Provider Competency In Privileging Resource
ProviderCompetency inPrivilegingKathy Matzka, CPMSM, CPCSConsultant/Speaker1304 Scott Troy RoadLebanon, IL 62254kathymatzka@kathymatzka.comwebsite: www.kathymatzka.comPhone (618) 624-8124
BIOGRAPHICAL SKETCH, KATHY MATZKA, CPMSM, CPCSKathy Matzka, CPMSM, CPCS is a speaker, consultant,and writer with over 20 years of experience incredentialing, privileging, and medical staff services. Sheholds certification by the National Association MedicalStaff Services (NAMSS) in both Medical StaffManagement and Provider Credentialing. Ms. Matzkaworked for 13 years as a hospital medical staff coordinatorbefore venturing out on her own as a consultant, writer,and speaker.Ms. Matzka has authored a number of books related tomedical staff services including both the fifth and sixtheditions of the Compliance Guide to Joint CommissionMedical Staff Standards, and The Medical Staff MeetingCompanion Tools and Techniques for Effective Presentations. For the past eight years,she has been the contributing editor for the credentialing industry’s premiercredentialing publication, The Credentials Verification Desk Reference and, recently, itscompanion website The Credentialing and Privileging Desktop Reference.She has performed extensive work with NAMSS’ Library Team developing and editingeducational materials related to the field including CPCS Certification Exam PreparatoryCourse, NAMSS Core Curriculum, PMSM and PCS Professional DevelopmentWorkshops, and Independent Study Programs. These programs are essentialeducational tools for both new and seasoned medical services professionals. She alsoserves as a speaker and instructor for NAMSS.Ms. Matzka shares her expertise by serving on the editorial advisory boards for threepublications - Briefings on Credentialing, Credentialing, Peer Review Legal Insider, andAdvisor for Medical and Professional Staff Services.Ms. Matzka is a highly-regarded industry speaker, and in this role has developed andpresented numerous programs for professional associations, hospitals, and hospitalassociations on a wide range of topics including provider credentialing and privileging,medical staff meeting management, peer review, negligent credentialing, providercompetency, and accreditation standards.In her spare time, Ms. Matzka takes pleasure in spending time with her family, listeningto music, singing with her church worship team, traveling, hiking, fishing, and otheroutdoor activities.
Table of ContentsOverview and Introduction.1Definitions of Credentialing and Recredentialing .1Why Do We Do It? .1What Do Accrediting and Regulatory Bodies Require?.2Primary Source .14Developing an Effective Privileging Process .16Clinical Privileges.16History of Privileging .16Medicare CoPs Regarding Privileges .16Joint Commission Standards Regarding Privileges .17Privileging Systems.20Sample Privilege Forms .21Category Example .22Core Privileges Example.23Requests for New Privileges .42Evaluating and Documenting Practitioner Competency.44What Is Competence? .44Current Competence.44Work History and Affiliations .45Sample Letter: Facility Privileges and Competency Validation .46Sample Letter for Verification of Training.48Peer Recommendations .51Provisional Appointment .54Joint Commission Standards for FPPE/OPPE .55Sample Ongoing and Focused Professional Practice Evaluation Policy .67Documenting Recommendations.71Sample language for medical staff minutes: .71Sample language for Board minutes:.71Recommendation and Approval Form for Medical Staff Appointment and ClinicalPrivileges .72Proctoring .73Peer Review Policy: Definition of Peer.75Sample Policy Regarding Proctoring .76Sample Proctorship Forms.79Proctoring Summary Report.81Medical Proctor’s Report Sample 1.82Medical Proctor’s Report Sample 2.83
Provider Competency in PrivilegingOVERVIEW AND INTRODUCTIONDefinitions of Credentialing and RecredentialingNAMSSCredentialing is the process of obtaining, verifying and assessing the qualifications of ahealthcare practitioner to provide patient care services in or for a healthcare entity.Recredentialing is the process of obtaining and evaluating data to support the continuedcompetence of the healthcare practitioner to provide patient care services in or for ahealthcare organization.Source NAMSS Core CurriculumJoint CommissionThe Glossary in Joint Commission manual defines credentialing as the process ofobtaining, verifying and assessing the qualifications of a healthcare practitioner toprovide patient care services in or for a healthcare entity. The introduction to thecredentialing standards includes more detail: “Credentialing involves the collection,verification, and assessment of information regarding three critical parameters; currentlicensure; education and relevant training; and experience, ability, and currentcompetence to perform the requested privilege(s). Verification is sought to minimize thepossibility of granting