Abstract of Joint Commission Medical Staff Standards for a clinical leader.

1. Medical Staff Standards
What a clinical chief needs to know.
Part 1
Excerpts from Joint Commission Medical Staff Guidelines
Michael Wagner, MD FACP
Chief, Internal Medicine and Adult Primary Care
Tufts Medical Center, Boston MA
April 2010
Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010

2. Introduction
The Joint Commission has outlined general principles regarding the credentialing and
privileging of practitioners on the medical staff. For a new leader of a department or division,
he/she may never have read the standards. The following slides cover a sub‐set of the medical
staff standards that all chiefs and chairs should be aware of.
Another point is the Joint Commission is stressing an evaluative process that is dynamic, data
driven and aimed at improving the quality of care provided by the medical staff as a condition of
maintaining medical staff privileges. With the continued expansion of electronic health records
and pay for performance data, practitioners and their department leaders have more
information then ever before.
The challenge for the physician leader is obtaining, analyzing and reporting individual and
aggregate provider and patient performance data. In this first part, I will outline the Joint
Commission key principles for medical staff assessment. In the next part, I will outline the
approach we have taken in the Division of Internal Medicine and Adult Primary Care.
If you are a chief or chair of a clinical department and are responsible for the credentialing and
privileging of physicians this outline might be useful, but I would recommend you read the
original Joint Commission document. The medical staff office has a copy of the most current Joint
Commission standards. This outline is merely an attempt to make sense of the standards and
translate the standards into a operational plan.
Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010

3. Contents
• Framework for quality
• Hierarchical structure of the medical staff
• Principles of individual and aggregate patient and physician performance
• Roles and responsibilities of the Chair (Chief) of the department
• Medical Staff has leadership role in organization performance
improvement
• Credentialing and Privileging
• Peer Review Recommendations
• Focused Professional Practice Evaluation (FPPE)
• Ongoing Professional Practice Evaluation (OPPE)
Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010

4. Framework for Quality
In order to begin the discussion on objective performance based
evaluation of physicians, it is important to outline the domains of quality
that we operate under. I separate quality into five distinct areas:
– Safety ‐ Avoidance of error or avoidance of anticipated negative effect from an
intervention
– Engagement ‐ Customer satisfaction
– Clinical Quality ‐ Application of evidence based medical interventions for specific clinical
conditions at both the patient and population level
– Communication ‐ Transfer of relevant clinical information to the next provider of care
– Value ‐ Improving the application of care for a patient or a population of patients in a
resource constrained environment ( Value= Quality/ Cost)
Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010

5. Joint Commission – Medical Staff Standards
Hierarchy
Hospital
Medical Staff
Department/ Clinical Service Area
Division
Practitioners
NP/PAs
Fellows
Residents
Medical Students
MD/DO
Chair/Chief – accountable individual
Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010

6. Joint Commission – Medical Staff Standards
Relationship between individual and aggregate assessment
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For a division or department
Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010

7. Joint Commission – Medical Staff Standards
Roles and responsibilities of the Chair (Chief) of the department
• Oversight of clinical related activities of the department
• Oversight of administratively related activities of the department, unless otherwise provided by the hospital (PO
has administrative oversight of the clinics)
• Continuing surveillance of the professional performance of all individuals in the department who have delineated
clinical privileges
• Recommending to the medical staff the criteria for clinical privileges that are relevant to the care provided in the
department
• Recommending clinical privileges for each member of the department
• Assessing and recommending to the relevant hospital authority off‐site sources for needed patient care,
treatment, and services not provided by the department or the hospital
• The integration of the department or service into the primary functions of the hospital
• The coordination and integration of interdepartmental and intradepartmental services
• The development and implementation of policies and procedures that guide and support the provision of care,
treatment, and services
• The recommendation for a sufficient number of qualified and competent persons to provide care, treatment and
services
• The determination of the qualification and competence of the department or service personnel who are not
licensed independent practitioners and who provide patient care, treatment, and services
• The continuous assessment and improvement of the quality of care treatment, and services
• The maintenance of quality control programs, as appropriate
• The orientation and continuing education of all persons in the department or service
• Recommending space and other resources needed by the departments of service
Bold – my additions
Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010 From Joint Commission Medical Staff Standards MS.01.01.01

8. Joint Commission – Medical Staff Standards
Medical Staff has leadership role in organization performance improvement
• The organized medical staff provides leadership for measuring, assessing, and improving
processes that primarily depend on the activities of one or more licensed independent
practitioners, and other practitioners credentialed and privileged through the medical staff
process
• Consisting of
– Medical assessment and treatment of patients
– Use of information about adverse privileging decisions for any practitioner privileged through the
medical staff process
– Use of medications
– Use of blood products and blood components
– Operative and other procedures
– Appropriateness of clinical practice patterns
– Significant departures from established patterns of clinical practice
– The use of developed criteria for autopsies
– Sentinel event data
– Patient safety data
Bold – my emphasis
Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010 From Joint Commission Medical Staff Standards MS.05.01.01

9. Joint Commission – Medical Staff Standards
Medical Staff has leadership role in organization performance improvement
• The organized medical staff participates in organization‐wide performance
improvement activities
• Consisting of
– Education of patients and families
– Coordination of care, treatment, and services with other practitioners and hospital
personnel, as relevant to the care, treatment, and services of the individual patient
– Accurate, timely, and legible completion of the patient’s medical records
– Review of findings of the assessment process that are relevant to an individual’s
performance. The organized medical staff is responsible for determining the use of
this information in the ongoing evaluations of a practitioners competence
– Communication of findings, conclusions, recommendations, and actions to improve
performance to appropriate staff members and the governing body.
Bold – my emphasis
Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010 From Joint Commission Medical Staff Standards MS.05.01.03

