Attachment 3 ARCAP Charter Mar 22.pdf

AMEDD Professional Management

Command - Credentialing Division

Army Reserve Credentialing

Advisory Panel Charter

Last Revised:

MARCH 2022

Army Reserve Credentialing Advisory Panel Charter

Table of Contents

I. Authority/Mission 3

II. Collaborative Responsibilities 4

A. TSG (The Surgeon General) 4

B. USAMEDCOM 4

C. APMC Commander 4

D. Chief, Credentialing Division 4

E. OIC Army Reserve Credentialing Advisory Panel 5

F. Credentialing Division Project Manager 5

G. Risk Manager 5

III. Advisory Panel 6

A. Member Profiles 6

B. Selection Process 7

C. Terms of Service 8

D. Qualifications 8

E. Substitution 8

F. Executive Committee 9

IV. Review Process 11

A. Overview 11

B. Meeting Preparation 11

C. Conduct of Meeting 12

D. Review Method (Checklist) 13

E. Exception Management 14

V. Closed Loop Reporting 16

A. Required Reports 16

B. Chain of Command Reporting 16

VI. Attachments i Nomination Form 19 ii APMC Credentialing Division Checklist 20

I. Authority/Mission

The Army Medical Department (AMEDD) Professional Management

Command (APMC) Credentialing Division operates under the authority of the Commander who in turn reports to the Commanding General, Army

Reserve Medical Command (ARMEDCOM). Policy guidance (Army

Regulation 40-68) is provided by US Army Medical Command

(USAMEDCOM) Quality Management Directorate.

The intent of the Army Reserve Credentialing Advisory Panel (ARCAP) is to provide a Clinical Quality Management Program (CQMP) within the command for Army Reserve AMEDD privileged providers. The mission of the ARCAP is designed to support military treatment facilities (MTFs) and

Operational clinical privileging process by ensuring privileged providers credential’s are clinically ready through a peer review process.

Issue of Confidentiality: Information contained within a Providers’

Credentials File (PCF) is considered “Confidential” information and protected under the “Privacy Act of 1974”. Information reviewed will not be discussed or provided to anyone outside the panel. Panel members will never disclose any information within the files received or reviewed in this process.

II. Collaborative Responsibility

A. The Surgeon General (TSG)

The Surgeon General (TSG) as senior medical officer in the Department of the Army (DA) is responsible for the quality of health care delivered to all categories of beneficiaries and in all military treatment facilities (MTFs).

TSG establishes Clinical Quality Management Program (CQMP) policy and accrediting guidance for the Department of Defense (DOD), (AR 40- 68, p.1, 1-4a).

B. United States Army Medical Command Quality Management Division Staff (USAMEDCOM QMD Staff)

The USAMEDCOM QMD Staff will exercise broad oversight responsibility for implementing the AMEDD Clinical Quality Management Program (CQMP) as delegated by the TSG. They will provide corporate level guidance within the AMEDD on credentialing, performance-based privileging, outcomes management, medical staff appointment, accreditation processes, clinical advice, and clarify standards of care, practice, policy, risk management and/or adverse actions (AR 40-68, page 1, 1-4e).

C. APMC Commander

The Commander will be responsible for the administration of credentialing IAW AR 40-68, the effectiveness of the CQMP, Performance Improvement (PI), and Risk Management Programs (RMP) within his/her unit. He/she will employ qualified subject matter experts as necessary to conduct quality-of-care peer reviews, and will ensure the recommendations from the ARCAP are appropriate. He/she will validate those recommendations in writing to those providers whose Provider Credentialing Files (PCFs) are determined to be deferred or disapproved, as well as, to the provider’s Brigade, Unit Commanders, and the points of contact (POCs) delegated by those Commands.

D. Chief, Credentialing Division

The Chief, Credentialing Division answers directly to the Commander and oversees the Credentialing personnel to include military, DA Civilians (DACs), and contracted Credentialing Staff (CS).

The Chief, Credentialing Division gives direction and oversight for all ARCAP activities prior to final approval by the Commander to include budget, panel members, changes in the ARCAP charter, issues identified by the ARCAP, and reporting.

