And now, I would like to introduce our speaker to get us started with today's presentation. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility, Patient Safety and Risk Management and Operations for COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, Laura served as the Director of Western Region, Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regents University, a Doctor of Jurisprudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. Thank you for being here with us this morning, Laura, and we invite you to go ahead and get us started. Okay. Thank you, Lindsay, and welcome, everyone. As Lindsay mentioned, we're talking about some areas on CMS, that's the Center for Medicare and Medicaid, but I'm also going to throw in some of the Joint Commission standards as it relates to the two topics, and the two topics today are medical staff, what's required, and then telemedicine, because they overlap so much. Now, some of this information may not be applicable to your hospital, depending on what size you are, but I do also try to weave in not only critical access hospitals, but acute hospitals together. I always include my disclaimer, this information is just that, just informational only. It is not meant to be legal advice, nor establish any attorney-client relationship, so please reach out to your in-house counsel or legal counsel or legal representative to whomever that happens to be for advice as it relates to you and, in specific, your specific state law. Well, I want to start off with a brief introduction of why we are here today. Those of you who have gone through a state survey, maybe it's been through Joint Commission as a deemed status, you know you don't want to get one of these, and that is the statement of deficiencies, where they find you didn't quite meet the expectations, and then of course when you have to submit the plan of correction, and no facility, no care provider ever wants to receive the notice of involuntary termination from the Medicare-Medicaid agreement. That is such a huge financial impact for any facility or provider. How does this thing work? How does CMS work? Well, the regulation, the law, that starts in the Federal Register, and then CMS has the responsibility, first off, to publish the regulation in a transmittal, and by the way, those transmittals, I'll show you how to get to those, and those are notices to their surveyors. Then they put together interpretive guidelines, survey procedures. It explains to the surveyor, hey, this is the rationale behind the regulation, and this is who to go look at, who we want you to talk to. They put the updates in then to the manual. There are three types of survey. Certification, complaint, which hopefully you never have one of those, and then a validation survey, where perhaps they're going back out after they've done a survey and they found deficiencies, or they're following along with one of the accrediting organizations. If you are out of compliance, then that's when you get your statement of deficiency. There have been several changes over the past five years. Now, that sounds like a long time, but for CMS, it's really not, but the way you want to keep up with those changes, one, subscribe to the Federal Register, because then you'll get keys on this is the new regulation. You want to make sure you have the most recent manual. It first came out in 86, multiple updates, of course. For acute hospitals, your last update came out in July of last year. Critical access hospitals, your last one was in 2020. Now, they're still trying to put together some of the changes. As we go through some of the programs this year, there'll be some changes that CMS has made, and they're still not in the manual, but I show you how to get to those. If there is a new manual, always check the transmittal page. It's the quick way to find out what was new, what was revised, and what was then taken out. I always recommend those of you who work in compliance or if this is part of your job duties, please check the certification site monthly, because that's where they put the memos to their surveyors. To get to the Federal Register and all of the other resources, I put the links on that previous slide. Once you're in there to the Federal Register, enter your email address, hit submit, and you will start getting your emails. This is what the overall appendix for the manual looks like. Now, they did just make a few changes. It doesn't apply to what we're talking about today, but I'm going to show you once we get into the memo site, that's where you'll want to see them. That came up with the Community Mental Health Center. There were some changes that came up with those. For each one that CMS has responsibility over or provides services for, you will have a manual. Again, critical, yours happens to be W. Acute, yours is A. I would also keep handy, if you're looking to download these, keep an eye on that Q, that's the immediate jeopardy. That's where, if there is an issue or complaint that CMS receives that jeopardizes the health, safety, or well-being of patients, they'll be knocking on your door within two days. Each manual has its own table of contents. You can see here, they put in here on the most recent manual, the last update, and you will see the transmittals. When you're in the manual online, click that transmittal blue lettering, and this is what will bring you to it. It goes in most recent to oldest. You want to go to that revision number, and this is just an example of what that one would look like. This was a major one. They bid back in 2020, and you will see on the right-hand side, part of it says revise new or delete. Again, very easier way to see what did they change with that manual. For the memos, again, I would urge you to keep an eye on this. Put this link into your SERF engine as a favorite. You'll want to check it monthly just to see what has changed. You can see on here, it will tell you the memo number and to whom it applies. When did it come into effect? That's just an example of what one looks like. This happened to come out in March of last year, and it talks about the revisions to Appendix A for the QAPI, just the interpretive guidelines. We still do not have them for Appendix W. They're still not out. They're still working on them. I'm going to talk deficiency reports really quickly. These reports, we can access them. They did major changes in December of last year. It's only available, data's only available since 2017. The rest of it's gone. It includes acute care, critical access, rural hospitals, short-term care hospitals, psychiatric hospitals. If you're a hospital, it will include that type of facility. Has the tag numbers. No plan of correction. If you want it that badly, you can request it. They do update this quarterly, and so I've got the link here on this slide. You can see as you scroll down to the bottom of the page, it will say full-text statement. They have changed this and it's massive now. As a note, if you're going to filter and sort according to tag number, you must include the appendix letter and the four-digit number. If you don't, you're going to get the wrong information. For this one, I just pulled up A286. That would be under patient safety and patient rights. That's how you would find it. Another way, at this point in time, is through hospitalinspections.org. You can access much more information through this route. When you get into their site, go to where it says search your state, and you get this wonderful gray. Just put the cursor over your state, click it, and it brings up all the hospitals within your state. It's nice because you can really focus on which hospital you want to look at. If you're new to your role, I would urge you to look here. Then you'll have some information and background on where you were. I just pull up one of my old ones. It gives you the last date of the report and, like I said, much more information. It will tell you what was the issue. They call it violation as opposed to a deficiency. They call it violation. It gives you the date, the tag number, and much more information than you would ever get off of the one from CMS. What we're talking about today, I've included the tag numbers and the number of deficiencies. Again, only since 2018. They are very few. There were much more prior to this. As you can see, some of them, they really talk about organization and the medical staff. Telemedicine really hadn't had that many deficiencies, which is good. I thought maybe once some of the for telemedicine after COVID had gone away, we might see a spike, but really hospitals didn't. It's good to know that they were able to continue practicing according to what the manual and the requirements were. Again, some of those with the bylaws, those were just some of the higher numbers for a total of 943. It used to be in the thousands. That's not it. These are simply for acute hospitals. I'll talk about criticals in just a minute. Overall, why were hospitals cited under these two areas? One of the big ones, really, they kind of went hand in hand. They were doing something outside the scope of practice. Maybe you have a mid-level, also known as advanced practice provider, who were doing something they weren't supposed to be doing according to what the state law says. State law establishes their scope of practice. CMS will tell you this is what we want their education level to be, but this is what the state, they tell them what they can and can't do. Then again, along with that, doing something they're not privileged and credentialed to do. Another one was they didn't hold the medical staff accountable to the quality of care that should have been according to what's reflected in the QAPI data. Physicians weren't assessed for competency. Very many of those didn't follow their bylaws, rules, and regulation. That was another highly cited area. They didn't even have specific criteria in order to show competency. I noticed there was some chatter on the ASHRAE website, or LISRB, if any of you belong to them. One of them happened to be, how do we establish criteria and competency for robotic surgery? Well, that's up to the medical staff to make that decision. What would be a competent person? Here in that situation, they were probably cited because they didn't have that criteria. Areas we've already talked about, no history and physical on the record, inadequate history and physical, there was no patient assessment, H&P wasn't done according to the timeframes 24 hours before surgery requiring anesthesia, and then some involving policies, missing required policies, or they had not been updated for many, many years. I want to just do a quick overlap between the governing body and medical staff section. As you go through and you're reading some of this, governing body is the same as your board. They're the ones who are responsible for everything that occurs within your hospital, but there's an overlap and there's three tags in particular, 44, 45, and 53. And Lindsey did mention, we have a few of these questions and I like to start out early because it gives me a basis for where I can go further. So Lindsey, would you put that first question up for me? I sure will. Okay. This says, excuse me, our board recently added other non-physician practitioners eligible for appointment to the medical staff, including midwives, psychologists, dieticians, and certain pharmacists. The question here is the question here. Okay. So you should now have your options, yes, no, or not sure. As we get into the midwife section, there