Recently, a number of our member hospitals have been cited by TJC for not adequately credentialing outside providers. It first came to our attention in August 2008 in Alabama where they were found non-compliant with MS.4.20 for not credentialing outside radiologists used for x-ray interpretations. A similar issue arose in January 2009 when an Indiana state hospital was cited under LD.04.01.05 EP2, because their X-ray services were not supervised (even on a consulting basis) by a radiologist. Now the citation is being made in Pennsylvania on an even broader scale for their not having credentialed (to include primary source verification) the medical providers at their local hospitals, when they send their state hospital patients out for treatment.
In each of these cases, TJC either implies or states that the findings of non-compliance are rooted in CMS standards. This suggests to us that the new TJC rigor on C&P may be related to their recent re-application for deemed status with CMS. We have now spoken with a source within CMS that confirms their support for the type of citation being reported by TJC surveyors. We were told that the CMS basis for this is to be found in a combination of their Governing Body and Medical Staff COP. However, there is also a 2004 letter that is still in effect that reportedly provides summary guidance on the matter. We have also located that letter (S&C-05-04) and posted it in our SL2 CMS library for your convenience [http://www.fieldsinc.com/SL2_CMS.html#SL2_MS_PrivilegingRequirements]
Bottom Lines: • Based upon our conversation with CMS and review of S&C-05-04, the reported TJC claim of a CMS basis for findings of non-compliance appears to be accurate… even if unreasonable. • TJC has now cited a significant number of our hospitals on the issue of failing to credential and privilege outside providers (even radiologists, when there is a question of their actually providing medical care) • Clarifications shared with us from SIG on this matter have so far been consistent in support of the citations
Member Assistance needed • Please inform us if you know of a facility (state hospital or other) that has developed an acceptable solution to the outside C&P issue • Please send us copies of recent, specific citations related to this issue so we can evaluate them for consistency • Please share any relevant SIG clarifications you have obtained on this issue. We will post them for your reference and analyze them for any indication of an acceptable compliance strategy. [See 'Special Topic' button on the left] • Please alert appropriate central office staff to this issue. Their informed support may soon be needed.
Suggested Interim Compliance Strategy • Be sure that you have written agreements in place for all contracted clinical services that clearly require compliance with relevant TJC standards in general and C&P requirements when appropriate • Utilize the precedent established for Credential Verification Organizations (CVO) in TJC standards HR.01.02.05. Use a similar monitoring/sampling approach to show good faith efforts to ensure competence and primary source verification (PSV) • If cited for non-compliance on this issue, politely insist on having the specific TJC standard and element of performance identified. Also request that the citation be ‘flagged’ for central office review.
Please continue to follow this matter on the Discussion Board (www.shccDiscuss) and in e-mailed SHCC Alerts. If we can find no reasonable compliance solution, there may ultimately be a need to formally petition CMS and TJC for a re-evaluation of the relevant COP and standards. We will keep you informed. Please share your input via the Discussion Board, Customer Service/Suggestion Box, or e-mail me directly at RFieldsMD@FieldsInc.com or call our office at 770.389.3800.
For Contracted Services with a Joint Commission accredited organization: The contracting organization (OMH facility) can specify in the written agreement that the contracted organization will ensure that all contracted services provided by LIPs will be within the scope of their privileges or obtain proof (i.e., a copy) of each LIP's privileges to fulfill the contract. You don't have to C & P any of the practitioners unless your organization wishes to do so, as long as there is language in the contract as stated above. Leaders monitor contracted services by communicating the expectations in writing to the provider of the contracted services (can be a part of the written agreement or in addition to it), and improve contracted services that do not meet expectations.
For Contracted Non-Joint Commission accredited organizations: The contracting organization (OMH facility) must C & P each LIP for the services to be provided through the full medical staff processes. Therefore, if your contract is with a non-JC accredited group, you must C & P each LIP.
Non-contracted services from an off-site LIP: If the off-site practitioner writes orders which must be implemented at the organization (your facility) upon the patient's return, the organization (your facility) must C & P the practitioner. OR your facility can turn the order from the off-site practitioner over to any physician who is already privileged to write those particular orders and that person would write orders under his/her name and take full legal responsibility for such orders (this is OMH recommended practice). If no orders are written by the outside practitioner, no C & P is required. You should as good practice ensure that the off-site practitioner has a current license (PSV).
Consultants: TJC's interpretation of consultants is that they consult to the attending. They do not provide care, direct care or write orders for care. As such, they do not need to be C & P'd. They may only make recommendations to the attending physician. The attending then decides whether to provide care, direct care or write orders for care, treatment or services. If the consultant in the act of consulting should also write orders for care which you implement under their name, then they must be appropriately C & P'd for the specific activities they provide. You should make sure as good practice that consultants also have a current license (PSV).