E. OIC Army Reserve Credentialing Advisory Panel (OIC ARCAP)

The OIC ARCAP is appointed by the Chief, Credentialing Division who is responsible for the overall daily operations for the ARCAP and the organization’s CQMP for privileged providers. The officer in this role will be expected to collaborate with various staff members and agencies to coordinate the ARCAP calendar, identify qualified candidates to serve on the panel, be responsible for the ARCAP budget estimates, logistics, and approval of the privileged provider roster for each meeting. The OIC will provide timely reporting of ARCAP results to the Command, and evidence of implementation of ARCAP recommendations to the panel.

F. Credentialing Division Project Manager (CDPM)

The CDPM or designated authority will be responsible for the administrative preparation of PCFs for review and management of the review process. The CDPM will confer with the OIC ARCAP on approval of the final ARCAP roster of providers to be reviewed, compliance rates for providers, Credentialing Specialists, and files requiring follow-up.

G. Risk Managers (RM)

The RM is an officer appointed by the Chief, Credentialing Division who has primary oversight for Impaired Provider Files (IPF). This officer is the designated authority to which all risk management, adverse events and outcomes identified from the ARCAP PCFs are reported. This officer will collaborate with the appropriate agencies for interpretation of policy and regulation. The RM is responsible for initiation of Show Cause Actions in coordination with personnel and other divisions of the Command resulting from the ARCAP findings or other actions.

III. Advisory Panel

A. Member Profiles

The Advisory Panel will represent privileged providers from all clinical specialties within the United States Army Reserve Medical Department, with the exception of Veterinary Corps. Ideally, these members will be Army

Reserve officers and will receive an additional duty appointment letter signed by the APMC Commander in coordination with their unit commander.

1. Assigned Members

a. Chairman - The ARCAP Chairman should be a Medical Corps officer having the clinical experience and credentialing expertise to be ultimately accountable for the panel’s performance. This person oversees the due process of the ARCAP and its primary functions.

He/she will be assigned upon the recommendation of the Chief, Credentialing Division and approved by their command for final appointment by the APMC Commander.

b. The Vice Chairman - The ARCAP Vice-Chairman should also be a Medical Corps officer with the clinical experience and credentialing expertise to ultimately be accountable for the panel’s performance in the absence of the Chairman. This position is recommended by the Chief, Credentialing Division and approved by their command for appointment by the APMC Commander.

c. Active Component MTF Commander or Deputy Commander for Clinical Services (DCCS). An MTF Commander or DCCS will be assigned to the Board in order to assure continuity with active component medical treatment facility (MTF) interests and procedures.

d. US Army Medical Command (MEDCOM) or office of the Surgeon General (OTSG) Representative. A MEDCOM or OTSG representative will be assigned to the Board in order to assure procedural continuity and compliance with AMEDD and OTSG regulations and policies.

e. ARCAP Officer in Charge (OIC). The ARCAP OIC for the centralized credentialing program will be responsible for the administrative management of the board process. This member will fulfill the role of Board Secretary and will be responsible for coordinating the Board Meetings to include creating the agenda, completing meeting minutes, and managing the meeting follow-ups.

2. Appointed Members

The designated Corps members will be responsible for reviewing the following Areas of Concentration (AOCs):

a. 60-Series Medical Member (MC) - This member is a MC privileged provider responsible for reviewing credentials for 60 and 62 series.

b. 61-Series Surgical Member (MC) - This member is a MC privileged provider responsible for reviewing credentials for 61 series. Should a member of the 61 series be unavailable for the ARCAP, a member of the 60 or 62 -series may review these files and vice-versa.

c. Dental Corps (DC) Member - This member is a DC privileged provider responsible for reviewing credentials for 63 series.

d. Specialist Corps Member (SP) - This member is a SP privileged provider responsible for reviewing credentials for 65 series.

e. Army Nurse Corps (AN) Representatives - This member is an AN privileged provider who is responsible for reviewing credentials for

66F and 66P series.

f. Medical Service Corps (MS) Member - This member is a MS privileged provider responsible for reviewing credentials for 72, 73 and 67 series.

g. Alternates - The Chief, Credentialing Division will identify a group of Alternate Panel Members Elect to serve as substitutes for appointed members of the panel who may not be able to attend meetings. All primary appointed members will be responsible for notifying the OIC at least 30 days in advance to ensure timeliness of orders.

