable patient access to health center services ◦ Must be appropriate for the health center’s patient population ◦ Must consider the size, demographics and health needs
  • 9. Requirements for Compliance  Health center must have operating procedures for the initial and recurring review of credentials for all clinical staff  Health center must have operating procedures for the initial granting and renewal of privileges for all clinical staff  This applies to all health center employees, individual contractors and volunteers: ◦ Licensed Independent Practitioners (LIP) ◦ Other Licensed and Certified Practitioners (OLCPs) ◦ Other Clinical Staff (OCS)
  • 10. Requirements for Compliance  Health center must maintain secure files for all categories of clinical staff  Files must contain up to date documentation of all credentialing and privileging elements  Health center must ensure all contracted or referral providers are appropriately credentialed and privileged  How is this accomplished?? ◦ Language in the formal written contract or referral arrangement ◦ Documentation of the credentialing and privileging procedures utilized by the organization you are contracting with or referring to
  • 12. Evaluation of Compliance  Review of Documentation ◦ Current staffing profile with name, position, hire date, FTE status, specialty and translation capability (spreadsheet) ◦ Policy/procedures for credentialing and privileging of LIPs, OLCPs and if applicable, other clinical staff ◦ Sample credentialing and privileging files (SVP, page 17) ◦ Credentials Verification Organization (CVO) contract ◦ Sample of the formal contracts/referral arrangements reviewed under Required and Additional Health Services
  • 13. Evaluation of Compliance  Staff Interviews ◦ Verification of process with Clinical Leadership and staff responsible for credentialing and privileging  Site Tours ◦ Tour of two sites, one where the majority of services are provided ◦ If a Column I service can not be observed during a site tour, documentation of the service in the patient’s medical record must be provided (Refer to Required and Additional Health Services)
  • 15. Back to Basics Credentialing and privileging… Oh… I thought they were the same thing?
  • 16. Definitions Credentialing The process of assessing and confirming the qualifications of a licensed or certified health care practitioner Privileging/Competency The process of authorizing a licensed or certified health practitioner’s specific scope and content of patient care services
  • 17. Definitions Licensed Independent Practitioner (LIP) Physician, Dentist, Nurse Practitioner and Nurse Midwife, or “ any other individual permitted by law and the organization to provide care and services without supervision, within the scope of the individual’s license and consistent with individually granted clinical privileges
  • 18. Definitions Other Licensed or Certified Health Care Practitioner (OLCP) An individual who is licensed, registered or certified but is not permitted by law to provide patient care services without direction or supervision. Examples include: • Laboratory Technicians • Medical Assistants • Registered Nurses • Dental Hygienists
  • 19. Definitions Other Clinical Staff A clinical staff member that performs services in a state, territory or other jurisdiction that does not require licensure or certification. Examples include: • Medical Assistants • Dental Assistants • Community Health Workers
  • 20. Definitions Primary Source Verification Verification by the original source of a specific credential to determine the accuracy of a qualification reported by an individual health care practitioner. Examples include: • Internet verification (i.e., state database) • Direct correspondence • Reports from Credentials Verification Organization
  • 21. Definitions Primary Source Verification Possible sources for PSV of education and residency for physicians include: • American Medical Association (AMA) Masterfile • American Board of Medical Specialties • American Osteopathic Association Physician Profiles • Education Commission for Foreign Medical Graduates (ECFMG) – International graduates licensed after 1986
  • 22. Definitions Primary Source Verification Possible sources for PSV of certifications for other LIPs (i.e., PA, NP, etc.) include: • American Nurses Credentialing Center • American Midwifery Certifying Board • National Commission on Certification of Physician Assistants
  • 23. Definitions Secondary Source Verification Methods of verifying a credential that are not considered an acceptable form of primary source verification. Examples include: • Notarized copy of the credential • Copy of the credential that is made from an original by approved staff
  • 24. Definitions Reappointment The process of verifying expired credentials and re- privileging of a licensed or certified health care practitioner on a recurring basis
  • 25. Credentialing and Privileging Activities Credentialing and Recredentialing activities for LIPs include: • Verification of identity – Initial only • Verification of current licensure, registration or certification – Primary source • Verification of education and training – Primary source, initial only • National Practitioner Data Bank Query • Verification of DEA Registration • Verification of basic life support training
