The Credentialing And Privileging Toolbox
TheCredentialingand PrivilegingToolboxField-Tested Documents for Compliance,Management, and Process ImprovementMerella Schandl, BS, CPMSM, CPCS
Credentialingand PrivilegingToolboxField-Tested Documents for Compliance,Management, and Process ImprovementMerella Schandl, BS, CPMSM, CPCS
The Credentialing and Privileging Toolbox: Field-Tested Documents for Compliance, Management,and Process Improvement is published by HCPro, a division of BLR.Copyright 2017 HCPro, a division of BLRAll rights reserved. Printed in the United States of America.5 4 3 2 1ISBN: 978-1-68308-203-3No part of this publication may be reproduced, in any form or by any means, without prior writtenconsent of HCPro or the Copyright Clearance Center (978-750-8400). Please notify us immediatelyif you have received an unauthorized copy.HCPro provides information resources for the healthcare industry.HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and JointCommission trademarks.Merella Schandl, BS, CPMSM, CPCS, AuthorDelaney Rebernik, EditorErin Callahan, Vice President, Product Development & Content StrategyMatt Sharpe, Production SupervisorVincent Skyers, Design Services DirectorVicki McMahan, Sr. Graphic DesignerJake Kottke, Layout/Graphic DesignJason Gregory, Cover DesignerAdvice given is general. Readers should consult professional counsel for specific legal, ethical, orclinical questions.Arrangements can be made for quantity discounts. For more information, contact:HCPro100 Winners Circle Suite 300Brentwood, TN 37027Telephone: 800-650-6787 or 781-639-1872Fax: 800-785-9212Email: customerservice@hcpro.comVisit HCPro online at www.hcpro.com and www.hcmarketplace.com.
Table of ContentsAbout the Author.vAbout the Contributors.viiIntroduction.xiChapter 1: Workflow Management.1Tool 1.1 Application Checklist for Initial Appointments and Reappointments. 6Tool 1.2 Physician and APP Application Checklist. 8Tool 1.3 Initial Appointment/Reappointment Recommendation Form. 9Tool 1.4 Recommendation and Approval Form for Medical Staff Appointment and Clinical Privileges . 11Tool 1.5 Confidential Professional Peer Review Reference and Competence Validation Form . 13Tool 1.6 Teleradiology Core Privileges . 16Tool 1.7 Worksheet for Consideration of New Procedure/Privilege. 20Tool 1.8 New Practitioner Onboarding Checklist. 21Tool 1.9 Physician Orientation Policy. 24Tool 1.10 Medical Staff and Non-Physician Practitioner Orientation Agenda. 26Tool 1.11 Resident and Postgraduate Clinical Student Rotation Checklist. 28Tool 1.12 Student Preceptorship Checklist. 29Chapter 2: Medical Staff Governance.31Tool 2.1 Hospital Medical Staff and Limited Health Practitioner (LHP) Categories:Responsibilities, Prerogatives, Fees. 36Tool 2.2 Credentials Committee Annual Report. 37Tool 2.3 Bylaws Language for Granting Temporary Privileges. 39Tool 2.4 Telemedicine Bylaws Language. 40Tool 2.5 More Telemedicine Bylaws Language. 42Tool 2.6 Bylaws/Rules and Regulations: Completion of Medical Records. 43Tool 2.7 Bylaws/Rules and Regulations: H&P Performance and Documentation . 45Tool 2.8 Medical Staff Credentialing and Privileging Policy for Moderate Sedation. 47Tool 2.9 Hospital Affiliation Query Policy. 48Tool 2.10 Telemedicine Credentialing Policy. 49 2017 HCProThe Credentialing and Privileging Toolboxiii
Chapter 3: Practitioner-Facing Communications.53Tool 3.1 Request for New Applicants’ Proof of Identification. 57Tool 3.2 Onboarding Welcome Letter. 59Tool 3.3 Deficient H&P Completion Letter. 60Tool 3.4 Medical Staff Suspension Letter. 61Tool 3.5 Memo to the Medical Staff: First Communication Regarding a New Technology. 62Tool 3.6 Letter to Medical Staff: Follow-Up Communication Regarding a New Technology. 63Tool 3.7 Meeting Minutes: Robotic Surgery Steering Committee. 65Chapter 4: Credentialing and Privileging Roles and Responsibilities.69Tool 4.1 MSP Job Description: Director, Credentialing and Data Center. 74Tool 4.2 MSP Job Description: Manager, Credentialing and Data Center. 76Tool 4.3 MSP Job Description: Supervisor, Credentialing and Data Center. 