B. Selection Process

The selection process for the panel will adhere to the following guidelines:

1. Army Reserve AMEDD officers will be screened from the APMC databank of privileged providers by the CDPM/ ARCAP OIC and qualifications reflected in the PCFs will be reported to the Chief, Credentialing Division.

2. The candidates will be nominated by the Chief, Credentialing Division at which time the OIC ARCAP will contact the selected providers to determine their availability and commitment to the ARCAP mission.

3. Recommended nominees and their qualifications for service will be reviewed by the Chairman of the Panel (and/or his/her designate(s)) will interview the candidates and qualifications for service.

4. The Chairman of the Panel (and/or his/her designate(s)) will provide recommendations to the Chief, Credentialing Division for final approval. Unit Commanders should be contacted for recommendations and references (Attachment i).

C. Term of Service

Members of the Panel will serve on appointment for a two (2) year term and may be staggered to provide for general continuity in future years.

Terms for all members will be considerate of PCS issues and unit requirements that may arise during their service on the Panel. In the case that a PCS requirement causes a member to resign the position, an alternate Member Elect will fulfill the responsibilities until a replacement is appointed to the position.

D. Qualifications

Panel members tasked with reviewing and verifying clinical credentialing must meet the following qualifications:

1. Members must possess clinical expertise within their AOC or specialty as evidenced by verification of education and Panel certifications (when applicable).

2. Members will be either O-5 or O-6 in rank, but more junior officers will be considered on a case-by-case basis.

3. Members must be in excellent clinical and operational standing within their respective organization as evidenced by recommendations / referrals by unit commanders.

4. Members must have a thorough understanding of the credentialing and privileging processes employed at the Medical Treatment Facility or Operational Environments.

5. Member must have the authorization and opportunity to participate in regular Panel meetings.

This requires the approval of the unit of assignment commander and first line supervisor if they are not attached to the APMC.

E. Substitution.

Substitution for an Assigned Member of the Board shall follow these rules:

1. Substitutions shall be approved by a simple majority vote of the Board. Substitutions shall be valid only for the Board meeting in which the substitution was approved.

2. For the ARCAP OIC (and Secretary), another Risk Manager (RM)/Quality Assurance (QA) Officer from the credentialing division may fill that role.

3. For the MEDCOM and DCCS representative, another member from the Army MEDCOM/OTSG or DCCS with comparable background and experience may fill those roles.

F. Executive Committee

The following guidelines address the Executive Committee (EXCOM) of the

ARCAP:

The EXCOM of the ARCAP shall be called into session for the confidential discussion of a provider’s adverse credentials information (e.g., license restrictions, substance abuse) or at the discretion of the Chairman. The Chairman may request a meeting of the EXCOM as needed either during a scheduled ARACP meeting, or by conference call.

Membership shall be comprised of the Assigned Members and the Appointed Members of the ARCAP present for a given panel meeting. A Corps representative shall be included if a case is presented involving a provider whose Corps is not otherwise represented on the EXCOM. The ARCAP OIC shall serve the EXCOM in an administrative role. The meeting shall be closed to other members of the Board and other non-member attendees.

The EXCOM shall meet in closed session. All matters discussed during the session will be held confidential by the members of the Committee after the meeting. Minutes of the EXCOM shall be published separate from the Minutes of the ARCAP meeting as a whole and shall be marked “FOUO/FOIA Exempt (Exception 4 applies).” Minutes of the EXCOM will be distributed only to members of the EXCOM.

After discussion of the adverse credentials, the EXCOM will make one of four recommendations to include:

Monitor/ Defer/ Disapprove

Perform an Evaluative ECT

Submit an AOC Change

Process a Show-Cause packet

The EXCOM will additionally make recommendations regarding any follow-up documentation and/or actions that need to be taken.

The EXCOM will collaborate with AA (MEDCOM) and State Impaired Programs; as part of the Army Reserve Impaired Healthcare Personnel Committee (IHCPC). The ARCAPs EXCOM and assigned RM are tasked with providing support and oversight of personnel who are enrolled in an IHCPC.