10. Joint Commission – Medical Staff Standards
Credentialing and Privileging
• General competencies
– Patient care
• Compassionate, appropriate and effective care for health promotion, prevention of illness, treatment of disease and end of life care
– Medical/clinical knowledge
• Demonstrate knowledge of established and evolving medical information relevant to the care of their patients and education of others
– Practice‐based learning and improvement
• Use of evidence based methods to evaluate and improve care practices
– Interpersonal and communication skills
• Demonstrate communication skills that enable effective relationships with patients, family and other members of healthcare team
– Professionalism
• Commitment to continuous professional development, ethical practice, understanding diversity and responsible attitude toward their patients,
profession and society
– System‐based practice
• Understand context and systems in which medicine is practiced and apply this knowledge to improve health care
• Elements of performance
– Application to medical staff follows clearly defined process
– The credentialing process is based on recommendations by the organized medical staff
– The credentialing process is approved by the governing body
– The process is outlined in the medical staff by‐laws
– The identity of the applicant is verified
– Primary source verification for
• Current licensure
• Training
• Current competence
Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010 From Joint Commission Medical Staff Standards MS.06.01.03

11. Joint Commission – Medical Staff Standards
Privileging
• Medical staff is responsible for implementing a privileging process that includes:
– Developing and approving a procedures list
– Processing the application
– Evaluating applicant‐specific information
– Submitting recommendations to the governing body for the applicant specific delineated privileges
– Notifying the applicant, relevant personnel, and, as required by law, external entities of the privileging decision
– Monitoring the use of privileges and quality of care issues
• Decisions to grant, deny or limit should be based on the following (not all are listed):
– Data from professional practice review by an organization that currently privileges the applicant
– Peer and/or faculty recommendations, and include
• Medical/clinical knowledge
• Technical and clinical skills
• Clinical judgment
• Interpersonal skills
• Communication skills
• Professionalism
– Relevant practitioner‐specific data as compared to the aggregate data, when available
– M&M data, when available
– Documentation as to the applicants health status
– All of the criteria used are consistently evaluated for all practitioners holding that privilege
Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010 From Joint Commission Medical Staff Standards MS.06.01.05

12. Joint Commission – Medical Staff Standards
Peer Review Recommendations
• Peer recommendations are used in circumstances where there is insufficient peer review data available
• A recommendation should be made by a practitioners who:
– Is in the same professional discipline as the applicant AND
– Has personal knowledge of the applicant
• Sources may include the following:
– An organization performance improvement committee, the majority of whose members are the applicant’s peers
– A reference letter(s), written documentation, or documented telephone conversation(s) about the applicant from a
peer(s) who is knowledgeable about the applicant’s professional performance and competence
– A department or major clinical service chairperson who is a peer
– The medical staff executive committee
• Content
– Medical/clinical knowledge
– Technical and clinical skills
– Clinical judgment
– Interpersonal skills
– Communication skills
– Professionalism
Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010 From Joint Commission Medical Staff Standards MS.07.01.03

13. Joint Commission – Medical Staff Standards
Focused Professional Practice Evaluation (FPPE)
• Rational
– Initial granting of privileges is based on peer recommendation. During an initial period the applicant should be
reviewed and a focus professional practice evaluation must be completed
• Elements of performance
– Applied to all applicants at the time initial privileges are granted
– Time limited, but can be extended
– Evaluation method can be changed, if needed
– Evaluation methodologies can include, but are not limited to:
• Chart review
• Monitoring clinical practice patterns
• Simulation
• Proctoring
• External peer review
• Discussion with other individuals involved in the care of each patient
– During the FPPE the following must be outline and performed:
• Triggers indicating a possible performance issue
• Criteria to extend evaluation period
• Measures to resolve performance issue
• Consistent application of corrective action process
– Content of reviews should be treated like any other peer review process and should be kept confidential
Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010 From Joint Commission Medical Staff Standards MS.08.01.01

14. Joint Commission – Medical Staff Standards
Ongoing Professional Practice Evaluation (OPPE)
• Rational
– Ongoing professional practice evaluation allows the organization to identify professional practice trends that impact quality and patient safety.
Presumably, findings may require the organization to intervene and limit, suspend or terminate a practitioner's privileges
• Criteria may include, but are not limited to, the following:
– Review of operative and other clinical procedures performed and their outcomes
– Pattern of blood and pharmaceutical usage
– Requests for tests and procedures
– Length of stay patterns
– Morbidity and mortality data
– Practitioner’s use of consultants
– Other relevant criteria as determined by the organized medical staff
• Methods of collection may include, but are not limited to, the following:
– Periodic chart review
– Direct observation
– Monitoring of diagnostic and treatment techniques
– Discussion with other individuals involved in the care of each patient
• Relevant information is integrated into performance improvement activities. These activities adhere to the organization’s
policies and procedures intended to preserve any confidentiality or legal privileges of information established by applicable
law
• Medical staff bylaws should outline the course of action in the case of uncertainty regarding a practitioner’s professional
performance
• Elements of performance
– There is a clearly defined process that facilitates the evaluation of each practitioner’s professional practice
– The type of data to be collected is determined by individual departments and approved by the organized medical staff
– Information resulting from the ongoing professional practice evaluation is used to determine whether the continue, limit or revoke any existing
privilege(s).
Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care Tufts Medical Center, Boston MA April 2010 From Joint Commission Medical Staff Standards MS.08.01.03