As we head into 2021, watch for a more consistent surveyor approach to the Joint Commission Credentialing & Privileging Tracer. In the past, this session has been somewhat surveyor dependent and, thus, has varied in its level of scrutiny.

Seems that’s about to change.  TJC is establishing a more consistent format for this session. In addition, surveyors will be using a standardized tool for the Credentialing & Privileging Tracer. So, what should you expect from this session going forward? Let’s take a look and discuss some potential pitfalls.

Joint Commission Credentialing & Privileging Tracer: What’s covered?

First, there’s an opening discussion about the hospital’s credentialing and privileging process. In addition, surveyors cover three key areas during this 60 minute session:

1. Focused and Ongoing Professional Practice Evaluation: Policy review
2. Credentials Files Review
3. Additional Medical Staff Requirements:
   • Approval of the Dietary Manual
   • Education on antimicrobial stewardship
   • Education on opioid & pain management

Focused Professional Practice Evaluation (FPPE)

The surveyors are really zeroing in on how you implement FPPE for all new practitioners and for any new privileges for existing practitioners. They want to see FPPE for all Licensed Independent Practitioners. This includes Physician Assistants, Advance Practice Registered Nurses, Dietitians with privileges to write orders, Pharmacists with prescriptive authority, and Telemedicine providers.

Be sure to check out the recent FAQ: Credentialing & Privileging – Requirements for PAs and APRNs. Most importantly, surveyors are looking for quantitative (not just qualitative) data. For instance, this can include chart reviews, patient outcomes, medication ordering patterns, meeting attendance, complaints, and other performance measures. If your FPPE process is not data based, you’ll likely see that on your survey report.

Although the requirement for FPPE has been around for a while, some hospitals still struggle with it. For example, we frequently see survey findings for lack of “triggers” defining when a practitioner who’s on OPPE would be placed on FPPE. (This is called “for cause” FPPE to distinguish it from FPPE for new practitioners or new privileges.)

The following are good examples we’ve seen of triggers for FPPE:

• 10% of medical records lacking complete documentation of MD in-person evaluation for restraint or seclusion
• 10% of verbal orders not authenticated within 24 hours (per hospital policy)
• Less than 90% compliance with documentation of mental status exam in psychiatric evaluations
• 5 or more substantiated complaints from patients or families
• Less than 75% attendance at required Medical Staff committee meetings

For further guidance on FPPE, see the TJC FAQ: FPPE – Understanding the Requirements. Moreover, be ready for surveyors to test the validity of your FPPE process. Frequently, they’ll request the file of a practitioner you’ve placed on FPPE “for cause” since your last triennial survey. They want to see you followed your FPPE policy in this situation.

That wasn’t the case for one hospital who received the following finding: “The organization did not collect any focused professional performance evaluation data when an FPPE review was triggered by a failure to detect a significant finding on the admission physical examination of a patient.”

Ongoing Professional Practice Evaluation

Similar to FPPE, the requirement for OPPE has been around for a while. As a result, surveyors expect to see a smoothly running process in place.

A few key points to keep in mind: First, your OPPE process must be ongoing. That means it happens more frequently than annually. Every nine months is the minimum interval. Most hospitals do it quarterly.

Second, the OPPE data should be quantitative and practitioner-specific. Peer recommendations cannot substitute for OPPE data.

Third, TJC has made it clear that routine peer review of cases that happen to “fall out” for review is not acceptable. Similarly, raw volume data (number of admissions, number of consults, etc.) is not acceptable.

Many findings we see are for lack of OPPE for specialty practitioners. For example:  anesthesiologists, radiologists, and podiatrists.

Also, be careful about how you define privileges and OPPE for “specialty“ populations. See the following finding from one survey:

“The hospital gave several medical staff members special privileges in geriatrics, addiction, and child/adolescent treatment beyond the basic set of psychiatry privileges.  However, the OPPE data collection on these practitioners did not address the quality of their work specific to these areas of practice.”

Lastly, for advice on doing FPPE and OPPE during the pandemic, see the recent TJC FAQ Meeting FPPE and OPPE Requirements during the COVID-19 Emergency.

Credentials Files Review

In addition to FPPE and OPPE, the Joint Commission Credentialing & Privileging Tracer covers the routine requirements: license verification, National Practitioner Data Bank query, ID verification, etc. Most hospitals don’t have many problems with that part.

Occasionally, we see oversights like granting privileges for functions the LIP doesn’t perform. For example, privileges for psychiatrists to conduct physical exams when they don’t actually do that at the hospital.

Another heads-up: Make sure if you have practitioners prescribing buprenorphine that they have the appropriate DEA waiver to prescribe that medication.

Telemedicine Practitioners

Some hospitals run into problems on survey around the credentialing and privileging of telemedicine practitioners. Be aware: If you use contracted telemedicine practitioners, you’re still responsible for their credentialing and privileging. Essentially, you have three options under MS.13.01.01:

1. Do all the credentialing and privileging of the telemedicine practitioners through your own medical staff OR
2. Use the credentialing information from the telemedicine organization and privilege those practitioners through your own medical staff OR
3. Use the credentialing and privileging decision from the telemedicine organization if it is Joint Commission accredited AND the practitioner is already privileged by that organization for the same privileges to be provided at your organization.

Continuing Medical Education (CME)

We sometimes see hospitals struggle to maintain documentation for CME. Be aware: You don’t need to collect copies of trainings attended.

You can use an attestation by the LIP stating they’ve attended CME as required for their license. However, you must add the stipulation that the LIP will produce proof of attendance upon request. See the TJC FAQ Continuing Medical Education – Documentation.

Joint Commission Credentialing & Privileging Tracer: Additional Requirements

There are a few additional medical staff requirements in recent years that hospitals sometimes overlook. Specifically, these include the following:

Dietary Manual: The Medical Staff must approve the hospital’s Dietary Manual (PC.02.02.03 EO 22.) They also need to do that if there are substantive changes to the manual.

Antimicrobial Stewardship: There must be a process in place for educating Medical Staff members on antimicrobial stewardship (MM.09.01.01 EP 2). This should occur at time of hire and “periodically thereafter” based on hospital policy.

Education on Opioids & Pain Management: There must be a process in place for educating Medical Staff members on pain management and safe use of opioid medication (LD.04.03.13 EP 3.) The scope of this education should be based on the needs of the patient population.

Finally, be on the lookout for the 2021 TJC Survey Activity Guide. It will include a Medical Staff Credentialing & Privileging Checklist as well as a Medical Staff Bylaws Document Review Tool. Both will be important resources for your survey preparation.

Barrins & Associates Consultation

We’re resuming our Mock Surveys and Continuous Readiness Consultations in full force. Most importantly, we’re covering all these recent updates to the Joint Commission survey process. We can help make sure you’re prepared and confident come survey time!