The IHCPP is designed to provide support, assistance, and rehabilitation to those healthcare personnel who suffer from a condition that negatively influences, or has the potential to negatively influence, optimal performance.

Impairment applies to the manifestations of emotional or psychological conditions, alcohol or other drug use/abuse problems/dependency and physical limitations when the individual’s physical condition places the safety of patients or others in jeopardy. Proper medical profiling is essential if applicable to ensure command awareness and deployability.

The EXCOM will meet as needed to accomplish the following functions:

Recommend to or advise unit commanders a plan for management of healthcare personnel impaired by alcohol/other drug abuse/dependence, as well as behavioral health problems including emotional and behavioral disorders and when the provider becomes non-complaint with mandated programs (court, state, federal).

Ensure RM monitor the progress of impaired individuals during treatment, through aftercare, until the completion of the ongoing monitoring phase.

When impairment is due to alcohol or other drugs, the RM will review input from the provider’s State IHCPCs alcohol/other drug abuse clinical staff, the duty supervisor, and the involved healthcare staff member’s department chief or counselor as appropriate.

In cases of medical or psychiatric impairment, the RM will review statements of progress and recommendations from the impaired individual’s physician and duty supervisor and recommend appropriate actions.

If, as the result of a physical condition/disorder/problem, a DD Form 3349-G is written for a permanent condition (P3, P4) recommendations for referral to IDES may result in a duty limitation or recommendation for separation from service, the IDES ruling will be reviewed for its impact on the individual’s privileges or scope of practice. A Line of Duty (LOD), formal may need to be generated by the unit to determine cause or responsibility to the military.

IV. Review Process

A. Overview

The Panel’s activities must fall within the guidelines of AR 40-68 and all applicable Army Regulations (which typically includes the Army’s interpretation of The Joint Commission (TJC) credentialing regulations). A

USAMEDCOM representative may be contacted if needed, to provide the

ARCAP with further guidance concerning regulatory guidelines.

B. Meeting Preparation

The Credentialing Division will spend up to six calendar months preparing

PCFs for targeted panel meetings. Every privileged provider file is reviewed by the panel every twenty four months, plus or minus sixty days.

Those falling into the window of biennial review are targeted for presentation to the ARCAP.

When the panel meets, the CDPM and the appointed staff will have prepared the Provider Credentials Files (PCFs) to be reviewed. These files will be neatly organized as per AR 40-68 & TJC specification with a supplemental overview sheet providing each panel member a visual cue to the overall status of the file. The PCFs will be organized by clinical practice area and subdivided into the following categories:

1. Files that have been reviewed and are believed to be in full compliance

2. Files that have been reviewed and have areas that require review by the panel

3. Files that have been deferred from prior meetings that are being reassessed or represented for review

The OIC ARCAP will confirm the attendance of all panel members prior to each ARCAP and the specialty area of PCFs files being reviewed is represented by the skill. There must be a minimum of five of the seven appointed members to convene the panel. If the minimum numbers of members are not present, the panel will be rescheduled within 30 calendar days. The files scheduled for review will be added to the next scheduled

ARCAP roster.

C. Conduct of Meeting

The meeting will be structured to allow each Board member to conduct independent review of the PCFs assigned to them followed by a presentation of their findings and recommendations to the entire board.

The meeting agenda will be as follows:

1. Welcome. The Board Chairman will begin each meeting by welcoming the members and reviewing the minutes of the previous meeting. Corrections will be suggested and approved. (In the absence of the Chairman and the Vice Chairman, the Secretary will call the meeting to order.)

2. Statistical Overview. The Chairman will review the statistical reports from the previous panel as described in section (§ V. a.)

3. Board Member Independent File Review. Each Board member will be presented with a set of files to review independently. Review criteria are listed in attachment ii. File review may be conducted prior to the start of the Board meeting but must be completed prior to the presentation of the file to the Board as a whole.

4. Presentation of Reviewed PCFs (to the Board at large). PCF files will be presented in alphabetical order (rather than by specialty). The independent reviewer will provide their credentialing recommendation on each file as it is called. If no issues or exceptions have been found, then the PCF will be presented as such. If the reviewer has determined exceptions or concerns, the Board will review those issues in detail as outlined in the Exceptions Management section (§ IV. e.) After the board presentation and review of each PCF, the ARCAP will make one of four recommendations to include:

a. Approved

b. Deferred

d. Disapproved

e. Disapproved x2

5. EXCOM. (As required).

6. Conclusion and Adjournment. The Secretary will present a prospective view of the next Board files and other expectations for review by the Board.