  • 26. Credentialing and Privileging Activities Privileging and Reprivileging activities for LIPs include: • Verification of fitness for duty • Verification of immunization and communicable disease status • Verification of current clinical competence • Initial – Verification via training, education, reference reviews • Renewal – Verification via peer review, performance improvement activities
  • 27. Credentialing and Privileging Activities Credentialing and Recredentialing activities for OLCPs include: • Verification of identity – Initial only • Verification of current licensure, registration or certification – Primary Source • Verification of education and training – Primary or Secondary Source, initial only • National Practitioner Data Bank Query • Verification of DEA Registration (if applicable) • Verification of basic life support training
  • 28. Credentialing and Privileging Activities Privileging and Reprivileging activities for OLCPs include: • Verification of fitness for duty • Verification of immunization and communicable disease status • Verification of current clinical competence • Based on Supervisory evaluation of clinical competence per the job description
  • 29. Temporary Privileges • Privileges SHOULD: • Be granted in accordance with FTCA Guidelines • Be approved by the CEO upon the recommendation of appropriate department head • Privileges SHOULD NOT: • Exceed more than 90 days • Be renewed • Be granted in lieu of expired credentials
  • 30. Credentialing and Privileging Activities Initial Privileging and Reappointment  Privileging is completed after the health center has verified all necessary credentials for a practitioner  Re-appointment is completed on a recurring basis (i.e., every two years), as determined by the health center  Re-appointment involves the verification of expired credentials and re-privileging of practitioners  The health center determines who has approval authority for credentialing and privileging
  • 31. Credentialing and Privileging Activities Delineation of Privileges (Clinical Services) • Subsequent to credentials verification, the practitioner submits a request for clinical privileges, which includes completion of a Delineation of Clinical Services Form. • The Delineation of Clinical Services Form: • Includes only services and sites listed in the health center’s approved scope of project • Is specific to each specialty within the health center (i.e., Dental, Behavioral Health, Family Practice, Obstetrics) • Outlines Requested Services, Non-Requested Services, Approved Services and Non-Approved Services
  • 33. Peer Review Peer Review must be completed:  On a “routine and regular basis” ◦ Considered a quarterly QI Assessment per the Site Visit Protocol  Between providers within the same specialty who are similarly credentialed  In all clinical areas within the health center’s scope of project (Family Medicine, Obstetrics, Dental, Behavioral Health)  Using an industry standard tool that clearly evaluates the quality of services provided and does not only perform administrative review  Using a blinded methodology that ensures confidentiality of patient information
  • 34. Peer Review – Basic Concepts The results of Peer Review must be part of the health center’s Quality Improvement Program and incorporated into the LIP reappointment process, which is evidenced by documentation in: • Credentialing and Privileging Policy • Peer Review Policy • Quality Improvement Plan • Credentialing and Privileging Files
  • 36. Factors to Consider  The Credentialing and Privileging Policy does NOT require board approval – Best Practice? No  Credentialing and privileging of clinical staff (including LIPs) does not require board approval – Best Practice? No  The health center determines who has approval authority for credentialing and privileging  If the health center does not have other clinical staff, they do not need to be included in the procedures
  • 37. Factors to Consider  The Compliance Manual is the minimum standard for credentialing and privileging of clinical staff  Federal Tort Claims Act (FTCA) regulations are the highest standard for credentialing and privileging of clinical staff  Follow the guidelines and examples for primary and secondary source verification outlined in the HRSA Credentialing and Privileging File Review Resource
  • 38. Factors to Consider  An NPDB Query is required for ALL categories of clinical staff – No longer “as reportable”  Health Centers must ensure contracted and referral providers are appropriately credentialed and privileged ◦ Contracts/referral arrangements must include provisions to support credentialing and privileging of the contracted/referral providers; or ◦ Review the contracted organization’s credentialing and privileging process
  • 40. Additional Resources Compliatric https://www.compliatric.com/ HRSA Health Center Compliance Manual Health Center Program Compliance Manual | Bureau of Primary Health Care (hrsa.gov) HRSA SiteVisit Protocol Health Center Program SiteVisit Protocol | Bureau of Primary Health Care (hrsa.gov) HRSA Credentialing and Privileging File Review Resource Credentialing and Privileging File Review Resource (hrsa.gov)
  • 42. Michelle Layton BSN, MBA Infidium Healthcare Solutions, LLC michellel@infidiumhs.com Direct: 214-766-0333