As a follow-up to our webinar, Laurel McCourt, MD, former Joint Commission Surveyor, and Sara Cameron, CPMSM, CPCS, Senior Director, Professional Services, Hardenbergh Group, answer your questions about how to successfully prepare for an upcoming survey.
Q1: How are Medical Staffs moving to a 3-year reappointment cycle when CMS interpretative guidelines state “surgical privileges should be reviewed and updated at least every two years.” Does this include specialties like Gastroenterology that perform invasive procedures?
A1: According to hospital accrediting organizations and Centers for Medicare & Medicaid Services (CMS) standards, hospitals are required to review and update surgical specialties, including those in fields like Gastroenterology (GI) that perform invasive procedures, every two years. This can pose a challenge for hospitals that follow a three-year reappointment cycle for their medical staff.
To address this discrepancy and remain compliant with CMS standards, hospitals typically implement separate two-year review cycles specifically for surgical specialties. This ensures that necessary evaluations and updates are conducted for these fields within the mandated timeframe while maintaining the overall three-year reappointment cycle for the broader medical staff.
Here are some approaches hospitals may take:
In summary, while the general medical staff may follow a three-year reappointment cycle, hospitals often address the CMS requirement for a two-year review of surgical specialties by implementing specific measures such as biennial reviews, interim evaluations, dedicated subcommittees, or integrated systems to ensure these specialties are evaluated and updated in compliance with regulatory standards.
Q2: For practitioners who do not practice frequently at a facility, is it acceptable to obtain their clinical activity data from another institution they spend a significant amount of time at?
A2: Yes, according to hospital accrediting organizations like The Joint Commission (TJC) and the Healthcare Facilities Accreditation Program (HFAP), it is acceptable and often necessary to obtain clinical activity data from another institution where the practitioner spends a significant amount of time if they do not frequently practice at your facility. This practice is known as obtaining “primary source verification” or “secondary source verification,” depending on the workflow. To ensure compliance and maintain high standards of quality care, here are key steps to follow:
Q3: Do you recommend having the surveyor attend the Credentials, MEC, and/or Board meeting if it takes place during the survey?
A3: No, surveyors have a strict schedule to adhere to and limited time at the facility. It is not necessary to attend.
Q4: For organizations that have changed from a two-year to a three-year reappointment timeframe, what might a surveyor be looking for when reviewing these credentialing files?
A4: Your surveyor will confirm changes to the term of reappointment do not contradict state law and the appropriate process were followed to change governing documents, i.e., Medical Staff Bylaws and Policies. They will also ensure no provider exceeded their appointment term before these changes in process were approved by the governing board.
Q5: When reviewing credentialing files, do surveyors prefer the documents be compiled in a PDF or do they prefer seeing the MSP navigate the credentialing database?
A5: It depends. If you can easily navigate through the database, this is acceptable. However you choose to present the files, they need to be easy to see and projected on a screen if electronic.
Q6: Why does it seem like different surveyors look for different standards? We had two surveys completed and one surveyor had no finding while the second cited our facility.
A6: Surveyors are trained to interpret standards differently during different survey cycles. Be sure you are up to date on the latest interpretation of a standard, i.e., FAQs, etc. If you feel strongly you are in compliance, work with the quality manager to submit a clarification or ask for a clarifying call during the survey.
Q7: What tips you can give on reappointment steps for tele by proxy providers?
A7: While TJC does not use the term, “tele by proxy,” they do specify mechanisms for credentialing telemedicine providers. TJC: MS.13.01.01 references three mechanisms to perform credentialing of telehealth providers. Let the surveyor know which you chose. For example, the originating site privileges practitioners using credentialing information from the distant site if the distant site is a Joint Commission–accredited organization. The distant-site practitioner has a license that is issued or recognized by the state in which the patient is receiving telemedicine services.
Telemedicine services are often contracted, and the contract should include what the distant site will provide to the originating site for credentialing.
Q8: What are some best practices for a small hospital to stay in compliance with FPPE1? Some of what TJC requests is not possible for us to provide.
A8: Assuming FPPE1 means initial FPPE, the medical staff must determine the measures to track for FPPE based on the privileges granted. If a provider is actively practicing, then FPPE should be resolved in the first three months. TJC FAQs define what is acceptable for FPPE and OPPE when the provider has low volume at your facility.
“When practitioner activity at the ‘local’ level is low or limited, supplemental data may be used from another CMS-certified organization where the practitioner holds the same privileges.”
This FAQ and additional information related to low volume providers can be found here.
Q9: What can we do to make the surveyor’s job easier or more efficient?
A9: Ensure you have all the required documentation for the files chosen. This includes:
Schedule your Medical Staff Leaders during the medical staff session. Make sure everyone knows their role! Practice!!
Q10: What should I do when we receive a finding?
A10: A finding can be your friend! For example, if you have been asking for resources to more fully implement OPPE, a finding should lead to those resources being made available. In the case of a serious finding (lack of license or multiple providers practicing without appropriate privileges), leadership will become involved.
Actively work towards resolving the problem and achieving compliance. Then, investigate the issue in more detail to identify the root cause. Gather necessary resources to address it and prevent future occurrences.
Need help preparing for an upcoming survey? Our consultants are experts with extensive experience in regulatory compliance. Contact Us for more information.
Interested in viewing a recording of the webinar presented by Dr. McCourt and Sara Cameron? Click Here to watch.
