• JCAHO Proposes Radical Changes to Credentialing and Privileging Standards
  • December 5, 2005 | Author: Brenda T. Strama
  • Law Firms: Vinson & Elkins LLP - Austin Office ; Vinson & Elkins LLP - Houston Office
  • The Joint Commission on Accreditation of Healthcare Organizations ("JCAHO") has recently published Proposed Revisions to the Medical Staff Credentialing and Privileging Standards. The Proposed Revisions add new standards designed to improve continuous performance monitoring and identify substandard performance. Although many hospital peer review programs already incorporate elements of these new standards, the Proposed Revisions would require hospitals to develop detailed performance monitoring and clinical practice evaluation plans. Given their potential impact on hospital operations, medical staff offices will want to review the Proposed Revisions carefully and submit comments. The Proposed Revisions at http://www.jcaho.org/accredited+ organizations/critical+access+hospitals/ standards/field+reviews/07_cp_fr.htm are posted on the JCAHO website for comment through December 5, 2005.

    Generally, the Proposed Revisions amend the existing credentialing and privileging standards to ensure that the process assesses practitioner proficiency in the following six "General Competencies" identified by the Accreditation Council for Graduate Medical Education ("ACGME") and the American Board of Medical Specialties ("ABMS") joint initiative: (1) patient care; (2) medical knowledge; (3) practice-based learning and improvement; (4) interpersonal and communication skills; (5) professionalism; and (6) system-based practice.

    Most significantly, the Proposed Revisions add six new standards addressing three primary areas: (1) performance monitoring; (2) continuous practice evaluation; and (3) privilege-specific resource availability. This analysis highlights some key features of the new standards introduced by the Proposed Revisions.

    Performance Monitoring

    The Proposed Revisions include new standards related to performance monitoring -- the process for evaluating the competency of practitioners who are initially requesting privileges and/or currently privileged practitioners who are the subject of patient care concerns. Performance monitoring activities include chart review, monitoring clinical practice patterns, proctoring, and external peer review.

    Under proposed Standard 4.0, hospitals would be required to develop a detailed, objective, and clearly defined performance monitoring process. Among the required elements of a performance monitoring process would be:

    • clearly defined "triggers" that indicate a need for performance review;
    • criteria for conducting performance monitoring;
    • criteria for evaluating the performance of applicants initially requesting privileges;
    • criteria for evaluating the performance of practitioners who are the subject of patient care concerns;
    • method for establishing a monitoring plan specific to the requested privilege;
    • method for determining the duration of performance monitoring; and
    • circumstances under which monitoring by an external source is required.

    There also is an emphasis on standardizing the privileging decision-making process. Proposed Standard 5.0 would require hospitals to develop and uniformly apply an objective information review and analysis process that includes well-defined criteria to be considered in privileging decisions. Proposed Standard 6.0 addresses the privileging decision notification, including processes for notifying requesting practitioners of privileging decisions and available due process and for disseminating privileging decisions internally and externally, as appropriate.

    Continuous Practice Evaluation

    A central focus of the Proposed Revisions is to improve continuous performance review. To this end, the Proposed Revisions add new standards designed to ensure that a practitioner's performance is continuously monitored and quality of care and patient safety issues are identified as they arise.

    Proposed Standard 7.0 would require hospitals to factor continuous practice evaluation information into decisions to revise, revoke, or renew existing privileges. This entails developing a clearly defined, continuous evaluation processes for monitoring clinical practice and professional behavior. Although the type of data collected in the continuous evaluation process would be determined by the organization or department and approved by the medical staff, relevant data may include:

    • operative and other clinical procedure outcomes;
    • length of stay patterns;
    • mortality rates;
    • risk management data; and
    • a practitioner's use of consultants, pharmaceuticals and other treatment modalities.

    Proposed Standard 8.0 addresses the investigation of reported clinical practice concerns. It requires hospitals to have a clearly defined process for receiving, investigating, and addressing clinical practice concerns that ensures reported concerns are uniformly investigated and addressed.

    Privilege-Specific Resource Availability

    The Proposed Revisions also recognize the setting-specific nature of privileging. Under proposed Standard 1.0, hospitals may grant privileges only when the resources necessary to support the requested privilege are currently available, or will be available within a specified time frame. Meeting this standard would require hospitals to have a mechanism in place for determining whether or not sufficient budgetary, spatial, equipment, and staffing resources are in place to support the requested privilege.