Leadership: Are You Truly Maintaining Compliance?

Don’t forget these credentialing, privileging and peer-review items.

Are you caught in a whirlwind with challenges coming at you from all directions? You’re not alone. This is a time of incredible change in healthcare delivery, and ASC leaders are struggling to understand — not to mention meet — the new CMS reporting requirements.

It’s easy to focus on the tasks that are in your immediate future, to address events, or to fix a problem. But as an ASC leader, you cannot neglect an important part of your regulatory compliance and quality plan.

An invisible fire

Credentialing, privileging and peer review may not rise to the top of your “new fires” list, but that may be because you don’t know this particular blaze is burning until it’s too late.

Maintaining compliance requires meeting internal, external and time-sensitive tasks with the documentation to support it. To add to the complexity, expiring documents can be a moving target, along with changes during the appointment cycle that may have been overlooked. These changes can be new procedures that haven’t been approved by the governing body and aren’t reflected on the delineation of privileges, or new equipment such as lasers or robots that are not vetted through the privileging process.

It’s understandable to want to avoid making eye contact with these processes, but push yourself to make it a point to spend a few minutes to perform a quick review. You will either feel better about your situation or receive the reality check you need. Keep in mind that deficiencies in credentialing, privileging and peer review remain among the top 10 citations during accreditation surveys. That’s a terrible time to find out about the gaps in your processes.

Requirements rundown

It’s important to understand that although these processes are interrelated, each is separate and has its own purpose and requirements. Here’s an overview of each process.

• The credentialing process within an ASC is governed by a comprehensive framework that includes governing body and medical staff bylaws, policies and procedures, state statutes, accrediting agency requirements and federal regulations. This process involves verifying and assessing the qualifications, training, licensure, certification and adherence to professional standards for healthcare workers. In simple terms, providers must be legally qualified to become members of the medical staff and be granted privileges to perform specific procedures. “Legally qualified” means the practitioner possesses the credentials to practice within the state where the ASC is located. The ASC must validate the information, maintain current documentation and follow all internal and external policies. Whether contracting with a credentials verification organization or performing the functions internally, your practice must continuously meet the requirements.

• Privileging is the process of getting approval from the governing body to grant specific clinical privileges to healthcare professionals based on their demonstrated qualifications and competence. The ASC must validate the provider is professionally qualified through demonstrated competence, specialized training, certifications and experience. Privileging goes beyond credentialing, which establishes a practitioner’s general eligibility to practice. Privileging determines the specific scope of practice the practitioner is allowed within the ASC, tailored to their specialty, expertise and the types of procedures performed at the facility. The privileges that are requested and approved should be listed individually on the delineation of privileges, which is created during the initial appointment and updated during reappointment, and when adding or removing specific procedures.

• Peer review is a continual process within the Quality Assurance and Performance Improvement (QAPI) program. It involves evaluating and assessing the clinical performance of healthcare providers by peers with similar licenses and privileges. This process includes the systematic review of medical records, surgical outcomes and other relevant data to ensure patient care meets established quality and safety standards during reappraisal. The ASC must perform peer review and demonstrate how the information is incorporated into the QAPI plan and is included in the reappointment process.

Take action

Now that you better understand the purpose of each process, here are a few steps to evaluate your current state, identify gaps and create an action plan to address deficiencies. Your specific accreditation requirements will vary, but many basic rules will apply.

Your credential files should be complete, up to date and meet internal and external requirements. This sounds simple, but it can be easy to miss minor details.

A quick scan of your files can give you the information you need. Ideally, your files — whether electronic, paper or a hybrid — should be organized, with a cover sheet or spreadsheet that easily identifies expiration dates. If you don’t have such a quick-reference document while reviewing each file, now would be a great time to create one. Then proceed as follows:

• Verify that documents subject to expiration are current and plan for any that expire in the next 90 days. Examples include any required ongoing education, board certification, medical license, liability insurance or DEA license.
• Identify any documents that are expired or near expiration, and obtain a new document. Remember that providers who have an expired credential should not be allowed to schedule cases in your ASC.
• Obtain new documents via primary source verification, and run queries of the NPDP (National Practitioner Data Bank) and OIG (Office of Inspector General) according to your policy.
• Identify and separate any inactive files of providers who no longer work in your facility. Restrict inactive providers from access to scheduling cases.

Your process to grant privileges should follow your internal policies, while also meeting the external requirements.

• Review the files for completeness, including the request and granting of each procedure the provider is authorized to perform in the center.
• Validate that all procedures or new technology such as moderate sedation supervision, lasers, radiology machines or robotics are included in the delineation of privileges.
• Take the appropriate steps to remove any procedures from delineations of privileges that are not performed in the center.
• Review your files for expiration dates. Privileges should be reappraised within the timeframe set by your accrediting agency, with a minimum of every two or three years.
• Look for documentation that demonstrates that the decision whether to continue the practitioner’s current privileges without change, to amend those privileges, or to withdraw privileges entirely was based on the results of peer review and recommendation of qualified medical personnel.

Your process for peer review should be incorporated into the QAPI program. Your governing body is responsible for evaluating the care provided in the center. For practitioners, this is accomplished through peer review. The results should be incorporated in the reappointment process and used for making decisions to grant privileges.

• Evaluate your peer review process to ensure it includes a systematic review of medical records, surgical outcomes and other relevant data to ensure patient care meets established standards of quality and safety.
• Also evaluate to ensure you are including each practitioner’s case record, including measures employed in the ASC’s QAPI program such as emergency transfers to hospitals, post-surgical infection rates, other surgical complications and patient experience scores.
• Look for documentation of the peer review process, including findings, recommendations and any corrective actions taken.

Preemptive action

Credentialing, privileging and peer review are integrated processes. The best way to prevent deficiencies is to understand your policies, maintain current and complete records — and document every step of the way! You can find additional information on this topic via " A Guide to Credentialing, Privileging, and Peer Review." OSM