privilege(s) based on the review of fraudulent documents.”Why Do We Do It?There are a number of reasons for credentialing providers.Patient ProtectionThis is the number one concern. The patient is put before anything else. If you look atthe mission statement of any healthcare organization, you will find language that refersto providing high quality patient care. This can only be accomplished by allowing onlythose providers who meet certain high standards to treat patients.Risk Management ConcernsIf the patient suffers an adverse outcome at the hospital, the hospital can be held liable.If the provider has problems that would have been revealed by credentialing, butcredentialing was not performed, the hospital may be liable for any patient harm causedby the substandard clinician.Provider Competency in Privileging - Kathy Matzka, CPMSM, CPCS1
The case Darling v. Charleston Community Memorial Hospital, 211 N.E.2d 253 (Ill.1965) set the precedent that a hospital can be held directly liable for negligent failure toproperly credential a provider.In this case, the patient alleged that the hospital was negligent in the following areas: permitting the physician to treat his orthopedic injuries:not requiring the physician to update operative procedures;failing, through it’s medical staff, to exercise adequate supervision, especially sinceDr. Alexander had been placed on emergency duty by the hospital; andnot requiring consultation especially after complications set in.The hospital’s defense was that only the physician can practice medicine, therefore thehospital cannot be liable for the acts of a physician where reasonable care wasexercised in selecting the physician.The Illinois Supreme Court sided with the patient noting that hospitals do more than justprovide facilities for treatment, but assume certain responsibilities for the care of thepatient.Required by accrediting and regulatory agenciesAnother reason healthcare organizations credential is that it is required by accreditingbodies and regulatory agencies. The Joint Commission (Joint Commission) and theNational Committee for Quality Assurance (NCQA) standards require credentialing ofproviders.What Do Accrediting and Regulatory Bodies Require?Joint CommissionJoint Commission medical staff standards require any individual permitted by law andby the organization to provide care, treatment, and services without direction orsupervision to be credentialed and privileged. These individuals are known as licensedindependent practitioners (LIP). Although the granting of clinical privileges to these LIPsis required, Joint Commission does not require that they be appointed to the medicalstaff. This is left up to the hospital and varies by organization dependent upon theservices provided by the facility, state regulations, and the mind-set of the medical staffand community. The credentialing process for non-physician LIPs is usually similar tothat of a physician appointee due to the degree of patient care provided without directsupervision.Provider Competency in Privileging - Kathy Matzka, CPMSM, CPCS2
Medicare Conditions of Participation§482.12 CONDITION OF PARTICIPATION: GOVERNING BODYThe hospital must have an effective governing body legally responsible for the conductof the hospital as an institution. If a hospital does not have an organized governingbody, the persons legally responsible for the conduct of the hospital must carry out thefunctions specified in this part that pertain to the governing body.Interpretive Guidelines §482.12The hospital must have only one governing body and this governing body is responsiblefor the conduct of the hospital as an institution. In the absence of an organizedgoverning body, there must be written documentation that identifies the individual orindividuals that are responsible for the conduct of the hospital operations.§482.12(a) Standard: Medical StaffThe governing body must ensure the medical staff requirements are met.§482.12(a)(1) [The governing body must:] Determine, in accordance with State law,which categories of practitioners are eligible candidates for appointment to the medicalstaff;Interpretive Guidelines §482.12(a)(1)The medical staff must, at a minimum, be composed of physicians who are doctors ofmedicine or doctors of osteopathy. In addition, the medical staff may include otherpractitioners included in the definition in Section 1861(r) of the Social Security Act of aphysician: Doctor of medicine or osteopathy; Doctor of dental surgery or of dental medicine; Doctor of podiatric medicine; Doctor of optometry; and a Chiropractor.In all cases, the practitioners included in the definition of a physician must be legallyauthorized to practice within the State where the hospital is located and providingservices within their authorized scope of practice. In addition, in certain instances theSocial Security Act and regulations attach further limitations as to the type of hospitalservices for which a practitioner may be considered to be a “physician.” See 42 CFR482.12(c)(1) for more detail on these limitations.The governing body has the flexibility to determine whether other types of practitionersincluded in the definition of a physician are eligible for appointment to the medical staff.Provider Competency in Privileging - Kathy Matzka, CPMSM, CPCS3
