HT0011-20-R-0043 HFAS PWS Attachment 2e - DHA PM 6025.13 CQM in the MHS, Vol 4, Credentialing and Privileging.pdf

Defense Health Agency

PROCEDURES MANUAL

NUMBER 6025.13, Volume 4 August 29, 2019

Medical Affairs

SUBJECT: Clinical Quality Management in the Military Health System Volume 4: Credentialing and Privileging

References: See Enclosure 1

1. PURPOSE. This Defense Health Agency-Procedures Manual (DHA-PM), based on the authority of References (a) and (b), and in accordance with the guidance of References (c) through (s), establishes the Defense Health Agency’s (DHA’s) procedures to assign responsibilities and establish procedures for managing Clinical Quality Management (CQM) in the Military Health System (MHS). This DHA-PM replaces, in full, the contents of the DoD Manual 6025.13 (Reference (e)), which is targeted for cancellation. This DHA-PM, replaces, in Volume 2, the full contents, unless otherwise stated, of the following memorandums, which are targeted for cancellation: Assistant Secretary of Defense for Health Affairs Memorandum, "Policy on Reporting Joint Commission on Accreditation of Healthcare Organizations- Reviewable Sentinel Events in the Military Health System," July 13, 2004 (Reference (h));

Assistant Secretary of Defense for Health Affairs Memorandum, "Amplifying Guidance Relating to the Reporting of Sentinel Events and Personally Identifiable Information Breaches to the Office of the Assistant Secretary of Defense (Health Affairs)," February 13, 2012 (Reference (i)) [as related to the reporting of sentinel events only]; and Assistant Secretary of Defense for Health Affairs Memorandum, "Medical Quality Assurance and Clinical Quality Management in the Military Health System Sentinel Event and Root Cause Analysis Process Improvements," March 12, 2015 (Reference (j)).

2. APPLICABILITY. This DHA-PM applies to:

a. OSD, Military Departments, Office of the Chairman of the Joint Staff and the Joint Staff, Combatant Commands, Office of the Inspector General of the DoD, Defense Agencies, DoD Field Activities, and all other organizational entities within the DoD (referred to collectively in this DHA-PM as the “DoD Components”);

b. The entire MHS, including each DoD Military Medical Treatment Facility (MTF) and all other healthcare provided by the MHS;

DHA-PM 6025.13, Volume 4

c. Uniformed services personnel of the active and reserve components (including National Guard personnel in a Federal duty status), civilian, contract, volunteer, and other medical or dental healthcare providers who are assigned to and deliver healthcare; and

(1) Credentialed healthcare providers who are members of the Army National Guard or the Air National Guard, while working in a non-federal status (Reference (k) are subject to the procedures, policies, and authorities, as prescribed by their respective Army Regulation Reference (l)) and Air Force Instruction (Reference (m)), or as defined in the policies, rules, procedures, and laws of the State, territory, or District of Columbia in which they are credentialed and/or privileged;

(2) Trainees who have been granted clinical privileges outside the training program when patient safety concerns arise;

d. Managed care support contractors (MCSCs), designated providers, and overseas contractors, consistent with their respective contracts awarded by the DoD.

3. POLICY IMPLEMENTATION. It is DHA’s instruction, pursuant to authority delegated in Reference (b) and based on authorities in Reference (a) through (s), that:

a. Establishes CQM procedures in the MHS to provide an organized structure for an integrated framework of programs to objectively define, measure, assure, and improve the quality of care received by MHS beneficiaries.

b. Strengthens MHS CQM accountability, transparency, and standardization in the MHS.

c. Affirms the MHS’s unwavering commitment to quality healthcare for our beneficiaries, joint healthcare teams, and Combatant Commands across the globe, through CQM.

4. CANCELLED DOCUMENTS. This DHA-PM replaces, in Volume 2, the full contents of DHA-Procedural Instruction (DHA-PI) 6200.01, "Comprehensive Infection Prevention and Control (IPC) Program," April 24, 2017 (Reference (n)), which is being cancelled.

5. RESPONSIBILITIES. See Enclosure 2 of Volume 1.

6. PROCEDURES. Procedures specific to each program within the MHS CQM are addressed in Volumes 2–7 of this DHA-PM.

7. INFORMATION REQUIREMENTS. CQM uses several data capture, analysis, reporting, and decision support tools for patient safety, clinical quality assurance, and improvement to include the electronic medical record, databases such as the Joint Centralized Credentials Quality Assurance System (JCCQAS), and the Joint Patient Safety Reporting (JPSR), data visualization and report tools on CarePoint (a SharePoint platform), and more.

8. RELEASABILITY. Cleared for public release. This DHA-PM is available on the Internet from the DHA SharePoint site at: http://www.health.mil/dhapublications.

9. EFFECTIVE DATE. This DHA-PM:

a. Is effective on October 01, 2019.

b. Will expire 10 years from the date of signature if it has not been reissued or cancelled before this date, in accordance with Reference (c).