has been a few changes. CMS brought out some memos last year regarding nurse midwives or midwives within hospitals and what is their scope of practice and supervision for those folks in particular. We're still getting a couple of responses coming in here. And as you all are putting in your responses, just a quick note for those of you who joined a few minutes after we got started, if you have questions for Laura, as we go throughout the presentation, make sure that you're typing those into the Q&A found at the bottom of your Zoom window. And we'll pause during the time of these polling questions to address any of those questions as well. Okay. It looks like we've gotten some good mixed responses here. So I'm going to go ahead and share and give you guys results there. Yes, we did. Quite a good mix. Good. Good. All right. Let's start with the governing body, again, also known as the board. They have to make sure that the medical staff requirements are met. And they decide who gets to practice in your hospital, what category. That's up to you. The board decides we're going to allow midwives, great, or not allow midwives. However, the medical staff does have to include MDs or DOs and anyone else that the board deems, yes, they're a physician, they can come on board. That can be dentists, podiatrists, chiropractors, optometrists, whoever they want. That's fine. They can allow that. Practitioners included in that definition, however, have to be approved and authorized by the state where the hospital is located. So practitioners have to be licensed in that particular state. Based upon that, they should be granted privileges and appointment to the medical staff. As with any provider, they have to stay within their boundaries. They have to practice within their scope of practice. CMS, again, won't tell you what an MD can or can't do. That's up to the state. The state medical board determines that. We'll determine it for a dentist, chiropractic board for chiropractor, on and on and on. They determine what is the scope of practice for that individual. Now, the board can decide who else can come on board, again, according to what state law says can occur. CMS, in the manual, they have blue boxes, and they mention what the board can and can't do as far as credentialing. Now, when you get into these blue boxes, keep in mind, these you will not be cited on if you don't do that. It's information only, but it's really good information that you want to keep an eye on. That blue box does talk about credentialing others. Now, these are others that aren't added to your staff that can add on. That can be a clinical nurse specialist. That can be a CRNA. Maybe it's a nutritional specialist. The governing board, medical staff, irregardless of who they allow on, they both have to exercise oversight of those privileges, and that we do through credentialing and peer review, competency review. That's how that happens. This is what that blue box happens to look at. Again, it's not required. You can't be cited on it if you're not following what's in the blue box, but it's really good information. So, I want to talk about non-physician practitioners, PAs, nurse practitioners, et cetera. Nurses can be eligible for appointment and privileges if that's what your state law says they can do. I bring this up because, say, registered dieticians. Some states do not allow registered dieticians to have privileges to write orders, but some do. In fact, the majority now do. Other type of practitioners, they may have more limited scope, physical therapy, occupational therapy. Then you may have limited scope of practice that the state says, again, you can privilege them to do this. The governing board staff, again, they recognize oversight, and there's multiple privileges, whether it's courtesy, temporary, consultative, however it happens to be. Another thing you have to do, and this is, again, the overlap with the medical staff and the board. The medical staff and board have to have consultation with each other, and really this falls on the board to make sure that that does occur. They have to consult, must, not should, but must consult with at least one person who has the responsibility for the conduct of the medical staff, CMO, president of the medical staff, whoever that's going to be, and it must be a direct consult, periodic throughout the year. CMS recommends at least twice a year. Depending on your size, you may want that monthly. Maybe you have more than one hospital within your system. Whatever it is, the governing board really needs to have at least twice a year consult, because what they're trying to do is figure out in our hospital, are we having areas of concern? Is there a new service that they want to bring on? Again, there has to be that consultation, because the board is ultimately responsible for everything that happens within the hospital. Consultation, what do you cover? Well, anything that relates to the quality of care that is provided. Just being on the medical staff and on the governing board, that's not enough, unless that person is the director, the lead of the medical staff, and there's meetings that do still occur that discuss matters of patient care. Your president of the medical staff, your chief medical officer, can meet that requirement, but you still want to make sure there's some discussion during those meetings on the quality of care. If you have a multi-hospital system, then you have to consult with each CMO or person that is over that organized medical staff, and they want to make sure that the individual of that staff is assigned that responsibility. So, again, if you have more than one hospital in your system, each CMO has to make sure there's consultation with the governing body. You can do telemedicine. I shouldn't say telemedicine, telephone communications, Zoom meetings, face-to-face. If it's telecommunication, it must be synchronous communication, so there's questions back and forth. Can't do it by email. It has to be that direct consultation. So, that's the overlap between the governing body and the medical staff. Now, I'm just going to switch right over to the medical staff. I'm staying within the acute hospitals at this point in time. For all of these areas that I talk about, I put the tag numbers in the upper right corner. So, under this one, of course, you have to have an organized medical staff that functions under the bylaws, and you have to have bylaws that apply to everyone. And these bylaws are the ones that your governing body has signed off on. They've approved them and said, yep, that's how we're going to operate. If you have more than one hospital, each hospital can have a separate medical staff, or you can have an all-in-one, or it's a unified, or shared medical staff, as long as you meet the requirements. Now, before I get into a shared integrated staff, I just want to talk just plainly about a medical staff. The staff can include physicians, other categories of not only physicians, but non-physicians, as long as that's consistent with state law and scope of practice. All practitioners are privileged, then they have to play by the rules. They have to follow the bylaws and the rules and the regulations. The medical staff, you have to look at their credentials. Is this someone you want practicing? Not only do you look at their credentials, but there has to be periodic appraisals of what they're doing, the conduct of all members of the medical staff. By the bylaws, you determine how often that occurs. CMS recommends every 24 months, same with joint commission. Now, when they say recommends, I would do that. You can do it shorter if you have the time and the ability to do that, but at least every 24 months, because we want to make sure that what they said and could do before, they're still able to do and do it safely. What do we want to look at? Well, of course, competencies, and are they qualified to do that, to practice within that scope of practice? And of course, we want to make sure they're privileged and credentialed to do what they say they're competent to perform. So we look at a host of items. We look at their special training. What are they doing right now? Is this something that they want to do that's outside the normal scope of that particular specialty? But we also look at the outcomes. How often has a patient had to go back to surgery because say a bleed or an infection? What's their education? What's their licensure? And you can, by the way, you can go to your board of medicine. They are considered primary source verifications, but that doesn't mean you don't want to go back and also do some checkups with the references. When did they know them? How often have they known? When did they last talk with them? How did they interact with them? Have they maintained CMEs as required by state law and the bylaws? Are they complying with licensure requirements? Are they staying current on it? And then just basic, do they adhere to your rules? You have to evaluate each person, each person who has privileges. Are you going to continue them? Are you going to revise them? Now that can be okay because you may want to increase their privileges based upon maybe specialized training that they have done. Are you changing them or are you going to terminate their privileges? Do they want privileges that go beyond their list that's outside the category of that practitioner? If so, okay, they still have to be appraised by the medical staff and then signed off by the governing body. And again, if you're going to limit any privileges, don't forget the National Practitioner Data Bank. What are the reporting requirements that you have to do? Is it immediate that, hey, we're worried about this person, therefore we're going to do summarily suspend their privileges and then next day or that same day notify the NPDB. Credentialing, we have to look at what this person says their credentials are. Then the medical staff who's doing this looking at, they go and make recommendations to the governing body, say, hey, we want this person on our staff. And again, that candidate is subject to all the rules, all the regulations and all the bylaws of your medical staff. What do you want to look at? What are they requesting to do? Do they have evidence of licensure or any additional training? What is their basic training in education? Is there documented experience? In other words, can they show you proof that yes, they did their residency here? Maybe they went on and did a fellowship or a couple fellowships in their expanded area. And then of course, their references that you can go back and check on it. Recommendations, you then go to your board and say, hey, we're recommending that this person be granted general surgery privileges because that's within their scope of practice and what the state law says they can do. And of course, they're abiding by our bylaws. Of course, we cannot make a recommendation based on simply being board certified. You can require it, that's up to you, but that cannot be the sole basis for the recommendation for appointment. Both the medical staff and governing body, they have to enforce these requirements. And if that person, that practitioner isn't meeting the bylaws or going outside the bylaws or rules and regulations, they have to step up and take action. All members who have privileges in that area have to still have due process rights and protections. So if you're going to summarily suspend someone, there are certain rules and regulations that you have to follow, and that's in your bylaws on how