Attachment 4 NPPR Charter.pdf

Army Reserve Credentialing Non Privileged Provider Review Charter i

AMEDD Professional Management Command - Credentialing Division

Army Reserve Credentialing

Non Privilege Provider Review Charter

Last Revised:

January 2020

Table of Contents ii

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. Terms of Service 6

C. Qualifications

D. Substitution 7

E. Executive Committee 7

IV.

Review Process 10

A. Overview 10

B. Meeting Preparation 10

C. Conduct of Meeting 11

D. Review Method (Checklist) 12

E. Exception Management 13

V. Closed Loop Reporting 14

A. Required Reports 14

B. Chain of Command Reporting 14

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 (DHA-PM

6025.13), (Army Regulation 40-68), (Army Regulation 40-3) is provided by

US Army Medical Command (USAMEDCOM) Quality Management

Directorate.

The intent of the Army Reserve Credentialing Non Privilege Provider

Review (NPPR) is to provide a Clinical Quality Management Program

(CQMP) within the command for Army Reserve AMEDD non privileged providers. The mission of the NPPR is designed to support military treatment facilities (MTFs) clinical privileging process by ensuring non privileged provider’s credentials 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 not 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 local quality-of-care peer reviews, and will ensure the recommendations of the NPPR are appropriate. He/she will validate those recommendations in writing to those providers whose Provider Credentialing Files (PCFs) are determined to be disapproved, as well as, to the Soldier’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 NPPR activities prior to final approval by the Commander to include budget, panel members, changes in the charter, issues identified by the NPPR and reporting.

E. OIC Army Reserve Credentialing Non Privilege Provider Review (OIC

NPPR)

The NPPR Officer in Charge (OIC) is appointed by the Chief, Credentialing Division who is responsible for the overall daily operations for the NPPR and the organization’s CQMP for non-privileged providers.

The officer in this role will be expected to collaborate with various staff members and agencies to coordinate the NPPR calendar, identify qualified candidates to serve on the panel, and approve the non-privileged provider roster each meeting. The OIC will provide timely reporting of

NPPR results to the Command, and evidence of implementation of NPPR 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 NPPR OIC on approval of the final NPPR list of non-privileged providers to be reviewed, compliance rates, 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. This officer is the designated authority to which all risk management, adverse events and outcomes identified from the NPPR 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 utilizing ePAT in coordination with personnel and other divisions of the

Command resulting from the NPPR findings or other actions.

III. Advisory Panel

A. Member Profiles

The NPPR Review Panel will represent non-privileged providers from all clinical specialties within the United States Army Reserve Nurse Corps, Medical Specialty Veterinary Corps and Practical Nursing Specialty (68C).

Ideally, these members will be APMC RMs or Army Reserve Soldiers (ARS) and will receive an additional duty appointment letter signed by the APMC

Commander in coordination with their unit commander.

1. Assigned Members

a) NPPR OIC/Chairman - A Nurse 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 NPPR 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) Army Nurse Corps (AN) Representatives – The AN Corps representatives must hold one of the following AOCs 66B, 66C, 66E, 66G, 66N, 66S or 66T and having the clinical and credentialing expertise.

c) Army Veterinary Corps (VC) Representatives – The VC Corps representatives must hold one of the following AOCs 64A, 64B, 64C, 64D, 64E, 64F or 64Z and having the clinical and credentialing expertise.

d) Practical Nursing Specialty (68C) Representative. The Practical Nursing Specialist must have a current license with a strong clinical and credentialing expertise.

B. Term of Service

Members of the Panel will serve for a three (3) year term. 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 (ME) will fulfill the responsibilities until a replacement is appointed to the position.

C. Qualifications

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

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

2. Members will be O2 thru O5 in rank. E6 thru E8 for 68C.

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 non-privileging processes is various types of environments and training situations.

5. Member must have the authorization and opportunity to participate in regular Panel meetings to be held at APMC Forest Park, GA.

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

APMC.

D. 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 Program OIC (and Secretary), another Risk Manager 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.

E. Executive Committee

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

NPPR.

The Executive Committee of the NPPR shall be called into session for the confidential discussion of a non-privileged 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 Executive Committee as needed either during a scheduled NPPR meeting, or by conference call.

Membership shall be comprised of the Assigned Members and the Appointed members of the NPPR present for a given panel meeting. A Corps representative shall be included if a case is presented involving a non-privileged provider whose Corps is not otherwise represented on the EXCOM.