Enclosures

1. References

2. Credentialing and Privileging Glossary

4 TABLE OF CONTENTS

TABLE OF CONTENTS

ENCLOSURE 1: REFERENCES

ENCLOSURE 2: CREDENTIALING AND PRIVILEGING

GENERAL OVERVIEW

KEY OPERATIONAL DEFINITIONS

GOVERNANCE STRUCTURE

SCOPE AND CORE RESPONSIBILITIES

PROCEDURES

APPENDIX

SPECIALTY SPECIFIC LICENSURE, TRAINING, AND OTHER CREDENTIALS

REQUIREMENTS

GLOSSARY

PART I: ABBREVIATIONS AND ACRONYMS

PART II: DEFINITIONS

TABLE

Credentials Required for Privileged and Non-Privileged Providers Error! Bookmark not defined.

FIGURE

Privileging Process Overview

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ENCLOSURE 1

REFERENCES

(a) DoD Directive 5136.01, “Assistant Secretary of Defense for Health Affairs (ASD(HA)),” September 30, 2013, as amended

(b) DoD Directive 5136.13, “Defense Health Agency (DHA),” September 30, 2013

(c) DHA-Procedural Instruction 5025.01, “Publication System,” August 24, 2018

(d) DoD Instruction 6025.13, “Medical Quality Assurance (MQA) and Clinical Quality Management in the MHS,” February 17, 2011, as amended

(e) DoD Manual 6025.13, “Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS),” October 29, 2013

(f) National Defense Authorization Act for Fiscal Year 2017, Sections 702

(g) National Defense Authorization Act for Fiscal Year 2019, Sections 711 and 712

(h) Assistant Secretary of Defense for Health Affairs Memorandum, "Policy on Reporting Joint Commission on Accreditation of Healthcare Organizations-Reviewable Sentinel Events in the Military Health System," July 13, 2004

(i) Assistant Secretary of Defense for Health Affairs Memorandum, "Amplifying Guidance Relating to the Reporting of Sentinel Events and Personally Identifiable Information Breaches to the Office of the Assistant Secretary of Defense (Health Affairs)," February 13, 2012

(j) Assistant Secretary of Defense for Health Affairs Memorandum, "Medical Quality Assurance and Clinical Quality Management in the Military Health System Sentinel Event and Root Cause Analysis Process Improvements," March 12, 2015

(k) United States Code, Title 32, Sections 502 – 505

(l) Army Regulation 40–68, “Clinical Quality Management,” February 26, 2004, as amended

(m) Air Force Instruction 44–119, “Medical Quality Operations,” August 16, 2011

(n) DHA-Procedural Instruction 6200.01, "Comprehensive Infection Prevention and Control (IPC) Program," April 24, 2017, hereby cancelled

(o) United States Code, Title 10

(p) U.S. Department of Health and Human Services, Health Resources and Services Administration. NPDB Guidebook. Rockville, Maryland: U.S. Department of Health and Human Services, 2018

(q) Health Affairs Policy 05-002, “Health Insurance Portability and Accountability Act National Provider Identifier Enumeration Policy for Military Health System Individual (Type 1) Health Care Providers,” January 26, 2005

(r) DoD Instruction 1402.05 “Background Checks on Individuals in DoD Child Care Services Programs,” September 11, 2015, incorporating change effective July 14, 2016

(s) United States Code, Title 34, Section 20351

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ENCLOSURE 2

CREDENTIALING AND PRIVILEGING

1. GENERAL OVERVIEW. The credentialing and privileging process serves as the foundation for quality and safe care by ensuring qualified and competent staff deliver care in a manner that is consistent with their education and training, and the scope of services approved by their organization. This enclosure details the required documentation providers must have and maintain, the process for validating these credentials, and the methods for assessing competency to provide patient care.

a. Purpose. To direct the credentialing and privileging process for MHS healthcare providers.

b. Functions. The following sections related to the Credentialing and Privileging (CP) Program include requirements for licensure, credentials, and provider competency assessment. It describes the Privileging Authority and privileging process. It also addresses the responsibility of clinical leaders to manage the scope of a provider’s independent practice; and the requirements for oversight of non–privileged providers.

2. KEY OPERATIONAL DEFINITIONS. Knowledge of these terms is essential to understanding the scope, core responsibilities, and procedures of the CP Program. A full list of definitions for this manual is included in the Glossary.

a. adverse practice action. Restriction, reduction, or revocation of the clinical practice of a non-privileged provider as a result of a due process professional review action, based upon evidence of misconduct, impairment, or incompetence, or any conduct that adversely affects, or could adversely affect, the health or welfare of a patient.

b. adverse privileging action. Denial, restriction, reduction, or revocation of clinical privileges as a result of a due process professional review action, based upon evidence of misconduct, impairment, incompetence, or any conduct that adversely affects, or could adversely affect, the health or welfare of a patient.

c. approved postgraduate training. Postgraduate training program accredited by the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), or other similar entities regulating healthcare provider training programs.