you're going to summarily suspend them. That means giving them notice, giving them an opportunity to respond. You might wanna keep this in mind, keep your credentials separate for each medical staff member. Where you keep them, totally up to you. Just make sure they are secured. And again, they repeat it. If you are limiting privileges, then you may need to have some reporting to the National Practitioner Data Bank. I wanna talk about this case. Some of you probably remember it. We all remember the comedian Joan Rivers. Well, she had a procedure in an outpatient surgery center, a laryngeoscopy, and in order to do that, of course, she had to be sedated. Well, the person who came in to do this particular procedure, he wasn't certified, he wasn't qualified to do this. He wasn't credentialed to do this procedure in the outpatient surgery center. So instead, what they did was they had another individual observe this gastroenterologist doing the procedure. Well, that's all he was authorized to do, was observe him, that was it. Because the person who was doing the actual, doing the procedure wasn't credentialed to do it. So that's why they had to have the person oversee it. We know what happened with that outcome and it was devastating. And so as a result, this particular surgery center and the medical staff and those who are associated with it did face some legal action because they didn't properly appoint and credential the person doing that. That's why it's so critical, not just from a litigation standpoint, but from a patient safety standpoint. Then we have to have organization and accountability. Again, this was one of the areas that was fairly well cited. The medical staff is accountable to the governing body for the care that is provided. And again, you can have your own individual medical staff or you can share a medical staff, but it has to be put together in a way that the governing body has approved it. If you have an executive committee, the majority must be empties or DOs. And the responsibility for the medical staff, they are assigned to a physician, an empty and DO. Or if your state law permits it, a dentist or podiatrist can have that responsibility for the medical staff. But again, if it is, you have an executive committee, the majority must be empties or DOs. The conditions do create checks and balances on the overall framework and how everybody functions between the governing body and the medical staff because the medical staff has its own lines of authority and the governing body has its own lines of authority. The medical staff, they have oversight. You do peer review, you do privileging, et cetera. On the other hand, the governing body says, okay, that's all good and well, but we're gonna tell you who gets to come and practice in our hospital. Again, the categories for those who the medical staff will have responsibility overall. As far as the medical executive committee, the bylaws, rules and regulations, you can have that. When you have a larger medical staff, that sometimes is beneficial. Fewer people can really take the reins and help meet the requirements. It's not required, but you may, so again, some of the larger hospitals and their medical staff, they tend to find this as a little bit more efficient and they can delegate many of the medical, many of the functions of the medical staff to that executive committee. More efficient, they can approve policy and procedures that are required. Again, your bylaws set it up and determine what is their scope of authority, what are their responsibilities. They do have to be accountable, whether it's an executive committee, really the medical staff overall, that's accountable for the quality of care that's provided. And again, we show that through appointment, going back and reappraising and evaluating, doing it through peer review, but they also through approval of the policy and procedures and participating in QAPI. And that's how the hospital functions and how we improve what goes on within the hospital. I mentioned at the beginning, the surveyors, the conditions of participation of survey procedures, not everyone does. So when there are some significant ones, I like to bring these up. And in this one in particular, the surveyor will make sure there is an organized structure for your medical staff. It is formal and it is organized. In other words, who reports to who, what is the chain of command, so to speak, when you're talking a medical staff. And they also want to check out what are the responsibilities of both, not only the medical staff, but the governing body. Are they in the rules, regulations, and the bylaws? The surveyor will also make sure the majority of your medical executive committee, if you have one, are physicians or whether it's MDs or DOs. But they'll also talk to the CEO and they'll talk to the medical staff leadership. Usually they do these separate because what they're trying to find out is how do you make sure that medical staff, you're meeting the requirements of accountability on quality of care. For the CEO, they're going to ask, okay, what kind of communication is there back and forth between the governing body? Yeah, how often do you hear from them? If you hear of a problem, how are you communicating with each other to make sure that those issues are addressed? They want to know what are their duties? What are their responsibilities? How do they do them? And how do you make sure the staff is accountable for the quality of care? And that could be, well, we are doing, it's a biannual, every two years, we're looking at each individual provider. Are they meeting the expectations? How do you do that? How do you make sure they're accountable? We're looking at medical records. We're looking at, say, outcomes through QAPI. That's how they want them to describe it. I mentioned before about a system. So I'm going to talk just briefly about a system. If you're part of a system where each hospital is separately certified, you can have one integrated system. That's up to you. And that's the medical staff. Now, you have to make sure this is okay with your state laws because some states may not permit it. My state in Colorado, yes, they do. They allow it. But each hospital, if you're going to do this, again, so it's hospital B, hospital C, you're each individually certified. The nice thing here, you don't have to have a distinct organization of your medical staff and structure. You can share, or you can have hospital-specific bylaws, rules, and regulations. You can share medical staff leadership. You can share credentialing and privileging, which can come in very handy if that's what you're going to do. Again, a unified medical staff. I want to make a distinction here. A multi-campus hospital where you have many inpatient areas that are provider-based, remote location, that is not multi-hospital system. That's just a lot of hospitals, that's all. System is different. You've got one hospital that is certified. They're not separate. This is your multi-campus hospital. They don't have separate medical staffs, and they're not a unified medical staff according to the regulation. Now, if you do have many hospitals within your campus and you're part then of a system, then you can share that unified medical staff with all the other separately certified hospitals in the system. So I always like to take, for example, we have the University of Colorado Health Systems here. They got hospitals all over the state. That is a multi-campus hospital. Now they do participate and try to work with, in a system, one other hospital, and that's Children's Hospital. And so those are separately certified hospitals, but yet they can share systems if they want to. What you have to do, if you're gonna do this, if you're gonna share your medical staff, each hospital has to show that, of course, the members of your medical staff, they have privileges, and they voted by a majority to accept this one, this unified integrated medical staff structure, or they have an option to opt out. They can stay separate. They have their own staff, their own bylaws, rules, and regulations. They can opt out to do that. If you have physicians on your staff who are strictly telemedicine, nothing more, they're not eligible to vote. If you're gonna do this, of course, the governing body has to elect and approve the unified medical staff, and that means you may need to amend your bylaws, rules, and regulations. If you were, my goodness, almost 20 years ago, 10 years ago, excuse me, can't add here, July of 2014, if you had a shared staff before them, then what they wanna see is evidence that the board elected to do it. Same rule, so it has to be okay by your state laws, and that it is not expected the bylaws that were in effect as of 2014 addressed such a unified system, but you are expected that you amend them in a timely fashion, and, of course, still have that opt-out provision because it may be over time, you realize maybe it wasn't such a good collaboration to come together and work like this, but that's what you have to have in place. What if your hospital is acquired by a system, and you still are going to keep your own Medicare certification? Well, that's fine, your governing body can still say, hey, we're still gonna have this unified medical staff, but you have to do the same, medical staff has to approve it, you have to make any changes to the bylaws, rules, and regulations, and that's no later than six months after that acquisition. So I just wanted to touch on those in case you are facing that. We've seen so many acquisitions, mergers, acquisitions, and some of the information now, we're starting to see hospitals pulling away from that a little bit more than we had this huge merger of acquisitions going on, and now that's not happening so much, but it's starting to step back a bit. Well, going back to the requirements, as far as how you're going to do this, bylaws, they have to describe the process for self-governance, this is, again, unified, how you're going to appoint, privilege, credential, oversight, do peer review, have due process, and that's what the surveyor wants, they want documentation of those, again, if you're in a unified medical staff. You have to take into account each hospital situation, what kind of patients do they have, what kind of services are they providing? Is it acute, is it a rehab, or strictly behavioral health? And you could be a different size, you could have a 500-bed hospital, you could have a 100-bed hospital, a teaching hospital, you may even be in different states, so just keep that in mind if you are going to do this, but your policy and procedures have to be clear on how you're meeting the needs of each hospital. We want to make sure that what's happening at your large hospital is being addressed at the same level of your smaller hospitals, and issues for that particular location are considered and addressed. Again, you've got a small 100-bed hospital, maybe in an urban area, a lot different situation than you do in, say, a large metropolitan area where maybe you've got a lot of gang activity going on, as opposed to maybe the urban hospital, where you don't have those issues. Each hospital has to have that accountability. Surveyor, they are going to interview hospital and medical leadership at each facility. They want to especially look at very specific items like standing orders. Are you going to share standing orders? And if so, have they been approved by each leadership, not just medical, but pharmacy and nursing leadership? How are you going to