The NPPR OIC shall serve the Executive Committee as the Chairman. The meeting shall be closed to other members of the Board and other non-member attendees.

The Executive Committee 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 NPPR 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 a PCF, the EXCOM will make one of two recommendations to include:

Monitor

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 also serve as the Army Reserve Impaired Healthcare Personnel Committee (IHCPC). The IHCPC is tasked with providing support and oversight of personnel who are enrolled in the Impaired Healthcare Personnel Program (IHCPP). 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.

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

Recommend to the APMC commander a plan for management of healthcare personnel impaired by alcohol/other drug abuse/dependence, as well as psychiatric problems including emotional and behavioral disorders.

Recommend to the APMC commander a plan for management of healthcare personnel impaired by alcohol/other drug abuse/dependence, as well as psychiatric problems including emotional and behavioral disorders.

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 IHCPC will review input from the alcohol/drug abuse clinical staff, assigned counselor, the duty supervisor, and the involved healthcare staff member’s department chief, as appropriate.

In cases of medical or psychiatric impairment, the IHCPC will review statements of progress and recommendations from the impaired individual’s abuse assigned counselor and/or state board representative and recommend appropriate actions.

If, as the result of a physical condition/disorder/problem, an Non Duty PEB or IDES (MEB) recommendation results in a duty limitation or recommendation for separation from service, the PEB ruling will be reviewed for its impact on the individual’s privileges or scope of practice. If the non-privileged provider is unable to fully perform his/her AOC or MOS, appropriate modification of the individual’s scope of practice will be written on a DA Form 3349-SG Physical Profile Record.

IV. Review Process

A. Overview

The Panel’s activities must fall within the guidelines of AR 40-68 and all applicable Army Regulations and The Joint Commission (TJC) credentialing regulations. A USAMEDCOM representative may be contacted if needed, to provide the NPPR with further guidance concerning regulatory guidelines.

B. Meeting Preparation

The Credentialing Division will spend up to three calendar months preparing PCFs for targeted panel meetings. Every non-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 NPPR this includes those Soldiers considered Blue File.

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 NPPR will confirm the attendance of all panel members prior to each NPPR and the specialty area of PCFs files being reviewed is represented by the skill. There must be a minimum of 3 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 NPPR list.

C. Conduct of Meeting

These meetings 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 OIC/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. 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 board presentation and review of each PCF, the CCB will make one of four recommendations to include:

a. Approved

b. Deferred

c. Disapproved

d. Disapproved x2 (Show Cause Packet)

5. EXCOM/IHCPC. (As required).

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

7. Conclusion 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.

8. Post Processing. Following the review session, a memorandum for each file will be generated for each deferred and disapproved file indicating the Board’s final decision. The Chief, Credentialing Division or Commander will certify each of these documents by signature or electronic 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 OIC will be responsible for creating and distributing the Meeting Minutes.

D. Review Method -Checklist

The PCF reviews will be conducted from a checklist format 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 – APMC Credentialing Division Consent and

Demographic Data

b. Section II- Primary Source Verification (PSV) Specialty certification, Diploma, Primary Source Verification (PSV) Primary Education, 68C

Certification from the Academy of Health Sciences, Joint Base San

Antonio, TX

c. Section III- Risk Review Summary (if required) and Details of adverse actions and most current National Practitioner Data Bank query (NPDB)

d. Section IV- PSV State Licensure; Are all licenses current and in good standing, Basic Life Support (BLS), Advanced Cardiac Life

Support (ACLS), Pediatric Advanced Life Support (PALS) etc..

e. APMC Form 12 License Certification and/or Registration

Acknowledgment Form

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.

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-compliant/non-responsive despite three (2) documented attempts, legal, competency, malpractice, or 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/OIC will convene the panel for reading of the results and/or discussion of any exceptional files after the review of all scheduled files.

Following the review, the Chairman will certify by signature all approved PCFs. These documents will be returned to Credentialing Division for placement in the PCF.

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 NPPR

The OIC NPPR 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

1. Minutes and Pending Action List

The NPPR 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 NPPR OIC and certified per signature by the

Panel Chairman.

B. Chain of Command Reporting

Subsequent to the convening of the Panel proceedings, the NPPR 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 Soldier will have their file identified as “Disapproved” by the NPPR. 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

Staff Judge Advocates Office. A Show Cause package will include, but not limited to: A memorandum for record to the Soldier’s Command, and the NPPR’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).

KATHY L. BLOYD

LTC, AN

Chief, Credentialing Division