78Tool 4.4 Medical Staff Officer Job Description: President. 80Tool 4.5 Medical Staff Officer Job Description: Vice President. 83Tool 4.6 Medical Staff Officer Job Description: Secretary-Treasurer. 86Tool 4.7 Department Chair Assessment Form. 88Tool 4.8 Job Analysis Form. 89Tool 4.9 Annual Competency Validation: Credentialing Coordinator. 90Tool 4.10 Credentialing Specialist Performance Improvement Plan . 94Chapter 5: Strategies for Addressing Top Focus Areas and Trouble Spots.95Tool 5.1 Case Study: Creating a Lean Credentialing Process.100Tool 5.2 Value Stream Maps for CVO Credentialing File TAT Reduction Initiative.105Tool 5.3 Policy for Credentialing and Privileging Nonindependent PractitionersThrough the Human Resources Department.107Tool 5.4 Supervising Physician/Physician Assistant Collaborative Agreement.109Tool 5.5 APP Competence Assessment: Leveraging Collegiality to Improve Compliance .112Tool 5.6 Allied Health Peer Review Case Rating Form: Nurse Practitioner (NP).116Tool 5.7 Focused Professional Practice Evaluation (FPPE) Report.118Tool 5.8 Credentials File Summary of Adverse or Potentially Adverse Issues.121Chapter 6: Regulatory and Accreditation Compliance.123Tool 6.1 Policy & Procedure: Monitoring of Medicare/Medicaid Sanctionsand State Sanctions or Limitations on Licensure. 126Tool 6.2 Provider 360 Professional Practice Evaluation Summary. 129Tool 6.3 Audit Tool for New Applicant Credentials File. 130Tool 6.4 Audit Tool for Reapplicant Credentials File.131Tool 6.5 Audit Tool for Credentials File Expirables. 132Tool 6.6 Summary Credentials File Chart Audit: Initial Applicant. 133Tool 6.7 Medical Staff Services Credentialing Audit Tool. 135Tool 6.8 Medical Affairs Dashboard. 136ivThe Credentialing and Privileging Toolbox 2017 HCPro
About the AuthorMerella Schandl, BS, CPMSM, CPCSMerella Schandl, BS, CPMSM, CPCS, is a professional speaker,author, and independent consultant with 25 years of healthcareexperience. Schandl entered the industry in 1993 while working toachieve an associate of science degree. While serving in healthcaremanagement positions, she earned a Bachelor of Science degreein workforce education and development from Southern IllinoisUniversity Carbondale (SIU-C). After graduating SIU-C, Schandlmaintained her role as director while growing the medical affairsdepartment into an integrated healthcare environment. She wenton to assist in the building of a new hospital in Shiloh, Illinois.A current instructor for the National Association Medical StaffServices (NAMSS), Schandl contributed to the development ofthe NAMSS Leadership Certificate Program and was the 2015 recipient of the NAMSS Golden Key Award.She has held several leadership positions in the Missouri Association of Medical Staff Services (MoAMSS)and in MoAMSS’ Greater St. Louis Area chapter. She is also the 2017 recipient of the Graduate HealthcareManagement award from the Mid-America Healthcare Executives Forum.Schandl has had articles published in Synergy. She is currently completing a Master of HealthcareAdministration degree at Lindenwood University in Belleville, Illinois. 2017 HCProThe Credentialing and Privileging Toolboxv
About the ContributorsCanyon Vista Medical CenterCanyon Vista Medical Center is a 100-bed, Joint Commission–accredited acute care hospital and Level III trauma center in Sierra Vista, Arizona. Roughly 85% of the facility’s more than 200 credentialed practitioners arelicensed independent practitioners, while the rest are independent and dependent allied health professionals. The hospital, which employs 1.5 full-time medical staff professionals (MSP), organizes its medical staffinto three departments and eight service lines. Its governance groups include a medical executive committee, a credentialing committee, a peer review committee, and a code of conduct committee. Canyon Vistais a member hospital of RCCH HealthCare Partners, which has 17 regional health systems in 12 states and2,000 affiliated practitioners.Special thanks to Joyce L. Moore, MPA, CPCS, CPMSM, Canyon Vista’s medical staff director, for sharingthe facility’s