minimize any drug errors? They're kind of getting in the weeds on some of these survey procedures with these unified hospitals. Does the policies consider what that hospital's circumstances are? What about your formulary, even? Have you taken into account different formularies, and has the medical staff considered that? What about consent requirements? Are those any different? Infection prevention. You may have something totally different at a rehab hospital than you do at a pediatric hospital. And how do you make sure your QAPI programs meets the requirements for each facility? So that's under the unified. Otherwise, bylaws, just the same, adopt and enforce them. The governing body has to approve them and include a statement of duties and privileges for each category of provider. The bylaws have to include a statement of what those categories are. Again, active, courtesy, referring, whatever it happens to be. Specific privileges reflect the activities or of the physicians or practitioners, and that category can do competently. You can't assume just because I'm a physician, I can go and deliver babies, or that I'm a physician that I can go and do surgery. Individual ability to perform each task must be individually assessed. That's a lot of responsibility, especially if you're using an integrated system. Our next question, Lindsay. Okay, excuse me. I'm gonna read this first part, and then I'll post the question there on the screen for you to have the opportunity to answer. So this is a scenario that says hospital C is due for a state survey. One week prior to the anticipated visit, the chief medical officer, a neonatologist, had privileges summarily revoked, concerns surrounding capabilities. Two other physicians, a neonatologist and pediatric intensivist, submitted resignations in protest, leaving the hospital without sufficient specialty coverage. And the question, will this be a concern during a survey? And let's get that up here on the screen for you. Okay, there are your options. Yes, no, or not sure. I don't see any pending questions at the time right now, Laura. Good, and this was a situation that came up. It wasn't, it was a smaller hospital. So this is actually based on a situation that did occur at one of my hospitals and, oh dear, what are we going to do now? We've gotten some pretty consistent answer here. I'll go ahead and end this and share that result there for you. Yes. Will it be a concern? Because again, we have the CMO, and the reason that there was a little tension, you could say, going on in this particular hospital with the organization of it, and so it was going to be an issue for this particular hospital. So as far as organization, the bylaws have to put together an organizational structure for your medical staff. The rules, the regulations, they have to make it clear. Number 1, what are the standards of practice for taking care of patients? Whether that's diagnosis, medical care, surgical care, rehab. The surveyor, what they're going to look for is, they want to see the bylaws, of course, and they want to first off make sure, do they tell them what is the formation of the leadership, and who's responsible for the review and evaluation of any clinical work that is performed by your medical staff? They have to describe the qualifications for a candidate. Where did they go to school? Graduation from an approved medical school, that they've gone through their residency, that maybe you want to include it in there, that they've got fellowship. If they're going to be doing certain surgical procedures, maybe they have an additional fellowship or post-fellowship training. What is the privileging process? That's the process, what steps are going to occur, and what is the criteria to determine those privileges? They have five in particular. At a minimum, this is what you must look at. The qualifications must describe, what is the character of this person? What training and experience have they had? What's their current competence, and how are you going to judge that? Then individual judgment. Does this person make sound clinical decisions, or are there some concerns with what's been going on with their clinical decision-making? As mentioned before, you cannot simply say, oh, you're board certified, great, you're online. Or you are a member of, say, the American Psychiatric Association, still not enough. They really want us to bear down and look at those individual qualifications. They also talk about history and physicals. We've talked about this in the past, but the bylaws really have to stress what the history and physicals include and their timeframe. The bylaws have to include that requirement that HMP is done within 30 days before admission, no later than those 30 days, or 24 hours after admission. They repeat this in two other sections, the surgery section and the medical records section. It is pretty much word for word. CMS is trying to get this point across to us, needless to say. The staff, you adopt the bylaws to carry out those responsibilities on history and physical, but overall, it must be on the chart before the patient goes to surgery, except when you have that healthy outpatient. They also talk about advanced practice providers, your nurse practitioners, PAs, your clinical nurse specialist. The regulation does expand that category of folks who can do a history and physical if the state law permits it. So that's where you wanna start. Can a PA do a history and physical within your state law? And if so, then the hospital has the option to elect that. Also, they don't have to, but they can. If that's going to be the case, the physician still is responsible for its content. What does that mean? They have to review it. They have to sign off when it's done by such provider. They just can't say, you go do it and you're done. They must make sure it's accurate. There has to be some entry into the medical record to reflect any changes to that history and physical. And of course, whoever does the history and physical themselves must be qualified and licensed. So here's just an example. You got a history and physical, family physician does it. The surgeon that day of surgery, or whenever they're admitted, they review it maybe at an update or so in conversation with the patient prior to surgery. Are there any changes that need to do it? And then they authenticate it. Usually it could be initial or say, I agree with the medical. The HNP has written and will proceed. They can use a note in the progress notes, maybe a stamp sticker, checkbox, whatever works for you. And I've just got some language on here. You don't have to use that language, just some suggested language. Again, HNP reviewed, patient examined, that's a biggie. And there's no change since the history and physical was completed. But they reiterate a complete HNP must be in the chart for every patient unless it meets the requirements of a healthy outpatient procedure. And then we have an assessment. The limitations, again, it must only be an outpatient procedure that requires anesthesia. It is that procedure that the medical staff has said, well, they really don't need one. So there's a, what does that mean? A policy on it. And the board has to approve. They have to sign off on that. So in this assessment, they can do that in lieu of the full history and physical, but you have to have a policy. You have to have which patient and which procedures or surgeries it applies. And the bylaws have to reflect those requirements. Like the history and physical, you still have to do the assessment and document it after registration, but before the surgery or procedure. Again, these are the ones that require anesthesia. What does the policy have to include, or at least consider? What's your patient? Who do you have there? How old are they? What's your diagnosis that you're going to be doing this procedure or the surgery? Is it more than one? And then of course, my patient. What's their comorbidities? Are there any national guidelines for this procedure under anesthesia and seeing the patient ahead of time? What is the level of anesthesia? Are we talking conscious sedation? Are we talking general anesthesia? What is the standards of practice for that assessment on that patient? If you have a patient who has a lot of comorbidities, maybe diabetes, vascular disease, heart disease, maybe they had a history of stroke, other comorbidities, uncontrolled diabetes, maybe that's not the person you want to do an assessment, maybe a little bit more and do the full history and physical. Of course, any state laws that you have to abide by, local laws that you also have to abide by. And then as far as other privileges, they still continue on criteria for determining privileges. The bylaws have to include what are those criteria? Governing body grants the privileges based upon medical staff recommendations. Now in telemedicine, it's a little different. In telemedicine, the governing body can say, you know what, we're gonna rely on what that other entity or hospital says in granting privileges to those telemedicine providers, but it must be in the written agreement. So I want to talk certified midwives. I mentioned this previously. There was a memo came out late last year and it's really what they're saying is, CMS recognizes that nurse midwives really are a great resource because they can provide care and good quality care for mothers and infants in areas where maybe it's underserved population. For acute hospitals, this is where it varies. Acute hospitals, you can privilege and credentials, excuse me, the certified nurse midwives. These are not lay midwives. These are certified nurse midwives. You can privilege them and credential them to be on the staff. There is no oversight for Medicaid or non-Medicare patients admitted by these nurse midwives, if state law and policy permits it. So if the state law says, yep, they can do it. You can have a policy that says, nope, we want oversight. You can do that. And here's the difference. Critical access hospitals, they still have to have oversight for all inpatients. Doesn't matter who admits them, they still have oversight. That includes non-Medicare patients, your Cignas, your Blues, those who are private pay. So there was a major difference in those two and CMS had to put out that requirement because CMS recognized that when they said, no, nurse midwives admit them, they don't have to have oversight. They said, oops, we kind of overstepped our bounds on that. All right, I wanna move over to critical access hospitals on talking on medical staff. Here, they put it under professional staff. It's not a separate tag or section number. They put it together under organization. So you have a professional healthcare staff that includes at least one MD or DO. And you must have at least one or more mid-levels if that's what you wanna do. You don't have to, but usually you do. The surveyor will look at your organization chart. They're going to look at work schedules. When are you open? When do you have patients? Who's covering for that hospital? Now I've separated out and put together most of these because they really fall in line with what the acutes are. So first off, you have ancillary personnel. They are supervised by professional staff. What's ancillary personnel? That's your aides, your techs. They're supervised by the professional staff. You have enough staff to give services and you have at least a physician or an advanced practice provider to provide care at all times. You have an RN, clinical nurse specialist, or an LPN