The Chairman will ask if there is further discussion of any files that have been presented, or if there are other matters that the Board needs to address. If there are none, the Chairman will adjourn the meeting.

7. Post Processing. Following the review session, a memorandum will be generated on all deferred and disapproved files by the board.

The Chief, Credentialing Division will certify each deferred memorandum by signature. The APMC Commander will certify each disapproved memorandum by signature. These documents will be returned to the APMC Credentialing Division for distribution to the Soldier and the applicable unit commander (s). A copy will also be included in the provider’s PCF. A full accounting of all Board activities, including all Board recommendations and decisions, will be captured in Meeting Minutes to be published and distributed at the subsequent Board meeting. The Board Secretary will be responsible for creating and distributing the Meeting Minutes.

D. Review Method -Checklist

PCF reviews will be conducted from a checklist format (Attachment ii) and will adhere to the following guidelines:

1. Panel Member Independent File Review - Each panel member will be presented a set of files to review independently, paying particular attention to the following contents of the PCF:

a. Section I –AMPC consent form, demographics and Initial e-

Application for Clinical Priviledges.

b. Section II – Civilian or Military Privileges, Scope of Practice, Letters of Reference, and Past Evaluations from military duty. Specific questions to be addressed include:

i. Has the provider been practicing in the areas for which he/she would be privileged?

ii. Does the practitioner maintain work related adverse actions (including malpractice claims)?

iii. Does the practitioner have credible and favorable references from employers?

iv. Have the practitioner’s peers and facility commanders provided performance evaluations indicating that the provider is competent and in good standing?

v. Does the practitioner require supervisory training to confirm clinical competency?

c. Section III – Details of adverse actions and most current National

Practitioner Data Bank query. Malpractice Insurance or statement.

d. Section IV – Curriculum vitae, and additional training in specialty.

e. Section V - Contains historical information and will require little, if any, review by the certification Panel.

f. Section VI – Majority of time will be spent reviewing the contents of this section which contains documents covering the following areas:

i. Education – Where did the practitioner attend medical school, perform internship, residency, and fellowship (if applicable). Has all required training been completed, certified, and is it consistent with the awarded AOC?

ii. State Licenses – Are all licenses current and in good standing?

iii. Certifications – Are all other applicable certifications, to include BLS and appropriate national certifications, current and in good standing?

iv Federal DEA and State DEA (if applicable)

v. NPI number

2. Presentation of Reviewed PCFs - PCFs will be presented in alphabetical order (rather than by specialty). The independent reviewer for each PCF will provide a brief overview of the current state of that

Soldier’s credentials and the appropriateness for approval. If no issues or exceptions are determined, then the PCF will be presented as such.

If the reviewer has determined exceptions or concerns, the Panel will review those issues in detail according to the Exception Management protocol.

E. Exception Management

The panel will handle questionable PCF files in an open forum model where no clear consensus and decision on approval, deferral or disapproval can be reached. An open discussion, moderated by the Panel Chairman, will be held to discuss in detail the issues in question. This discussion will likely result in a recommendation or a series of recommendations from the panel including, but not limited to:

1. Requests for additional information and research (e.g. additional letters of reference or performance evaluations from past duty).

2. Directives for completion of additional requirements by the Soldier (e.g., Evaluative Extended Combat Training (ECT) or AOC changes).

3. Unit Commander Intervention.

4. Disapproval of the PCF and subsequent recommendation to the Soldier’s unit commander for personnel action (e.g. non-responders despite three (3) documented attempts, legal, competency, malpractice, and impairment issues).

Any panel recommendation will be rendered by casting a vote using a quorum majority (two-thirds). In the case a “nay” vote or the vote is deferred, the appropriate follow-up actions (e.g. defer for further processing, confirm unclear data, defer for Soldier action) will be outlined by the panel and recorded appropriately for execution.

V. Closed Loop Reporting

A. Required Reports

The Chairman will convene the panel for reading of the results and/or discussion of any exceptional files after the review of all scheduled files.