d. clinical adverse action. Action invoked against a healthcare provider, privileged or not, with the result that the authority to practice clinically is adversely affected. Adversely affected privilege(s)/practice are the result of a due process professional review action based on evidence of misconduct, impairment, incompetence, or any conduct adversely affects, or could adversely affect, the health or welfare of a patient, and that leads to the inability of a provider to exercise

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their privilege(s)/practice with their own independent judgment. This is the collective term used in this manual that encompasses both an adverse practice action and an adverse privileging action.

e. clinical privileges. Permission granted by the Privileging Authority to provide medical and other patient care services. Clinical privileges define the scope and limits of practice for privileged providers and are based on the capability of the healthcare facility, licensure, relevant training and experience, current competence, health status, judgment, and peer and department head recommendations.

f. clinical privileging. The granting of permission and responsibility of a healthcare provider to provide specified or delineated healthcare within the scope of the provider’s license, certification, or registration.

g. competency assessment. Assessment of a healthcare provider’s knowledge, skills, and ability to deliver high quality, safe patient care. The Military Health System (MHS) assesses providers using standards from the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS), recognizing six areas of “General Competencies” including: patient care, medical/clinical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice. These may serve as the basis for healthcare provider care evaluation and privileging decisions.

h. continuing education. Education beyond initial academic or professional preparation approved by an appropriate certifying professional organization that is relevant to the type of care or service delivered in an organization.

i. credentialing. The process of obtaining, verifying, and assessing the qualifications of both privileged and non-privileged providers to provide safe patient care services. This assessment serves as the basis for decisions regarding delineation of clinical privileges, as well as appointments and reappointments to the medical staff. The required information should include qualification data such as relevant education, training, and experience; current licensure; and specialty certification (if applicable) as well as performance data, such as current competency, and the ability to perform the selected privileges. This data is collected, verified, and assessed initially and on an ongoing basis.

j. credentials. The documents that constitute evidence of appropriate education, training, licensure, experience, and expertise of a healthcare provider.

k. credentials file. A file containing pertinent information regarding an individual privileged provider to include credentialing and privileging documents, permanent performance data, medical practice reviews, continuing health education documentation, and information related to permanent adverse privileging actions.

l. credentials review. The credentials inspection and verification process conducted for healthcare providers before selection for military service, employment, and procurement. The

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credentials review process is also conducted for healthcare providers before medical staff appointment and granting of clinical privileges and is repeated at the time of reappointment and renewal of privileges.

m. current competence. The state of having adequate ability and up-to-date knowledge to perform the functions of a healthcare provider in a particular discipline, as measured by meeting these criteria.

(1) The provider has actively pursued the practice of their discipline within the past two years by having encountered a sufficient number of clinical cases to represent a broad spectrum of the privileges requested and that the individual has satisfactorily practiced the discipline as determined by the results of ongoing professional practice evaluation (OPPE).

(2) The provider possesses documented evidence of appropriate continued medical education to maintain the currency of skills and knowledge.

n. denial of clinical privilege(s). Refusal to grant requested privileges to a healthcare provider at the time of initial application or renewal. Denials that result from a professional review action following appropriate due process proceedings, and relating to evidence of the provider’s misconduct, impairment, or incompetence, or any conduct that adversely affects, or could adversely affect, the health or welfare of a patient are reported to the National Practitioner Data Bank (NPDB), state(s) of licensure, and other applicable certifying/regulatory agencies.

Denials that occur solely because a provider does not meet a healthcare institution’s established threshold criteria for that particular privilege, should not be reported to the NPDB - these are considered decisions based on eligibility and are not deemed to be a result of a professional review action.

o. focused professional practice evaluation (FPPE). A process whereby the organization evaluates the privilege/practice of the healthcare provider who does not have documented evidence of competently performing the requested privilege, or of demonstrated practice competency, at the organization. This process may also be used when a question arises regarding a healthcare provider’s ability to provide safe, high quality patient care. Focused professional practice evaluation is a time-limited period during which the organization evaluates and determines the healthcare provider’s professional performance.

p. healthcare provider. Any member of the uniformed services, civilian employee of the DoD, or contract employee authorized by the DoD to perform healthcare services.

q. Joint Centralized Credentialing Quality Assurance System (JCCQAS). A secure, worldwide healthcare provider credentialing, privileging, adverse actions, and risk management web-based application mandated by the Military Health System (MHS) used in the provider credentialing and privileging process. Portions of the information contained in JCCQAS are confidential, privileged and protected from disclosure in accordance with Section 1102 of Reference (o). JCCQAS is the official file for healthcare providers credentialed and privileged within the MHS.

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r. licensed independent practitioner (LIP). Any individual permitted by law and by the organization to provide care, treatment and services, without direction or supervision, and within the scope of the individual's license and consistent with individually granted clinical privileges.

s. monitoring and evaluation. A well-defined, time-limited, well documented plan of focused professional practice evaluation (FPPE) to confirm a healthcare provider possesses the knowledge, skills, and ability to render safe and effective healthcare. It must include a documented plan with delineation of clear expectations and measures of success. It requires a preceptor who provides full written evaluation of the monitoring period, with regular interval feedback, to both the provider and the Credentials Committee/Function. Privileges/practice remain intact during the period of monitoring and evaluation.

t. non-privileged provider. An individual who possesses a license, certification, or registration by a state, commonwealth, territory, or possession of the United States, and is only permitted to engage in the delivery of healthcare as defined in their granted scope of practice.