whenever you have one or more inpatient. So criticals, you don't have to have an RN on staff, on duty when you have a person. It's great if you do, and most criticals do anyway. They will have an RN on duty. The surveyors will look at the work schedule. By the way, they're gonna also interview your staff because they wanna find out, first off, if you had a patient and you had a problem, who did you reach out to? Who was on duty? How did you reach them? Was it a physician? Was it an advanced practice provider? Because what they're really looking for is to make sure there's enough sufficient personnel to take care of those patients. Then the tags go on to start talking about what are the duties of these physicians? Well, of course, they provide medical direction, whether it's consultation, supervision, actually in their working. And as far as advanced practice providers, they have to work with the physicians in developing, executing, and then reviewing the policy and procedures. With the advanced practice providers, the physicians have to periodically review patient records, give orders, care, services to patients. So these are the duties of the physician. They also have to periodically review and sign off on all inpatients that are taken care of by advanced practice providers. And they include in here a sample also of outpatient records, not all of them, but at least a sample of those outpatient records. The guidelines they talk about for inpatient records, really all records that they want open. So when the surveyors are on site, don't be surprised if they look at all of your inpatient records, and especially those who are being cared for by your advanced practice providers because that's what they're looking for. Are they looking for that physician review and sign off? Outpatients, what CMS recommends is 25% of your outpatient. It is not required, but it is a recommendation. On the record review, now for states who don't require review or co-signature, your physicians are not required to sign off on outpatient records. So I'm gonna make that clear, outpatient records. They still have to review and sign off on inpatient. As a hospital, you specify how long that's going to occur. Put it in your policy and procedures. And they can do it offsite if you have electronic records where they have secure access, they can do it once they're on site, however it works for that physician. Otherwise you have to have a physician around long enough so they can provide direction or supervision or even just consultation. Now, what they say in a critical access hospital, being present, that means you can see the whites of their eyes. They're physically on site. They don't say for how long, the minimum amount is not specified. You have the flexibility to determine those policies. Now they can provide direction, oversight by phone or some other electronic format, whatever works. But as far as being present, that's what they mean. They are physically there on site. You determine how long that runs. You can use telemedicine to fulfill some of those requirements, by the way. Other requirements and provisions, physician has to be notified when your advanced practice provider admits a patient. Medicare, Medicaid patients must be under the care of a physician and the quality appropriateness of the advanced practice providers, they're evaluated by the physicians who are on site. If you have the review for your physicians though, you've got a couple options. One, you can use your quality improvement organization, whether it's your Kepro or your Liftana. You can use another qualified entity. If you're in a rural health plan, that's fine. If you're a member of a network, that hospital, another hospital, they can do the care of the physicians. Now for telemedicine, same thing. You can use those three for your telemedicine review. I've just got a few other considerations for the medical staff. And one of them, they did back in 2019, eliminate the requirement that you have an autopsy program in order to be qualified for reimbursement. Because what they're trying to do is really reduce that burdensome requirements that really slowed down quality care. Now they defer to state law. Staff, try and at least get an autopsy if you can in the unusual deaths. Now, some states, if a death occurs within 24 hours after admission, it's automatically a coroner's case. The coroner makes that decision too, by the way. You may also want it for medical or legal purposes and education interest. But you'd still, they do say, if you can try and secure, but just have a policy. Who is going to get permission and how is that autopsy going to be conducted? And again, I mentioned this does not apply if the coroner orders one. If the coroner says, this is a suspicious death, I'm not sure, then all bets are off, it happens. You don't have to get consent in order to have that done. Many of them will notify the physician of record to sign off and provide data so that that can occur. Other conditions of participation, as far as compliance that affect the medical staff, I've got them all listed here. This is on slide number 94. So there's a lot of conditions that the medical staff has to be involved in. Of course, verbal orders, anesthesia, documentation, discharge, restraint, seclusion, ordering them, making sure the patient is checked over, pharmacy requirements, huge amount, and even contracted services. There may be some contracted services that the board wants the medical staff to be responsible to make sure, yeah, this is what we want in this contract, or maybe even sign off, take responsibility for that. All right, let's move over to joint commission. I'm gonna cover both medical staff and history and physical. There are 26 standards that follow what CMS says. And they really, the nice thing is they give much more information on certain requirements, especially with credentialing than what the conditions of participation do. Now, first off, and I've just got some of those listed out here, the medical staff, their bylaws address self-governance and accountability. This is an extremely long section, 37 elements of performance, that is large. It highlights the organized staff that pulls together these bylaws, rules, and regulation. They make sure the medical staff, every individual, complies with those rules. If you have deemed status, the bylaws must include a statement of what are the duties, the privileges for each. Now, I wanna put something in here. This is a little bit different. This is not in the conditions of participation. You have a way, this is through joint commission. Your medical staff has a process to manage conflict when there is maybe a disagreement going on between the medical staff and the executive committee. There are proposals to adopt a rule, regulations, amendments. There are just some things that medical executive committee wants to do and the rest of the staff doesn't. So they talk about that there's a process in managing that conflict. And also bylaws, there is a way for selection and how you remove medical staff officers. So again, these aren't in the conditions of participation. You might wanna look at those if you're starting to see some of these issues within your staff. Otherwise, then they go through very similar what is in the conditions of participation. Whether you have a unified integrated staff that neither simply the medical staff nor board can decide unilaterally that you're gonna do this. There has to be a vote. Multi-hospital systems, you can establish your unified staff if you want as long as state law permits it. And they do say in here, there is a medical staff executive committee. That's a little bit different. It's an elective for under conditions of participation. Like with the conditions, they oversee the quality of care. That they make sure that those who are providing care have appropriate privileges. And if you're in a graduate education program, the medical staff has a way, a defined process for supervision of those practitioners. This is again different. This is not in the conditions of participation. Those that are in, again, QAPI, medical staff has leadership role to improve care. It is an organized staff. They participate in organization-wide PI programs and activities. Privileging very similar that you grant privileges to each individual and they collect information. Again, licensure status, what is their training experience, their competence, their ability to perform what that person is requesting. They can deny or limit. They can renew, but it must be evidence-based process. It cannot be anecdotal. It must be evidence-based. Organized staff reviews and analyzes each applicant's information. And they then make the decision to grant, limit, deny, whatever. They still have to communicate that to the requester in a good time, a reasonable timeframe so that they can either provide more information or object to the status. And they also have a way, an expedited approval for initial credentialing if it is needed. There is certain criteria that must be met. You can grant temporary privileges also if you want. Then the staff, they provide oversight on quality and they use a criteria that they don't exceed three years for that appointment. Deliberations of medical staff and deciding privileges, we have to make sure that we are discussing it. Whether it's going through your PI committee, the medical executive committee, the department. In other words, if they are looking at the privileges, go and talk to people who work with them. Make sure that that's done fairly and objectively. They define circumstances when we do need to monitor. That's your focus professional practice evaluation. Maybe there's ongoing evaluation that you need to be doing in order to continue the privileges. Otherwise, medical staff evaluate, act on the reported concerns of a practitioner, whether it's a PA or a physician. Then we have to have mechanisms for that fair hearing and appeal. They must be in place. How do you identify and manage matters for just the health of the provider? That has to be separate from disciplinary. So if you have a physician who's just not acting right and their concerns about their health, then that has to be separate from any disciplinary process. Then they do say privileged practitioners participate in continuing education. I'm going to talk about the rest of them later when we get more into telemedicine. Otherwise, same with history and physical. No more than 30 days or 24 hours after admission. It has to be done before a procedure that requires anesthesia. For those done within that 30 days, make sure there's an update that it occurs 24 hours after admission and at least prior to that procedure. For dean status, if you are going to do the assessment, that's fine. It has to be completed and documented before you do your procedure, after registration and before those requiring anesthesia. HMP is documented and especially before operative or high-risk procedures. And the bylaws, they include the requirements for completing and documenting that history and physical. That's part of the dean status. You have minimum content that you must have for what you're going to do for the treatment and services. Monitor the quality of your history and physicals, that the medical staff, that those who are going to be privileged, they do the history and physicals and those that require updates. If permitted, then they can allow physicians who are not MD or providers who are not MDs to do all or part. Again, depends on what state law says they can