form featured in this toolbox.Ellis MedicineEllis Medicine is a 438-bed community and teaching healthcare system serving New York’s Capital Region.The system has four campuses—Ellis Hospital, Ellis Health Center, Bellevue Woman’s Center, and MedicalCenter of Clifton Park—five additional service locations, more than 3,300 employees, and more than 700medical staff members. Ellis offers an array of inpatient and outpatient services, including cardiac, cancer,emergency, neuroscience, and women’s services. Its medical staff services team consists of two cre dentialingspecialists and one manager.Special thanks to Kathy Tafel, credentialing and privileging consultant and Ellis’ former medical dental staffservices manager, for sharing the facility’s forms featured in this toolbox with the organization’s permission.Flagler HospitalFlagler Hospital is a 335-bed, Joint Commission–accredited acute care facility in St. Augustine, Florida. Its480 credentialed practitioners include 40 telemedicine providers, 43 nurse practitioners, 25 physician assistants, and 36 certified registered nurse anesthetists.Flagler’s affiliated practitioners are organized into nine departments and three department divisions, eachof which is overseen by a chief. Its governance structure features 16 committees and subcommittees, including bylaws, cancer, cardiovascular, clinical quality review, continuing education, credentials, and critical care. The medical staff services department consists of one director, one lead credentialing specialist,one credentialing specialist, and one special-projects coordinator.Special thanks to Terry Wilson, BS, CPMSM, CPCS, Flagler’s director of medical staff services, for sharingthe facility’s forms featured in this toolbox. 2017 HCProThe Credentialing and Privileging Toolboxvii
Hennepin County Medical CenterHennepin County Medical Center, operated by Hennepin Healthcare System, Inc., is a 484-bed, JointCommission–accredited teaching hospital in Minneapolis, Minnesota, that provides acute care and psychiatric care. The facility, which serves as a Level 1 adult trauma center and Level 1 pediatric trauma center,also includes a system of primary care and retail clinics throughout the county. Hennepin’s five-person credentialing staff processes applications for approximately 1,000 practitioners (roughly 600 physiciansand 400 non-MD independent practice providers). The medical staff is organized into 17 departments.Special thanks to Gerry Valeri, CPCS, senior credentialing specialist at Hennepin, for sharing the facility’sform featured in this toolbox.HighPoint Health SystemHeadquartered in Gallatin, Tennessee, HighPoint Health System has four member facilities throughout thestate: Sumner Regional Medical Center, the 155-bed flagship hospital; Riverview Regional Medical Center,a 25-bed critical access hospital; Trousdale Medical Center, a 10-bed critical access hospital; and LivingstonRegional Hospital, a 114-bed acute care hospital. Other affiliates include homecare, hospice, and severalphysician practices. HighPoint credentials approximately 459 practitioners, including 73 advanced practiceprofessionals.Special thanks to Kelly Anderson, credentialing specialist at Sumner, for sharing the facility’s form featured in this toolbox, which is under consideration for implementation at the three other hospitals in theHighPoint system.Hugh Chatham Memorial HospitalHugh Chatham Memorial Hospital is an 80-bed, Joint Commission–accredited facility and primary strokecenter. In addition to its main campus in Elkin, North Carolina, the hospital has more than 20 clinicalcenters providing services across the care continuum. Hugh Chatham’s one full-time MSP credentials 265affiliated practitioners, including 65 active physicians, 60 allied health professionals, four locum tenenspractitioners, and 61 telemedicine practitioners. The facility’s medical staff is organized into five clinicaldepartments (family practice/medicine, surgery, ED, OB/GYN, and radiology) and is governed by the medical executive committee, the credentials committee, and the board of