Examples include registered nurse (RN), licensed vocational nurse (LVN), registered dental hygienist (RDH), and medical technician.

u. ongoing professional practice evaluation (OPPE). A documented summary of ongoing data collected for the purpose of assessing a healthcare provider’s clinical competence and professional behavior. The information gathered during this process allows for identification of practice trends that may adversely affect, or could adversely affect, the health or welfare of a patient. It is the responsibility of the organization to determine the criteria used in the ongoing professional practice evaluation.

v. other authorizing document. A mechanism, such as registration and certification, by which a State, the District of Columbia, a Commonwealth, territory, or possession of the United States, grants authority to provide healthcare in a specified discipline. In specialties not licensed and where the requirements of the granting authority for registration or certification are highly variable, the validation by a national organization that an individual is professionally qualified to provide healthcare in a specified discipline. Special considerations apply in the case where healthcare is provided in a foreign country by any person who is not a national of the United States.

w. peer review. Any assessment of the quality of medical care carried out by a healthcare provider, including any such assessment of professional performance, any patient safety program Comprehensive Systematic Analysis (CSA) or report, or any other such assessment carried out by a healthcare provider under the provisions of this manual.

x. preceptor. A clinical peer who has been appointed in writing to evaluate a healthcare provider’s clinical practice. The preceptor is designated for consultation, clinical feedback, and general oversight of the clinical activities of the provider. A preceptor may review medical records, and conduct direct observation of a provider’s practice, however they are not required to be present for or approve the provider’s procedures or clinical decisions since the provider’s clinical privilege(s)/practice is not restricted in any manner. [Contrast with the definition for “proctor”.]

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y. primary source verification (PSV). Validation that a document is true and valid through contact with the issuing institution or its authorized agent.

z. privileged provider. An individual who possesses appropriate credentials and is granted authorized clinical privileges to diagnose, initiate, alter, or terminate regimens of healthcare within defined scope of practice.

aa. Privileging Authority. The Privileging Authority is a designated official who grants permission to individuals to provide specific care, treatment, or services within well-defined limits. The Privileging Authority also initiates and makes determinations on clinical adverse actions.

ab. proctor. A clinical peer who has been appointed in writing to supervise all or some of a healthcare provider’s clinical practice. The proctor is required in order for the provider to proceed in exercising designated clinical privilege(s)/practice. The proctor provides direct oversight of designated clinical activities and must co-sign all such documentation conducted by the provider. Certain procedures may require proctor approval prior to performing. All designated procedures will require some period of direct observation by the proctor. Proctors are required for providers with supervised privileges, and for those who have had a clinical adverse action taken against them with subsequent restriction in privilege(s)/practice. [Contrast with the definition for “preceptor”.]

ac. Report Authority. The official with responsibility to report to the National Practitioner Data Bank (NPDB), state(s) of licensure, and other applicable certifying/regulatory agencies following appropriate due process proceedings. The Report Authority is:

(1) The Director of the DHA with respect to matters arising from acts or omissions of healthcare providers privileged by a Privileging Authority under the responsibility of the DHA.

(2) The Surgeon General of the Army, Navy, or Air Force, respectively, with respect to matters arising from acts or omissions of healthcare providers privileged by a Privileging Authority under the responsibility of the Army, Navy, or Air Force, respectively.

(3) In cases in which the healthcare provider is privileged by more than one of the Report Authorities listed in subparagraphs (1) and (2), the one whose responsibility applies to the Privileging Authority most responsible for the matters under review. In cases of uncertainty, the DHA Director will designate the Report Authority. The designated Report Authority will ensure there is a comprehensive review of the entire matter.

ad. telemedicine. Telemedicine, also known as telehealth or virtual health, is the use of telecommunications and information technologies to provide health assessment, treatment, diagnosis, intervention, consultation, clinical supervision, education, and information across distances.

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(1) distant site. The distant site is where the healthcare provider providing the medical service is located at the time the service is provided via telemedicine. The DoD virtual medical center (VMC) may function as a distant site for purposes of this manual.

(2) originating site. The originating site is the location of a patient at the time the service is provided via telemedicine. The DoD virtual medical center (VMC) may be considered an originating site for purposes of this manual.

ae. virtual medical center (VMC). A VMC is an organization which serves as a coordination body overseeing the delivery of healthcare via telemedicine. The DoD VMC must operate in affiliation with an accredited MTF or be independently accredited. If the DoD VMC does not have its own Privileging Authority, it should use the Privileging Authority of an accredited MTF with which it is affiliated. The DoD VMC, acting as a distant site, must have a process in place to accept quality and safety feedback on the care provided, and take action as appropriate.

3. GOVERNANCE STRUCTURE

a. The DHA CP Program is managed by the CQM Branch in the Clinical Support Division (CSD) under the Deputy Assistant Director for Medical Affairs (DAD MA) within the DHA.