do. And then the medical staff, they define when it has to be countersigned. But just keep an eye on state law in that respect. Now, that is different from what CMS says, so just keep that in mind. Medical staff, you define the scope of the history and physical for non-inpatient services. Perhaps they're going to be doing, say, a pain procedure in their outpatient surgery center that's non-inpatient. They develop and maintain policies for an assessment versus the history and physical. Again, age factors, standards of practice, state and local laws. I want to point out one thing. These are not in the critical access standards for that assessment. It's simply for the acute hospitals. I have asked CMS, are you going to allow critical access hospitals that same option to do an assessment over a history and physical? And they say, we're not at liberty to respond to that question at this time. So for critical access hospitals, you don't have that benefit of an assessment over the full history and physical. Okay. Let's go ahead and move on to telemedicine. Before I do, do we have any questions, Lindsay, that you want me to answer? It would help if I wasn't double muted. I was talking and you couldn't hear me. I was just saying I don't see any at this time. Okay. All right. Well, that just brings us to the next slide anyway, because we now have, excuse me, well, we have now a question. Perfect. I'm going to go ahead and put that one on everyone's screen here. Okay. And it says, our facility has a policy on telemedicine that includes, and you can select all that apply to your organization here, proper use of service, who can access the service, privileging and credentialing for the remote site providers, practitioners who can provide telemedicine to other sites, circumstances when telemedicine cannot be utilized, or not sure that we have a policy on telemedicine. And as Laura referenced, if you do have any questions for her up to this point in the presentation, go ahead and be typing those into the Q&A option found there at the bottom of your Zoom window. Or if for some reason you don't see that option, you can of course type in any questions that you have there in the chat. I did see some questions that just came in to me personally asking for links to the slides, and I did go ahead and post those earlier there, but I'll go ahead and post this again for everyone to have in the chat now as a resource as well. We've got a couple of responses still coming in here, it looks like. Give me just another second. Okay, perfect. Go ahead and end this and share those results there. Okay. Oh good, they're all over. That's wonderful. I like a lot of those, the different varieties. Telemedicine. We probably all know it. We probably all have done it one form or another. It's provision of services by practitioners at a different site using electronic communications. Now there are two ways to do this. Simultaneously, in other words, you see the provider and they see you. That's simultaneous. Then non-simultaneously. Teleradiology fits under this. If you are using, and I'm only just going to say the service because I'm familiar with Nighthawk, and they are reading your x-rays at night, that's telemedicine. Believe it or not, that is still telemedicine. We know COVID expanded the use of it. It really was beneficial because not only did we get medical care provided, but it protected the providers from transmission. They noted in 2019, there were 840,000. 2020, 52.7 million incidences of telemedicine. In August CMS, they wanted to permanently maintain some of those expansions of telehealth, but they didn't quite happen. They made the proposal, didn't happen. These are just a percentage of those who have used telehealth. This is the most recent one. Those who did respond, you can see we had somewhat of a spike in 2021, but it's leveled off. It's still pretty significant on how many use telemedicine. They do see this as a huge strategic tool because it can help grow revenue. Efficiency, it's much easier or more efficient when the physician can be in their office. It improves safety. Sometimes outcomes, maybe patients will feel much more comfortable talking to a computer screen rather than face-to-face, plus patient have to get up, get in the car, drive to the office, etc. We saw this very, quite an increase also in mental health care, that the patients felt much safer in an area where they were familiar with rather than going into a physician's office. They have noted higher profits. 16 hospitals, their revenues bounced up from 2.4 to 4 million, so it was huge. Increased access to care, critical access hospital patients, especially at specialty care, really increased that access. Now they see 80 more additional services that can be furnished by telehealth, and we can bill for it at the same rate of inpatients. I got a notice from my healthcare provider in the system that they will charge for telehealth, and of course, you should. They're providing care. Let's start with acute hospitals. Governing body, you can have the medical staff at your hospital rely on the privileging credentialing of that other hospital and making recommendations on privileges. As an oversight, just an overview statement, those who provide telemedicine services to your patients must be privileged at your hospital. So just because they're providing the service, they still have to have privileges at your hospital, have to go through the whole thing. Now, this is also covered in tag 52 under the governing body section. So let's start with the hospital, just inside hospital. Your governing body has to make sure there is a written agreement with that hospital, and it must include all of these items, that the hospital is a Medicare participating hospital, that whoever is at that hospital has privileges to practice at that hospital. The hospital, that distant site hospital, has to give you a list of those privileges for each provider of that telemedicine service, and that the provider, the physician or practitioner, is licensed in your state where your patient is located. There has to be the originating hospital, that's you, you have to have evidence that there's been some internal review of that practitioner's performance in giving telemedicine services to your patient. Then you have to send that information back to their hospital on what you found out on that periodic review, including the adverse events, any complaints that you've received about that telemedicine provider. Entities, these are different. These are when they're outside, they're not in the hospital, group of physicians have gotten together and decided to do this. Now, it used to be CMS wouldn't reimburse for that, and then they realized, well, wait a minute, that doesn't make any sense, because they do provide that service. Well, the problem was CMS doesn't have any oversight for an entity like that. What they figured out was, well, we still want to be able to provide this service, make it available, so we're going to make an exception. In this situation, the governing body, again, can have their medical staff rely on the privileging decisions of that entity and making recommendations for privileges for those providers. There are entities around the nation that do provide strictly telemedicine. That's all they do. This way, again, you can be reimbursed, and there can be payment for those services. As with a hospital, the governing body has to make sure there's a written agreement with this entity that the entity's privileging credentialing process is the same as yours. Those are the same standards. They are privileged at that entity that you have a list of what they can do. Are they going to provide care to neonates? Are they going to provide care to peds, et cetera? There's a license in the state where your patients are located. Now, the reason they did this, again, is because this entity can include a hospital that does not participate in Medicare. Really, CMS is throwing a wide net for us here. You can have a Medicare participating hospital. You can have an entity or a non-Medicare participating hospital still considered an entity and still get the services. It is a really nice wide net that they're making available to us. Back to the entity, there's evidence that they are also looking at their practitioners' performance. Also, that you are doing the same, that you send information off to them about that practitioner, any adverse events or complaints that you get. The surveyor, this is what they want to see. They want to see a written agreement that includes all of those required elements, participating in Medicare or they're an entity, the list of those practitioners who are providing the service, that they're licensed, and that your written agreement says my hospital is going to rely upon you, entity or hospital, when we make a recommendation. They want evidence that you reviewed services that they provided to your patients. Now, one nice thing is, instead of having individual files for those telemedicine physicians, you can have one big file with all of those, whereas for your own physicians, you want individual files. Now, you can keep separate ones if you want. It's a lot of paperwork, but that's your decision. Critical access hospital, very similar. I know this is a pretty quick question, but it's a little bit different situation in this one. Lindsay, I think this will be our last polling question too. I believe so. Okay, so this one says that county hospital is a critical access hospital with one emergency physician and one APN on staff. There are situations where the on-call provider is occupied and another patient presents and is experiencing a possible medical emergency. The county would like to utilize telemedicine for the assessment and treatment of the presenting patient. And then the question is, would you recommend such? And let's get that question pulled up for you here. Okay, and then of course your options, yes, no, or not sure. And Laura, it looks like we've had one question come into the Q&A here for you. And this says, regarding telemedicine privileges, does it matter if the privilege list provided by the distant site includes privileges that won't be utilized at your facility? For example, neurologists who are just reading for your facility have additional privileges at their home facility. I don't think that's going to be an issue. I really don't. Because it's what do you want them performing at your hospital? So I see what they're saying. Let's say that you've got a neurologist who is reading sleep studies or seizure, but yet they're providing different services at your hospital. That's fine. Just make sure that if you're going to limit those privileges, you're just aware of that at your own hospital. So let me see if I can put a good example. I like the neurologist. That's a good one. So I'm at this hospital, and I need a neurologist to review or have a consultation with my physician who's in the emergency department. But my neurologist at the distant site hospital can do a whole host of other things. Just make sure that whatever their privilege and credential to do at your hospital, that you've got that list available. I wouldn't expand if that's not what your neurologist wants to do. Because they have to sign off on that. They have to make sure that, yeah, I'm willing to do this too. Do they really make sure that, again, that expansive list doesn't overstretch what that neurologist wants to do? I hope that answered the question. If not, let me know. Yeah, absolutely. Kristen said yes, that