Are any other states or hospitals being challenged by the more rigorous TJC approach to C&P of outside providers??? If so, please let us hear from you in this discussion. Depending on how widespread this issue is, it may warrant a formal petition of CMS and/or TJC to re-evaluate the requirement or at least help define reasonable compliance strategies for our hospitals.
Kudos to the folks in Pennsylvana. They appear to have done some good work in getting the Joint Commission to return to a more reasonable approach to the C&P of outside providers. Get our medical director to check the NASMHPD Medical Director's listserv where PA recently provided an update on this. We have a request in for more details and will provide what we can as soon as it is appropriately available. However, please let us know the status of this issue in your state. Even if it is just a line to say there has been no problem in your area, that is helpful. Thanks to all. RAF
Background: Over the last 6 months, member hospitals had been receiving unexpected deficiencies for what TJC surveyors considered inadequate credentialing and privileging of outside providers. First it was related to the interpretive services of radiologist but then went on to include physicians in emergency departments or specialty clinics…even in TJC accredited hospitals. For a while this was supported by SIG with the explanation that it was actually a requirement of CMS. This approach was questioned and constructively challenged during recent surveys of Pennsylvania hospitals. Subsequently, there were discussions between CMS and TJC that resulted in a return of TJC to acceptance of C&P work and data from accredited hospitals…at least in PA. Many thanks to PA, NY and AL for their support and contributions to our research. We are hoping there will be a formal announcement on this issue from TJC.
CMS: The following updated clarifications are based on two conversations with David Eddinger, Lead Analyst for the CMS Hospital Survey & Certification section and the CMS reference document, Survey and Cert Letter 05-04 (S&C-05-04)available at http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter05-04.pdf
1. CMS requires each hospital to evaluate each of its clinicians, to gather its own primary source verification and make its own privileging decisions. 2. Hospitals can agree to share quality data (e.g., competency) but you cannot rely upon another hospital’s credentialing process 3. If patients are sent to a provider at another Medicare participating hospital, it is not necessary to C&P that provider since that hospital is required to do so. It is your responsibility to do the best you can (reasonable man standard) to ensure you are sending patients to a hospital that provides safe, appropriate, quality care. 4. If patients are sent to a provider of medical care who is not at a Medicare participating hospital, that provider must be considered a member of the medical staff (not necessarily with voting privileges) and subjected to the C&P process. 5. CMS considers radiology interpretive services to be a provision of care and as such requires C&P for outside radiologists, individually and by name. 6. Although a written document is not required, they do recommend having an agreement in place especially to ensure that referred patients with emergencies are seen in a timely manner
TJC: The following updated clarifications are based on recent TJC correspondence and relevant standards. 1. Re: Need to C&P providers at other accredited hospitals – “…as long as the local hospitals are Joint Commission-accredited, there is no requirement for additional privileging/credentialing” – 4/2/09 by Anne Scott Blouin, RN. PHD, Exec VP. Accreditation and Certification Operations, Joint Commission 2. Re: Need to C&P providers without hospital affiliation or at non- accredited hospitals - We have no official word from TJC 3. Re: Contracted Services – For TJC this is governed by standard LD.04.03.09
Recommended Strategy 1. Re: Outside providers at other accredited hospitals – a. Minimum: Ensure that patients are referred only to providers who are credentialed and privileged for the desired services at a TJC-accredited hospital b. Better: In addition to the minimum above, implement an MOU or other written agreement with all referral hospitals that requires use of appropriately privileged providers and the ability to periodically monitor a sample of C&P data on relevant providers (ala the approach indicated in the TJC Glossary reference to CVO). Also require compliance with all relevant TJC standards. Sample of contract language successfully used in a 2009 survey is available at http://www.fieldsassociates.citymax.com/f/OutsideLIPCandPcontract.doc.
2. Re: Outside providers without hospital affiliation or at non- accredited hospitals – Credential and privilege them as consulting medical staff (this may or may not include voting privileges depending on your particular bylaws) 3. Re: Outside Radiologist/Radiology Groups – The general approach here is according to #2 above. However, if you are supported by a large radiology group, consider requesting (in a written agreement) that the agency to limit service for your patients to a smaller, more manageable subgroup. Still, you must privilege each individual radiologist used by name.
DRowe - I put your question to our contact in PA where much of this action took place and here (with her permission on 7/16/09) is the response:
Dr. Fields, The citations received by some of my sister hospitals were removed. Dr. Ann Bloun (sp ?) from TJC gave a ruling that credentialing of medical professionals who do not provide services on our campuses are not subject to the credentialing requirements. However, services provided on-site by consulting physicians are subject to these requirements including off-site doctors who read our EKGs, mobile x-rays, etc. it's been an interesting survey year!
Donna Donna M. Ashbridge, RN, MS Chief Executive Officer Danville State Hospital