The DHA CP Program Lead manages program operations in collaboration with the DoD Joint Credentials Working Group and ad hoc groups for JCCQAS.

b. The DoD Joint Credentials Working Group is co-chaired by the Deputy Assistant Secretary of Defense for Health Affairs ASD(HA) Health Services Policy and Oversight designee, and the DAD MA representative. Representatives should include members from the DHA CP Program, the Military Departments, DHA and DoD Offices of General Counsel, and subject matter experts as needed. The purpose of this working group is to develop, promote, and provide oversight, direction, and guidance to improve the quality of the CP Program and manage the JCCQAS to serve and support the overall needs of the CP Program.

4. SCOPE AND CORE RESPONSIBILITIES

a. Privileging Authority

(1) The DHA Director/Military Department designee are the Report Authority and the Privileging Authority for their respective organizations. Privileging Authority is delegable to MTF Directors/Military Department designee, or to DHA Market Directors/Intermediate Headquarters Directors/Military Department designee for centralized CP Programs.

(2) Privileging Authorities issue local credentials review and privileging directives as appropriate.

(3) Privileging Authorities must also provide a mechanism for privileged and non-privileged provider involvement in the credentialing and privileging process.

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(4) Privileging Authorities establish mechanisms to comply with the processes in this manual to ensure individual healthcare providers function within the scope of their clinical credentials, granted privileges, knowledge, skills, and abilities, and to ensure these credentials records are current.

(5) Privileging Authorities must ensure the clinical performance and professionalism of all assigned healthcare providers are measured with assessment and documentation at intervals not to exceed 6 months per the OPPE requirements outlined in this manual. Clinical Assessment Reviews/Performance Appraisal Reports must be produced at intervals not to exceed 2 years, or upon permanent change of station (PCS).

(6) Privileging Authorities must ensure MTFs have an effective peer review process and follow focused professional practice evaluation (FPPE)/OPPE policies and directives per this manual to ensure current clinical competency of its healthcare providers.

(7) Privileging Authorities shall grant clinical privileges to privileged providers using standardized, specialty-specific privileges contained in the JCCQAS Master Privilege List

(MPL).

(8) Privileging Authorities direct a healthcare provider to be removed from direct patient care, in accordance with the due process procedures outlined in this manual, when a provider’s suspected misconduct, impairment, incompetence, or any conduct may adversely affect, or could adversely affect, the health or welfare of a patient, or staff member.

(9) Impaired healthcare providers must have their clinical privileges/practice reviewed by the Credentials Committee/Function and the Privileging Authority. (See Enclosure 4 in Volume 3 of this manual.)

b. Legal Counsel. Servicing healthcare legal counsel, judge advocates, and civilian attorneys working for DHA or the Military Departments and performing duties supporting the MHS will, for purposes of this enclosure, provide legal counsel as needed for credentialing and privileging issues, to include policy development.

c. MTF Chief of the Medical Staff or Military Department Chief of the Medical Staff designee (descriptive term, role may also be known as Chief Medical Officer, Medical Executive Committee Chair, or other titles for similar responsibilities)

(1) Must be a privileged physician holding an active appointment to the medical staff and be appointed by the Privileging Authority.

(2) Is the principal executive staff advisor to the Privileging Authority concerning matters of healthcare provider management directives, quality, and scope of medical care.

(3) Has oversight of professional staff management and professional practice review.

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(4) Acts as a liaison between the members of the medical staff and the executive leadership.

(5) When absent, the Credentials Committee/Function and healthcare provider management responsibilities will be delegated, in writing, to another privileged physician upon approval of the Privileging Authority.

(6) Is authorized to intervene on behalf of the Privileging Authority to immediately summarily suspend the privileges/practice of a provider when there are concerns that a provider’s practice adversely affects, or could adversely affect, the health or welfare of a patient, or staff member, and maintain the summary suspension until the matter is investigated and resolved in accordance with the provisions outlined in Volume 3 of this DHA-PM.

(7) Ensures all medical staff applicants are oriented concerning bylaws governing patient care, medical staff responsibilities, professional ethics, off duty employment, continuing education requirements, privileging, and clinical adverse actions and due process proceedings.

(8) May singularly review and award temporary privileges in the absence of the Privileging Authority during periods of medical necessity (life threatening situations).

(9) Is accountable for ensuring the CQM procedures in this manual are followed and monitored for compliance. Collaborates with other executive leadership on the spectrum and quality of care delivered, particularly with those senior leaders accountable to CQM procedures and processes within the various clinical disciplines (e.g., Senior Nurse Executive or equivalent, Senior Enlisted Advisor or equivalent, and others).

(10) Advises senior leadership and the Privileging Authority when off-duty employment issues arise involving privileged providers that may negatively affect patient care and/or ability to accomplish mission requirements.

d. Clinical Directors/Department Heads (descriptive term, role may also be known as Medical Director, Clinical Service Chief, or other title for similar responsibilities)

(1) Brief all healthcare providers applying for a medical staff appointment with clinical privileges within their department on the local CP Program and on department or clinic specific processes and requirements.