answer is so perfect. Okay. All right. I'm going to go ahead and end this poll and share those results there. Okay. Oh, we got them. Good. We're all over. Okay. So let's just start first with telemedicine and TALA. We know some of the criticals don't have an MD in the emergency department. There could be a PA, nurse practitioner who have that training, if the states allow that. Now, the conditions say you have to have a physician immediately available. It can be by phone, by radio, that's fine. That means, yes, indeed, you can use telemedicine to meet those requirements. Because I've seen this happen where, you know, the physician is gone. They're not available. Maybe they're on vacation, whatever it is. Well, the hospital then has an agreement with another facility to provide that telemedicine ER coverage so that they are immediately available by phone, by electronic, that they can consult. So that is okay. You can still have your RN initially assess the patient. They can be the qualified medical provider to do the medical screening exam. But just note, MTALA is a separate different requirement. They do require the practitioner be available in the emergency department, physician, PA, nurse practitioner, clinical nurse specialist. They can be on call, and they can respond, but they must be on site within the 30 minutes. It cannot be met by telemedicine. So who's ever on site must get in there within 30 minutes in order to take care of that patient. So that doesn't exclude MTALA. You can't meet that requirement by telemedicine. It's a very fine line that they can use. The PA still has to be there, and they can work with the physician by telemedicine. The physician who's on call, if they request, if requested by that QMP, nurse RN, to make an in-person, that's fine. They must come to the hospital. So again, this is very different than telemedicine and MTALA. Otherwise, it's the same requirements for the acute hospital for your hospital. If you have an agreement, you must have that written agreement. They spell out what responsibilities for those who are providing services. They're appointed to the medical staff. That distance site hospital is Medicare participating. The physicians are privileged and credentialed there. They are licensed in the state where your hospital is. And again, the agreement must be in writing. You have to do internal review of those practitioners, send that information back to their own hospital, especially when that's an adverse event or it's a complaint. The hospital, they must participate in Medicare and give you a list of the practitioners who are covered and their privileges. Entity, again, same thing. If you're going to use an entity, then you have to make sure your agreement spells out the responsibility for those who have it. They are a contractor of services to your hospital. They have to make sure, the entity has to make sure that they provide services so that your hospital complies with all the conditions of participation. Same thing, the practitioners are licensed in your state and the agreement must be in writing. Governing body can rely on privilege and credentialing from that entity. But again, you have to provide information back to the entity when you've had a complaint or an adverse event. They need to do their own internal review. They do provide a definition for distance site entity. It's in the interpretive guidelines. These also include, just like the acutes, the non-Medicare participating or non-Medicare certified hospitals. That's considered an entity. I like it. Again, CMS put a very wide open space for us so that can occur. Credentialing, there are alternative ways you can do this credentialing. You can do proxy credentialing, either through the hospital or through the entity, whichever one, but you must have a written agreement. It also has to state their contractor services to you, that you can then meet all the conditions of participation. Again, I want to emphasize, they don't have jurisdiction over the entity, and so that's why they've allowed criticals and acute hospitals to use entities, but they have to make sure you meet the conditions. So really, they're kind of extending their oversight. The written contract does state that the hospital is Medicare participating, that the practitioners are privileged at that hospital, that they are privileged to provide services, and that they're licensed in the state where the patient is located. Same with the entity. The contract must say they're a contractor of services, that they utilize credentialing and privileging in a manner that meets all of the requirements in the conditions of participation, that they are covered by the agreement, and they're licensed in the state, and that you have evidence that you have done review of those services for those providers. Medical staff, look at doing an annual review and approve that list. You may have had experience with a certain provider at the other hospital that just doesn't work out, and so therefore, maybe we won't use them. Watch those adverse events and complaints. Those are crucial to keep on top of issues. Be aware of any grievances, and especially if you have requirements. Let's say you get a complaint from a patient who received telemedicine services while, say, they're in the ICU by a telemedicine provider. Well, make sure you're aware of the requirements that you have to meet, that maybe you need to respond to that grievance also. Also, make sure events are reported to that entity or facility and any requirements that you have to report to your committees, whether it's the board or medical executive committee. Now, here's just some additional comments. You don't have to do this, just some additional comments. The requirements don't apply where you're only using telemedicine equipment. In other words, patient's not a hospital patient, but somebody may use your equipment to make this call. None of this applies, but you might want to amend documents when you're doing, if you're starting to implement telemedicine, bylaws, administrative policy and procedures, the board report. Telemedicine really needs to be a part of your board report because you may start to pick up on issues that maybe you want to get rid of that contract with that provider, that entity, that hospital. And don't forget any of the oversight, the professional review. Have one file for your telemedicine docs. Make sure that the contract's approved by your governing body, medical staff, any other administration, your C-suite. Keep a list of those practitioners. And again, if you're having issues with a particular practitioner, don't worry about it. They're not going to be jumping on it right away. So just real quick, joint commission. They are in two standards for telemedicine. Leadership, because that talks about what's in your contract, and medical staff. They pretty much mirror what's in the conditions of participation. So the medical staff has to recommend services that can be delivered through telemedicine, and those who are responsible for that is done. They align with the conditions of participation. The governing body at the distance site, they're responsible to make sure this is done. At the originating site, you grant privileges based upon the recommendations from your medical staff. You still have the performance expectations that you monitor your contract's services that are provided. They have a note in here, and this is in the joint commission elements of performance. In most cases, each physician who does provide these services have to be privileged and credentialed, and they have to follow that process within the medical staff chapter. You have to have a written agreement, and it's the same thing. They're providing services that allow you to meet the requirements of the conditions of participation, and you make sure this agreement is in place, that it's current and it's reviewed. Credentialing, privileging, you can use the privileging decisions of that distance site, but the medical staff then has to make that recommendation. I just want some contract suggestions for the telemedicine. Again, I have to repeat my disclaimer. It's informational only. Please contact your attorneys when you're developing your contracts. So clearly identify the name of each party. If your name changes, and I'm only bringing it up because there's some hospital systems that they've changed their name again and again or they've been acquired, make sure your contracts reflect it and it's accurate. You want to confirm the hospital is a Medicare provider, that the providers, the medical staff, licensed practitioners from that other hospital, they are on an attachment along with what they can do and their specialties. The hospital, the distance site hospital, gives you an updated list with those providers, and make sure if anybody comes off that that's taken off your list. Include what's in the provisions for credentialing and privileging decisions. That credentialing of the distance site hospital helps you meet what you need to do, your conditions of participation, that you're going to rely on those credentialing and privileging decisions of that hospital, and, of course, everybody's licensed in your state, that you will look at a list of those providers before you're going to grant privileges to your hospital, that you will do internal review periodically of those providers, and that if there's an issue that comes up, that USC hospital will send it back to that distance site hospital. How and when, the number of days, what do you have to have and give notice if you're going to terminate the agreement and under what conditions? Is it going to be immediate termination because, oh, boy, they're not good providers, or 30 days, 60 days? Just some considerations to include. When will it be in effect? Who's going to sign off on it? And that's within each hospital. Usually someone within your governing body is going to sign off on that agreement. It's the entire agreement. Any changes have to be in writing and approved and that which law is going to apply if there's a lawsuit. Are you going to use binding arbitration? If so, under what conditions will that occur? So there are resources out there for you. CMS has them. Their learning network. There's articles on telemedicine. They even have a telehealth website. Medicaid, they also have a telemedicine website. I just want to include a few of these not to overwhelm you because there are several slides here. Like I said, this is what that Medicare Learning Network talks about, the table of contents. Now, the 1135 waiver, that's only in effect when there's been a declared emergency, public health emergency. If you don't have one, they don't apply. Also standards, follow national standards of care, whether it's rehab, EICU, video conferencing. Maybe you're going to do wound care by video conferencing or video telemedicine, whichever it happens to be. There are standards. There are guidelines out there. I've just listed a host of them here for you to tap into some of the practice guidelines that do occur. There is even a rural telehealth toolkit, seven modules. Very good on implementing the program if that's what you're going to do. Is it sustainable for your program? American Medical Association, they have resources, even a playbook that you can download. I've tried to include all of those that are free to you. Check with your liability carrier before you do this also. That's why I said find out which law is going to apply if you're going to be across state lines. They want