trustees.Special thanks to Tracey Russell, CPCS, medical staff coordinator at Hugh Chatham, for sharing the facility’s form featured in this toolbox.Kansas Heart HospitalKansas Heart Hospital is a 54-bed acute care facility in Wichita, Kansas, that provides specialized cardiovascular, surgical, and vascular services. The hospital, which undergoes CMS surveys and employs one full-timeMSP, credentials 250 practitioners, about 40 of whom are advanced practitioner professionals (physician assistants and advanced practice registered nurses). Special thanks to Taylor Diefenderfer, BA, BS, former medical staff coordinator at Kansas Heart, for sharing the facility’s form featured in this toolbox.Kathy Matzka, CPMSM, CPCS, FMSPKathy Matzka, CPMSM, CPCS, FMSP, is a speaker, consultant, and writer with 30 years of experiencein credentialing, privileging, and medical staff services. Matzka worked for 13 years as a hospital medical staff coordinator before venturing out on her own as a consultant, writer, and speaker. She holdsviiiThe Credentialing and Privileging Toolbox 2017 HCPro
About the Contributorsc ertification from the National Association Medical Staff Services (NAMSS) in both medical staff management and provider credentialing. She is one of the first recipients of the NAMSS Fellow Designation.Matzka is author of HCPro’s The Clinician’s Quick Guide to Credentialing and Privileging and coauthor ofHCPro’s Verify and Comply, Sixth Edition. She’s written and edited a number of additional books related tomedical staff services. Matzka has performed extensive work with NAMSS’ education committee developing and editing educational materials related to the field, including CPCS and CPMSM Certification ExamPreparatory Courses. She also serves as an instructor for NAMSS.MercyMercy is the fifth largest Catholic healthcare system in the United States, operating 43 acute care and specialty hospitals and more than 700 physician practices and outpatient facilities throughout Arkansas, Kansas,Missouri, and Oklahoma. Most, but not all, Mercy hospitals are accredited by The Joint Commission.The Credentialing and Privileging Toolbox features resources from two specific Mercy affiliates.Mercy Hospital St. LouisMercy Hospital St. Louis is an 859-bed facility and Level I trauma center in Creve Coeur, Missouri. Thefacility’s 1,749 credentialed practitioners are organized into 13 departments and 34 divisions. Medical staffgovernance groups include department committees, a credentials subcommittee, a medical executive committee, and a board of trustees. The hospital has five full-time MSPs.Special thanks to Tracy Brooks, CPMSM, CPCS, Mercy Hospital St. Louis’ manager of medical staff services, for sharing the facility’s forms featured in this toolbox.Mercy Credentialing and Data CenterMercy Credentialing and Data Center is the Springfield, Missouri–based centralized credentialing organization (CVO) for 40 Mercy facilities spanning the care continuum. Internal customers include acute carehospitals, critical access hospitals, ambulatory surgery centers, specialty hospitals, and clinics. Betweeninternal clients and delegated credentialing agreements, the 36-person CVO credentials roughly 12,000practitioners.Special thanks to Diane Meldi, MBA, CPCS, CPMSM, executive director of medical staff services for MercyQuality & Safety Center, and Allison Rhodes, CPMSM, CPCS, director of Mercy’s Credentialing and DataCenter, for sharing the CVO’s forms featured in this toolbox.OrthoIllinoi
and in MoAMSS’ Greater St. Louis Area chapter. She is also the 2017 recipient of the Graduate Healthcare Management award from the Mid-America Healthcare Executives Forum. Schandl has had articles published in Synergy. She is currently completing a Master of Healthcare Administration degree at Lindenwood University in Belleville, Illinois.
Sep 04, 2015 · Credentialing, Privileging, Clinical Competence, and Peer Review 9/4/2015 5 9 2015 ECRI INSTITUTE What is the Difference Between Credentialing and Privileging? Credentialing Step 1 Vett
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