(2) Continuously monitor the professional clinical performance, conduct, and health status of department staff members to ensure they provide healthcare services consistent with their clinical privileges and responsibilities. Monitor CQM and medical staff activities for providers assigned to their department and ensure OPPE for all providers under their supervisory leadership is conducted in accordance with this manual. Coordinate with the Medical Staff Professional (MSP)/Medical Staff Manager (MSM) to ensure FPPE monitoring and evaluation plans are implemented and completed appropriately for new providers and other circumstances in accordance with this manual. Review OPPE data no less than every 6 months for

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opportunities to learn and improve the safety and quality of care, and for unfavorable performance trends.

(3) Ensure non-privileged providers, clinical support staff, and other personnel providing healthcare services in the department receive appropriate clinical supervision.

(4) Maintain approved medical staff appointments with delineated clinical privileges on privileged providers assigned to their departments. Ensure providers’ privileging information is readily available to organizational healthcare personnel as appropriate.

(5) At intervals not to exceed 12 months, assess the facility-specific MPL, facility resources, and limitations. Recommend departmental, specialty, and facility-specific credentials and privileging criteria for staff appointment and reappointment.

(6) Make recommendations for medical staff appointment with clinical privileges based on the applicant's professional qualifications, health status (ability to perform), and current competence.

(7) Use provider-specific results of CQM peer review activities when making recommendations for medical staff appointments with clinical privileges.

(8) Monitor the CP Program for all healthcare providers within their departments.

Coordinate with relevant senior clinical leadership as appropriate (e.g., Senior Nurse Executive, Senior Enlisted Advisor).

e. Medical Staff Professional/Medical Staff Manager (formerly known as Credentials Manager)

(1) Reports to the Chief of the Medical Staff.

(2) Serves as the technical advisor to the Privileging Authority, Credentials Committee/Function Chairperson, and assigned providers on issues related to the CP Program to include at least: appropriate procedures in accordance with this manual and other directives;

accrediting organization (AO) standards; and applicable federal, state, and other mandated regulatory guidance.

(3) Coordinates and implements written policies and procedures applicable to all aspects of the CP Program and all other CQM Programs, as appropriate.

(4) Ensures providers' identification are verified by viewing, and obtaining a copy of, a current valid picture identification issued by a federal or state agency, such as a driver’s license, military identification card, or passport.

(5) Provides technical management, verification, and assessments regarding credentials information; processes privileging and medical staff appointment applications; and monitors and tracks licensure, certification, and registration status for all privileged providers, as outlined in this manual, and for all non-privileged providers as directed by the Chief of the Medical Staff.

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Must also ensure evidence exists in the credentials file that establishes the authority by which a non-governmental employee may be granted privileges by the Privileging Authority (e.g., volunteer agreement, information from the Contracting Officer, other).

(6) Collaborates with Clinical Directors/Department Heads to identify, collect, track, trend, and analyze OPPE and FPPE. Facilitates departmental compliance with ongoing monitoring of the medical staff for Credentials Committee/Function review and for recommendations to the Privileging Authority for re-privileging.

(7) Supports the Impaired Healthcare Provider Program as per Volume 3 of this manual.

(8) Provides support to Reserve Medical Unit Credentials Committee/Function as needed and as applicable.

(9) Serves as point of contact for fee-exempt Drug Enforcement Administration (DEA) registration and National Provider Identifier (NPI) Type 1 registration.

(10) Serves as the Privileging Authority’s JCCQAS database administrator authorizing user access, education, and training on new CP procedures, processes, and policies.

(11) Establishes and maintains current information in the JCCQAS electronic database including co-located units and other assigned military personnel, as needed (i.e., Individual Mobilization Augmentees [IMAs]). Maintain all required credentialing and privileging documentation in the provider’s credentials record relating to clinical performance.

(12) Initiates the credentialing, privileging, and medical staff appointment process.

Performs a comprehensive data quality and risk assessment review of the electronic Provider Credentials File and ensures documents are scanned, named in accordance with the standard naming convention, and uploaded to the provider’s credentials record.

(13) Performs relevant National Practitioner Data Bank (NPDB) queries, other applicable queries, and Primary Source Verifications (PSV). Performs risk assessment and authenticates the credentials of privileged medical staff members applying for initial clinical privileges and appointment to the medical staff or other changes in privileges as appropriate. Per the Chief of the Medical Staff, assures compliance with validation of non–privileged providers’ credentials, as well as relevant NPDB queries, other applicable queries, and PSV upon in-processing to the organization and with other changes in practice as appropriate.

(14) Maintains a system for internal staff to properly identify healthcare providers practicing at the organization, and to confirm clinical privileges or clinical scope of practice.

(15) Provides ongoing JCCQAS reports on expiring credentials (at a minimum of quarterly), to the Chief of the Medical Staff and Credentials Committee/Function.

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(16) Serves as point of contact for release of information regarding clinical privileges/ practice for healthcare providers who have, or previously had, an affiliation with the organization.