to make sure just they talk about the Institute of Medicine. Now the National Academy of Medicine, they talk about telemedicine, how you assess telecommunications for healthcare. And then the Federation of Medical Boards because they can have information on who's licensed, what are the requirements for licensure. And this is the most current one I could find, the July. It talks about registry, licensure, reimbursement, really good resource. And some additional requirements, standards of care during in-person. Well, it's the same as electronic. Establish that physician-patient relationship and make sure they're adhering to good guidelines. License where the patient's located and that there's a relevant medical history in the record. I included in here the telemedicine by state and what's required. So I've tried to include in here how you would link to those sites. That is their credentialing verification. They can do this service for you. Physicians, they can store core elements in there, so multiple states. And they use this, the state boards use that for primary source verification. And what are the cost information? Interstate licensing compacts, I do want to mention them. As of December, 37 states now have this. So it's nice because now physician, nurses, PAs, they can practice in multiple states. And it might help with not only just inpatient services but telemedicine reimbursement and help reduce and increase access. So I've included in here what are the compact states and who is required. Again, most of the states have interstate compact agreements. Two other resources for information on state laws, Center for Connected Health Policy and the National Conference on State Legislature for those who are included in the telehealth policy and coverage and reimbursement. Medicaid or Medicaid only for telehealth services. Very few states are just Medicaid only. So for contract, have a list of all the contracts in one place. Make it easy for when you do have to go find them. Make sure you have performance measures spelled out. So it is very simple what a person goes down and reviews. They don't have to come up with this information. Have a policy on telemedicine. AHIMA has a good one. Make sure staff, they know what that policy is and that they are complying with it. There's a practice brief from AHIMA and then just some recommendations on policy and procedure. So it brings us to our last one. We have a little bit of time here. I'll go ahead and read through this as far as what this requirement is. So we've got a university, Medicare Level 1 trauma, 700-bed trauma facility. They contract with other facilities around their state and even a nearby state for services because they serve as a distant site hospital. All members of the team, there is a team of telemedicine providers. They have compact licensures. Springs, it's a critical access hospital in a neighboring state. They have a contract for neurotrauma services with the university. The written agreement spells out that university will provide the Springs Hospital with telemedicine services to the extent it does not interfere or affect care at patients at university. This is a key for this situation. So we have a neurosurgeon. They are privileged and credentialed and they're only licensed to one state. This physician, this surgeon, is not a part of the team. So they contact, Springs contacts the hospital, university, because we've got a patient who came in with a rule-out brainstem infarct due to substance abuse. Another neurosurgeon who is on the team is on duty, but of course they're scrubbed in because they had a gunshot wound. Dr. B has a non-emergent surgery set up. All right, what are you going to do now? Because again, the one physician isn't on the team. She's not licensed in that state where the Springs is. What do they do in this situation? And here are your options available to you. You can choose maybe more than one or if you have any other suggestions. And then I'll tell you what the hospital ended up doing. So again, we have some good time. Give you guys back a little bit more time in your day. So Lindsey, are there any additional questions? Yes, it looks like we do have one. And I went ahead and put those options there up on the screen for you all to choose as a polling question there. So you can select one of the options that are on the screen for the discussion questions. So you can have that. And if you don't see your selection there, you can type in any other recommendations there into the chat as well. Okay, so this question asks, are we as credentialers required to verify originating site license as well as the receiving site or where we are located? Can you repeat that for me, please, Lindsey? It says, are we as credentialers required to verify the originating site license as well as receiving site or where we are located? Are you talking the hospital or the individual practitioners? Yeah, I'm not sure. And this question did come in anonymously. So if you are still on and you ask this question, if you could give us just a little bit more information there, we can make sure to answer your question. Because if the originating, if the distant site saying, yes, we're Medicare participating, they're going to have to stand by that. You can always ask for it. You can always go online and find out, are they a Medicare participating facility? And it might be in your benefit to do that if you have any concerns. And if anybody has any other kind of last-minute questions that possibly you just didn't type in earlier in the presentation, make sure that you're going ahead and typing those in either to the chat or the Q&A so we can make sure to address those. We do have just a little bit of extra time here today. And it looks like we've gotten some good responses here regarding this final discussion. So I'll go ahead and end that and share those results there. All right. So, yeah, this one, I agree with you. Do not reach out to the neurosurgeon and discuss the case. They're in surgery. Leave them in surgery. So that's very good. This may be an issue if they can't assist. Kind of depends on what other resources are available. That's always an option. Absolutely. My concern with having Dr. B relieve the other is that within their scope. I think it was a good alternative to put out there. That's why you want to make sure, you know, hey, this is going on. The other surgeon may be so far into that surgery, it is a safety issue for them to comply. So, you know, really having the other physician assist could be a licensing issue. So really what they need to do is you really can't help them. This is what we're going to try and do until we can get them relieved. We know of another hospital that perhaps can help us with it. This was an ugly, ugly situation. Eventually what they ended up doing was they talked to another facility to see if they could help out in the interim. And then the university really had to come up with an alternative plan to determine, hey, this happened. We know this happens. Now how are we going to prevent it from happening in the future? They ended up transferring the patient with the stroke to the hospital. They got them stabilized to the extent they could and then got them moved out. That was the only other thing they could do. They were stuck. There just wasn't any other safe alternative. So thank you for those who responded. Those were very good. It was a tough situation in that event. So just a couple additional resources. I have a few, the National Practitioner Data Bank, on how you get into that and who can access it. I know years ago they talked about, oh, we want the general public to have access to it. And, boy, did that get a backlash. And so there are just those who can. And the guidebook, that was the most recent one that I could locate. So just a few of them. Any additional questions? Please also feel free to reach out to Lindsey. She's really good about getting me those questions. And then I'll get back to Lindsey in direct response to those. So Lindsey, I'll turn it back to you. Yeah, absolutely. So we did have a clarification here to that previous question that says, speaking to the practitioner's medical license, when credentialing, do we need to verify their medical license at the originating site, where they are physically located, as well as their license in our state, where are they providing telemedicine consults to? Good point. Good. You can always go online and do your own verification. Usually, again, if you're relying on the privileges and credentialing, part of that should be you are verifying they are licensed in my state. But it never hurts to do that quick backup check going online and checking it yourself. You can do it for nurses, and I believe you can do it for physicians only. It takes just a few minutes, and it will satisfy that requirement to make sure, yes, indeed, it is done. I would do it individually myself to make sure they are indeed licensed in your state. Okay. And then this last question that I see here asks, does telemedicine need to be listed on the DOP as a separate privilege request? Yes. I would include that. Okay. I don't see any other pending questions. Let me post this for you all here in the chat. Just as a quick reminder that you will receive an email tomorrow morning, but just note that it actually comes from education. No reply at zoom.us. So if you don't see it in your inbox in the morning, it's possible that it got caught in your spam or quarantine folders because it is coming from that zoom email domain. And that email will include a link to the recording of today's session. And then again, a link to the slides. But I did go ahead and post the link again to the slides there in the chat for you to have as a resource now. And then just remember that the link to the recording is available for 60 days from today's date. And so you will need to click on that link and type in your information so that we can grant you access to that recording. We do have that additional security measure in place just to protect Laura's information here, make sure that those who have not registered correctly aren't getting access to the information. So again, you always need to click on that and type in your information that will prompt an email to come to us. And we typically approve those requests very quickly, honestly, typically within a few moments of receiving the request, but we ask that you give us one business day to grant those approvals. And then as Laura mentioned, if you do have any questions that possibly you just didn't type in today or you think of them later on, please don't hesitate to reach out to us at education at G H a.org. We'll be happy to get those questions over to Laura. And we are so thankful for her taking the time to thoroughly answer those in a timely manner. She certainly goes out of her way to do that. So we appreciate that very much. And we just thank you all so much for joining us today. And we looks like we have about 15 minutes to give you back of your morning or afternoon. And thank you so much, Laura, as always, for your time and the information that you shared with us today. We look forward to having you all back with us for future sessions and hope you all have a wonderful afternoon. Thank you so much, Laura. Thank you everyone. Thank you, Lindsay. Bye-bye.

risk management

patient safety

Laura Dixon

acute care

CMS regulations

Joint Commission

telemedicine

credentialing

privileging

compliance

critical access hospitals

medical staff

policies and procedures

Q&A