Furthermore, the governing body has the authority, in accordance with State law, toappoint some types of non-physician practitioners, such as nurse practitioners,physician assistants, certified registered nurse anesthetists, and midwives, to themedical staff. Practitioners, both physicians and non-physicians, may be grantedprivileges to practice at the hospital by the governing body for practice activitiesauthorized within their State scope of practice without being appointed a member of themedical staff.§482.12(a)(2) [The governing body must:] Appoint members of the medical staff afterconsidering the recommendations of the existing members of the medical staff;Interpretive Guidelines §482.12(a)(2)The governing body determines whether to grant, deny, continue, revise, discontinue,limit, or revoke specified privileges, including medical staff membership, for a specificpractitioner after considering the recommendation of the medical staff. In all instances,the governing body’s determination must be consistent with established hospitalmedical staff criteria, as well as with State and Federal law and regulations. Only thehospital’s governing body has the authority to grant a practitioner privileges to providecare in the hospital.§482.12(a)(3) [The governing body must:] Assure that the medical staff has bylaws;Interpretive Guidelines §482.12(a)(3)The governing body must assure that the medical staff has bylaws and that those bylawscomply with State and Federal law and the requirements of the Medicare hospitalConditions of Participation.§482.12(a)(4) [The governing body must:] Approve medical staff bylaws and other medicalstaff rules and regulations;Interpretive Guidelines §482.12(a)(4)The governing body decides whether or not to approve medical staff bylaws submittedby the medical staff. The medical staff bylaws and any revisions must be approved bythe governing body before they are considered effective.§482.12(a)(5) [The governing body must:] Ensure that the medical staff is accountableto the governing body for the quality of care provided to patients;Interpretive Guidelines §482.12(a)(5)The governing body must ensure that the medical staff as a group is accountable to thegoverning body for the quality of care provided to patients. The governing body isProvider Competency in Privileging - Kathy Matzka, CPMSM, CPCS4
responsible for the conduct of the hospital and this conduct includes the quality of careprovided to patients.All hospital patients must be under the care of a practitioner who meets the criteria of 42CFR 482.12(c)(1)and who has been granted medical staff privileges, or under the careof a practitioner who is directly under the supervision of a member of the medical staff.All patient care is provided by or in accordance with the orders of a practitioner who hasbeen granted privileges in accordance with the criteria established by the governingbody, and who is working within the scope of those granted privileges.§482.12(a)(6) [The governing body must:] Ensure the criteria for selection are individualcharacter, competence, training, experience, and judgment; andInterpretive Guidelines §482.12(a)(6)The governing body must assure that the medical staff bylaws describe the privilegingprocess to be used by the hospital. The process articulated in the medical staff bylaws,rules, or regulations must include criteria for determining the privileges that may begranted to individual practitioners and a procedure for applying the criteria to individualpractitioners that considers: Individual character; Individual competence; Individual training; Individual experience; and Individual judgment.The governing body must ensure that the hospital’s bylaws governing medical staffmembership or the granting of privileges apply equally to all practitioners in eachprofessional category of practitioners.§482.12(a)(7) [The governing body must:] Ensure that under no circumstances is theaccordance of staff membership or professional privileges in the hospital dependentsolely upon certification, fellowship or membership in a specialty body or society.Interpretive Guidelines §482.12(a)(7)In making a judgment on medical staff membership, a hospital may not rely solely onthe fact that a MD/DO is, or is not, board-certified. This does not mean that a hospital isprohibited from requiring board certification when considering a MD/DO for medical staffmembership, but only that such certification must not be the only factor that the hospitalconsiders. In addition to matters of board certification, a hospital must also considerother criteria such as training, character, competence and judgment. After analysis of allof the criteria, if all criteria are met except for board certification, the hospital has thediscretion to decide not to select that individual to the medical staff.Provider Competency in Privileging - Kathy Matzka, CPMSM, CPCS5