(17) Establishes and supports the creation of the provider profile within the electronic health record (EHR) system in collaboration with the health information technology office to provide access to the EHR upon appropriate credentialing and privileging of healthcare providers.

(18) Ensures protection of and access to Medical Quality Assurance Program material is in accordance with Section 1102 of Reference (o).

(19) Initiates annual system reviews to identify, analyze, and determine facility and resource capabilities that may impact safe and reliable healthcare. At intervals not to exceed 12 months, a review of facility-specific departmental criteria with appropriate department heads, Credentials Committee/Function is required to ensure criteria are appropriate to support the granting of clinical privileges. The local MPL must reflect facility capabilities.

f. Graduate Medical Education (GME) Training Office

(1) Maintain JCCQAS electronic records for providers in GME training programs.

Ensure the JCCQAS credentials record is current at all times. Maintain and update this database in accordance with the JCCQAS User Manual and this DHA-PM.

(2) Gather and ensure PSV of required documents, name documents in accordance with the standard naming convention, and upload documents to the provider’s electronic credential record.

(3) Serve as point of contact for fee-exempt DEA registration and NPI Type 1 registration for providers in the training program.

(4) Perform data quality review of the electronic credentials record and grant provider access to complete first e-application upon completion of a training program. Initiate PCS transfer of JCCQAS records and provider's credentials record.

5. PROCEDURES

a. Licensure, Certifications, and/or Registration of Healthcare Personnel

(1) Section 1094 of Reference (o) requires that a person practicing in the MHS may not provide healthcare independently unless the person has a current license to provide such care. A healthcare provider who is a licensed independent practitioner may not provide healthcare in accordance with this enclosure unless the provider’s current license is an active unrestricted license that is not subject to limitation on the scope of practice ordinarily granted to other healthcare providers for a similar specialty by the jurisdiction that granted the license.

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(2) A license is a condition of employment and applies in all healthcare settings, including deployment, and assignments in foreign countries. Licensure, certification, or registration is a qualification for employment as a healthcare provider in the MHS. Healthcare providers must have one current, valid, active, and unrestricted license. Additional licenses held by a provider must be in good standing whether they are inactive, expired, or limit the provider’s practice to a military setting. Providers in the MHS may not have one active license and another currently suspended or probationary license. For example, if a provider is licensed in both Texas and Tennessee, and the provider’s Texas license is active, but the provider’s Tennessee license is on probation, restricted, or is temporarily suspended, the provider would not meet requirements for clinical practice in the MHS.

(a) An unrestricted license:

1. Does not waive or reduce continuing education (CE) requirements (section 1094a); training; testing; investigation; or sanction authority.

2. Has no restrictions pertaining to clinical competency.

3. Does not restrict practice to a military or federal facility.

4. Does not waive the standard license fee solely on the basis of the member being in the military if such a waiver would have the appearance, as determined by the DAD MA, of a license not fully comparable in all respects to a full fee license.

5. Does not waive or extend license renewal date solely on the basis of the member being in the military.

6. Allows the healthcare provider unabridged permission to practice in any civilian community in the jurisdiction of licensure without having to take any additional action on the license.

(b) Healthcare providers who fail to maintain compliance with licensing, certification, or registration requirements outlined in this manual will be removed immediately from patient care. Such providers may be subject to personnel actions (e.g., as a condition for employment, failure to keep licensure by being late on fee payment may prompt disciplinary personnel actions), clinical adverse actions (e.g., any adverse action taken by the state authority may prompt a QAI), or both, which may lead to NPDB and other applicable certifying/regulatory agency reporting. (See Enclosure 3 of Volume 3 of this manual.) Consult with servicing healthcare legal counsel. Also, see Reference (p).

(c) Appropriated funds cannot be used to pay fees for obtaining and maintaining a license, except in the following instances: If DHA/Service mission requires a military provider to participate in an external resource sharing agreement, or training agreement, with a civilian institution that does not recognize the licensure portability statute, the provider may be reimbursed up to $500 of the state licensure fee under Section 1096(d) and Section 2015(b) of

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Reference (o). Appropriated funds may also be able to reimburse a volunteer for obtaining a license in the state where volunteering if the individual already possesses a current, valid, active, unrestricted license in any other jurisdiction, similar to other federal employees.

(3) Section 1094 of Reference (o) mandates that, notwithstanding any law regarding the licensure of healthcare providers, a designated licensed individual practitioner may practice their profession in any location in any jurisdiction of the United States, regardless of where the provider or patient is located, so long as the practice is within the scope of authorized federal duties. For this purpose:

(a) A covered healthcare provider is one who is a member of the Military Services, civilian DoD employee, personal services contractor in accordance with Section 1094 of Reference (o), or other healthcare professional credentialed and privileged at a federal healthcare institution or location specially designated by the Secretary for this purpose. The DoD VMC is considered a federal healthcare institution in accordance with Section 1094 of Reference (o).