Once the results have been read and recorded the CDPM will compile the information and submit a deviation report to the Chief, Credentialing Division and OIC ARCAP.

The OIC ARCAP will review the results for any follow up actions that must be conducted by the RM and will review the compliance for Panel meeting preparation.

Deviation Report Includes:

Total number of files reviewed

Total number of approved files

Total number of deferred files

Total number of disapproved files

Approval rate % (this is strictly the number approved divided by the total number reviewed)

B. The ARCAP OIC will maintain a list of all providers for whom recommendations were made in previous panel reviews to include current status of the action. This list will be provided to the panel for accountability at subsequent meetings. Minutes from each panel meeting will be maintained by the ARCAP OIC and certified per signature by the Panel Chairman.

C. Chain of Command Reporting

Subsequent to the convening of the Panel proceedings, the ARCAP OIC will forward the names of the Non Responsive and Non Compliant

Soldiers to the Chief, Credentialing Division and APMC Commander. A by-name list of the Soldiers, Unit, and Medical Command will be reported to the General Officer level.

A Non Responsive, twice Non Compliant provider will have their file identified as “Disapproved” by the ARCAP.

A Disapproved PCF will require the submission of a Show Cause package by the RM assigned, to the appropriate command with the recommendation from each command’s JAG/SJA. A Show Cause package will include, but not limited to: A memorandum for record to the

Soldier’s Command, and the ARCAP’s Non-approval/Disapproved status.

If no response is received by their Commander by the suspense date, the issue will be reported to the USARC Surgeon’s Office for resolution (which will be stated in the MOA).

The Army Reserve Credentialing Advisory Panel acts in an advisory capacity to the MTFs through ICTB preparation and Soldier’s Chain of

Command. The final decision to determine clinical competency and grant privileges at either a fixed MTF or Operational Privileges rests with each privileging authority.

WILLIE M FEAGIN

LTC, AN

Chief, Credentialing Division

DEPARTMENT OF THE ARMY

US ARMY MEDICAL COMMAND

FT SAM HOUSTON, TX 78234

The Following Officer Is Nominated To Serve On The Army Reserve Credentialing Advisory

Panel. AMEDD BRANCH: PANEL DATE:

MEMBER

Last Name First Name: MI:

SSN: Rank: DOR: AOC:

COMPO: Gender: Race:

Duty Information

Duty Location:

Position Title:

Address:

City:

State: Zip Code: -

Duty Phone: Ext. FAX:

E-Mail Work:

Alternate Contact Information (optional):

Home Phone: Cell Phone:

Pager:

E-Mail Home:

E-Mail AKO:

Remarks:

Travel Information:

Closest Airport: Travel by POV:

Attachment i

APMC Credentialing Division Summary Checklist

Rank: _______ Name:___________________________________

Mandatory Items are in bold letters.

SECTION I YES NO N/A

APMC Credentialing Division Consent Form (sign/date every 2 years) e-Application (every 2 years)

SECTION II

Two Letters of Reference (supervisor or peers every 2 years)

Primary AOC > Secondary AOC >

PSV for all Civilian Privileges, CURRENT JOB TITLE:

Scope of Practice/Civilian Privileges (every 2 years)

SECTION III

Risk Review Summary

Malpractice Insurance or statement NPDB/HIPDB Query (every 2 years)

SECTION IV

CV/Bio Summary (sign/date every 2 years) Continuing Education (last 3 years)

SECTION V

SECTION VI

Federal DEA or Statement Stating not required to have (every 2 years) State DEA (if applicable)

BLS

ACLS [mandatory for ER physician, and CRNA] PSV for Profession Certification Primary Certification in:

Additional Certification in:

PSV for all State License(s) State Licenses (every 2 years-at least one unrestricted license) Foreign Medical Graduate Certification (ECFMG/Fifth Pathway) PSV for all Additional Education (if any) Additional Education (Postgraduate Training) if applicable.

PSV for Primary Education Primary Education AMA (if applicable)

NPI

Does AOC match Civilian Privilege: YES / NO Primary Certificate : YES / NO

FOR CCB USE ONLY

Approved Deferred Denied

Comments:

Signature: Date:

Attachment ii