§482.22 CONDITION OF PARTICIPATION: MEDICAL STAFFThe hospital must have an organized medical staff that operates under bylawsapproved by the governing body and is responsible for the quality of medical careprovided to patients by the hospital.Interpretive Guidelines §482.22The hospital may have only one medical staff for the entire hospital (including allcampuses, provider -based locations, satellites, remote locations, etc.). The medicalstaff must be organized and integrated as one body that operates under one set ofbylaws approved by the governing body. These medical staff bylaws must apply equallyto all practitioners within each category of practitioners at all locations of the hospitaland to the care provided at all locations of the hospital. The single medical staff isresponsible for the quality of medical care provided to patients by the hospital.§482.22(a) Standard: Composition of the Medical StaffThe medical staff must be composed of doctors of medicine or osteopathy and, inaccordance with State law, may also be composed of other practitioners appointed bythe governing body.Interpretive Guidelines §482.22(a):The medical staff must at a minimum be composed of physicians who are doctors ofmedicine or doctors of osteopathy. In addition, the medical staff may include otherpractitioners included in the definition in Section 1861(r) of the Social Security Act of aphysician: Doctor of medicine or osteopathy;Doctor of dental surgery or of dental medicine;Doctor of podiatric medicine;Doctor of optometry; and aChiropractor.In all cases the practitioners included in the definition of a physician must be legallyauthorized to practice within the State where the hospital is located and providingservices within their authorized scope of practice. In addition, in certain instances theSocial Security Act and regulations attach further limitations as to the type of hospitalservices for which a practitioner may be considered to be a “physician.” See§482.1
All hospital patients must be under the care of a practitioner who meets the criteria of 42 CFR 482.12(c)(1)and who has been granted medical staff privileges, or under the care of a practitioner who is directly under the supervision of a member of the medical staff.
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
UNESCO EDUCATION SECTOR 5 Systems thinking competency Anticipatory competency Normative competency Strategic competency Collaboration competency Critical thinking Self-awareness competency Integrated problem-solving competency Promotion of key competencies for sustainability ESD enables all individuals to contribute to achieving the SDGs by equipping them
1 Introduction 1 1.1 Background of the Study 1 1.1.1 Definition and meaning of Competency 2 1.1.2 History and Evolution of Competencies 8 1.1.3 Competencies for Sales Staff 12 1.1.4 The Sales Competency Model 19 1.1.5 ASTD Competency Model 20 1.1.6 Competency Mapping 24 1.1.7 Model of Competency Mapping 27
2.1 Competency Dictionary; in which competencies are described according to a specific competency model. The Competency dictionary is established according to the following format: Competency clusters: Represent a group of competencies that are naturally linked with one another as well as specific areas in HR.
This document provides healthcare professionals, hospitals, healthcare systems and non-hospital affiliated centers with credentialing and privileging guidelines for providers who attend hyperbaric oxygen treatments (HBO2). The goal is to ensure optimal patient safety and the appropriate utilization of hyperbaric medicine. Hyperbaric Medicine
Core Competency Area 5: Observation and Assessment 43 Core Competency Area 6: Diversity and Dual Language Learners 47 Core Competency Area 7: Family and Community Relationships 50 Core Competency Area 8: Health, Safety, and Nutrition 54 Core Competency Area 9: Professionalism and Ethics 59
Competency Model, the Supervisory Competency Model, and now the General Employee Competency Model. Each of the competency models were developed specifically for public sector employees, and outline the specific skills and behaviors required for success on the job for the group of employees for which each model was developed. The finalized .
COMPONENTS OF NURSING COMPETENCY In order to make nursing competency measurable, since it is a holistic and integrated concept, many research-ers seek to identify its main components. Matsutani et al.8 analyzed the definitions, attributes, elements and structure of nursing competency by reviewing articles in English about nursing competency.