(b) A jurisdiction of the United States is a state. For the purposes of this document, the District of Columbia, a Commonwealth, a territory, or a possession of the United States will be referred to as a state henceforth.

(c) Portability of state licensure does not apply to:

1. Non-personal services contractor healthcare providers, unless specifically stated in the applicable contract and specifically approved by the ASD(HA).

2. Non-DoD personnel, unless specifically approved by the ASD(HA) or detailed to DoD.

(d) DoD Components must follow the procedures established in this section prior to assigning licensed individual practitioners to other federal agency or non-federal healthcare institutions.

(4) The ASD(HA), as delegated by the Secretary of Defense, may waive licensure requirements outlined in this manual in special circumstances. A waiver may be considered in circumstances where a state’s unrestricted licensure requirements place an undue burden on the uniformed Service member or federal employee by mandating participation in programs incongruous with federal policy. Examples include requirement to live in the state of issuance, mandatory contribution to a medical injury compensation fund, or the requirement to maintain private malpractice insurance. Waivers will not be granted on the basis of a healthcare provider’s assignment in a non-clinical position.

(a) At the time of license renewal, the licensure waiver must be re-submitted. If the criteria are not met, the waiver will lapse.

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(b) Requests for waiver of licensure requirement are made to ASD(HA). The waiver must be documented in JCCQAS with the date of the waiver reflecting the expiration of the applicable time period of licensure.

(5) For a U.S. citizen to be hired outside the U.S. jurisdiction, the respective Privileging Authority will obtain a waiver from the host country to hire the individual under a non-personal services contract. This waiver must have a statement that the individual will provide services only on the U.S. Federal enclave. Additionally, the individual must have a current, unrestricted license from any U.S. state, or the individual may obtain a current, unrestricted license or other authorizing document from the host nation via endorsement or reciprocity.

(6) Foreign military providers may be assigned to U.S. installations to provide medical care for their personnel only. They practice under the authority of local host agreements and are not subject to DoD CP Program requirements. The providers are not under the medical supervision or oversight of the DoD Privileging Authority. All care provided by the foreign military providers is subject to the oversight and regulations of the provider’s country of licensure. Local host support agreements govern DoD support to these providers.

b. Credentialing Requirements for Privileged and Non-Privileged Providers:

(1) This section presents a comprehensive list of provider credentials. Specific credentials requirements by provider type are included in the Appendix to Enclosure 2: Specialty Specific Licensure, Training, and Other Credentials Requirements. The requirement for PSV is specified in Table: Credentials Required for Privileged and Non-Privileged Providers. PSV is required on initial privileging or on a recurrent basis, as designated.

(a) A qualifying educational degree, as required by specialty. For foreign medical graduates, an approved certificate by the Educational Commission for Foreign Medical Graduates (ECFMG) is required for graduates of foreign medical schools, other than approved schools in Canada. If the ECFMG certificate is dated prior to 1986, medical school graduation must be verified (prior to this date, the ECFMG did not verify graduation from medical school before issue of the certificate).

(b) Post-graduate training certificates (i.e., internship, residency, fellowship). All new certifications require a one-time PSV.

(c) All current professional licenses, certifications or registrations, including those the healthcare provider previously held that are now inactive, expired, or suspended, must undergo initial PSV. The healthcare provider must submit an explanation for all inactive, expired, and/or suspended licenses. In addition, for initial and renewal PSV, a list of all healthcare licenses ever held must be provided with an explanation for: any challenges to licensure or registration, any voluntary or involuntary relinquishment of licenses, or any licenses that have been subject to disciplinary action.

(d) Accounting of experiences and all gaps in active practice dating back 10 years or to the qualifying degree is required. For initial privileges, a written list of prior work history is

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required. Providers previously privileged in the MHS who have not had a break in service for more than 180 days, do not require a written work history. The work history tab in JCCQAS provides documentation to fulfill the credentialing requirement of previous work history review.

MSPs/MSMs will work with providers to ensure this information is accurate and up to date.

Validation for work history may be obtained via contact with a prior work location by administrative staff and does not require healthcare provider or clinical leader endorsement.

(e) Current American Red Cross or American Heart Association Basic Life Support (BLS) Certification. Although Advanced Life Support (American Red Cross), Advanced Cardiovascular Life Support (American Heart Association), Advanced Trauma Life Support, Pediatric Advanced Life Support, Advanced Life Support in Obstetrics, or the Neonatal Resuscitation Program may need additional performance requirements, they are not a substitute for the BLS requirement. Privileging Authorities will ensure life support training (Basic Life Support [BLS], Advanced Life Support [ALS], Pediatric Advanced Life Support [PALS]) is available to personnel to meet deployment requirements. Waiver requests for healthcare providers who cannot perform hands-on cardiopulmonary resuscitation due to temporary or permanent physical disabilities can be sought through the Privileging Authority. Waivers for other situations, e.g., for care rendered by telemedicine providers to an originating site via privileges by proxy, may also be considered by the Privileging Authority.

(f) A DEA Administration Certificate is any Federal DEA registration(s) and/or the DoD fee-exempt DEA original certificate.