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Credentials File Audits: Tools and Techniquesfor Credentialing ComplianceSession Code: TU06Date: Tuesday, October 24Time: 9:30 a.m. - 11:00 a.m.Total CE Credits: 1.5Presenter(s): Kathleen Matzka, CPMSM, CPCS

Credentials File Audits:Tools and Techniques for CompliancePerforming Credentials File Audits:Tips and Techniques for Credentialing ComplianceKathy Matzka, CPMSM, CPCS, FMSPWhat We Will Cover Reasons for Audits How Audits are Performed Creating Audit Tools Reporting/Follow-up3Kathy Matzka, CPMSM, CPCSwww.kathymatzka.com1

Credentials File Audits:Tools and Techniques for ComplianceReasons for Audits Comply with Requirements Negligent Credentialing Issues Tool for Performance Evaluation Everyone Makes Mistakes!4Medicare CoP Privileging CriteriaCharacterCriteria5CMS Survey Procedures Review credential files to determine if the facility complies with CMS requirementsand State law, as well as, follows its own written policies for medical staff privilegesand credentialing Review the hospital’s method for reviewing the surgical privileges of practitioners.This method should require a written assessment of the practitioner’s training,experience, health status, and performance6Kathy Matzka, CPMSM, CPCSwww.kathymatzka.com2

Credentials File Audits:Tools and Techniques for ComplianceHow Audits are PerformedStep 1Determine process to be auditedStep 2Select filesStep 3Review file, logging resultsStep 4Compile summary reportStep 5Share results77Determine Process to be AuditedNewApplicantReapplicantExpirable8Identify Elements to be ws/P&PIncludetimeframes9Kathy Matzka, CPMSM, CPCSwww.kathymatzka.com3

Credentials File Audits:Tools and Techniques for ComplianceRecord Selection ction”)Stratifiedsampling10Creating the Audit Tool – New Ap11New Application Summary Report12Kathy Matzka, CPMSM, CPCSwww.kathymatzka.com4

Credentials File Audits:Tools and Techniques for ComplianceCreating the Audit Tool - Reap13Reapplication Summary Report14Creating the Audit Tool15Kathy Matzka, CPMSM, CPCSwww.kathymatzka.com5

Credentials File Audits:Tools and Techniques for ComplianceSharing Results16Follow-upDiscuss Resultswith StaffDetermine Causeof DeficienciesDevelop ActionPlan One-on-one Departmentalmeeting Lack of knowledge Performancedeficiency Retraining Staffing New P&P17Tracking Audited Files Keep record ofall audits Try to audit allfiles over aperiod of time Continuousmonitoring18Kathy Matzka, CPMSM, CPCSwww.kathymatzka.com6

Credentials File Audits:Tools and Techniques for ComplianceMost Common Deficiencies Inappropriate peer references NPDB over 2 years at recredentialing Privilege forms not completed correctly Not all facility verifications returned prior to approval Inconsistent dating Approval signatures missing or out of sequence19Exercise: How Much Time to Audit YOUR FilesStep 1: Multiply number of credentials files X 20 minutes100 X 20 minutes 2000 minutes# filesStep 2: Divide number of minutes by 60 minutes (number of minutes in an hour)2000 minutes / 60 33.33 hours required for auditsStep 3: Divide number of hours required by the number of work weeks in a year (i.e. deduct number of vacation weeks) to deter mine how much timeyou will have to spend each week to audit all files in a year.33.3 hours required for audits / 50 weeks worked in a year .67 hours20Record RetentionWho cansee this file? Policy for Access,Retention, andContent Policy forPractitioners noLonger on StaffDo I REALLYneed to keepthis?How long do Ineed to keepthis?21Kathy Matzka, CPMSM, CPCSwww.kathymatzka.com7

Credentials File Audits:Tools and Techniques for ComplianceQuestions22Kathy Matzka, CPMSM, CPCSwww.kathymatzka.com8

Credentials FileAudits:Tools and Techniques forCredentialing ComplianceKathy Matzka, CPMSM, CPCS, FMSPConsultant/Speaker1304 Scott Troy RoadLebanon, IL 62254kathymatzka@kathymatzka.comwebsite: www.kathymatzka.comPhone (618) 624-8124

BIOGRAPHICAL SKETCH, KATHY MATZKA, CPMSM, CPCS, FMSPKathy Matzka, CPMSM, CPCS, FMSS, is a speaker, consultant, and writer with 30years of experience in credentialing, privileging, and medical staff services. Ms. Matzkaworked for 13 years as a hospital medical staff coordinator before venturing out on herown as a consultant, writer, and speaker. She holds certification by the NationalAssociation Medical Staff Services (NAMSS) in both Medical Staff Management andProvider Credentialing. She is one of the first recipients of the NAMSS FellowDesignation. The Fellow Designation is the pinnacle of achievement andacknowledgment for the Medical Services Professional (MSP), recognizing a careerMSP who has made outstanding contributions to the profession through service as aleader, mentor, and educator.Ms. Matzka has authored a number of books related to medical staff services includingMedical Staff Standards Crosswalk: A Quick Reference Guide to The Joint Commission,CMS, HFAP, and DVN Standards, Chapter Leader’s Guide to Medical Staff: PracticalInsight on Joint Commission Standards, Compliance Guide to Joint CommissionMedical Staff Standards, and The Medical Staff Meeting Companion Tools andTechniques for Effective Presentations. For eight years, she was the contributing editorfor The Credentials Verification Desk Reference and its companion website TheCredentialing and Privileging Desktop Reference. She is co-author of the HcPro’spublication Verify and Comply: Credentialing and Medical Staff Standards Crosswalk,Sixth Edition. Her latest book is The Clinician’s Quick Guide to Credentialing andPrivileging which is a resource for physicians and other practitioners.She has performed extensive work with NAMSS’ Education Committee developing andediting educational materials related to the field including CPCS and CPMSMCertification Exam Preparatory Courses and Study Guides, CPMSM and CPCSProfessional Development Workshops, Standards Comparison Grid, and NAMSS CoreCurriculum. These programs are essential educational tools for both new and seasonedmedical services professionals. She also serves as instructor for NAMSS.Ms. Matzka shares her expertise by serving on the editorial advisory boards for twopublications – Credentialing Resource Center Journal, and Credentialing & Peer ReviewLegal Insider.Ms. Matzka is a highly-regarded industry speaker, and in this role has developed andpresented numerous programs for professional associations, hospitals, and hospitalassociations on a wide range of topics including provider credentialing and privileging,medical staff meeting management, peer review, negligent credentialing, providercompetency, and accreditation standards.In her spare time, Ms. Matzka takes pleasure in spending time with her family, listeningto music, traveling, hiking, fishing, and other outdoor activities.

Table of ContentsTable of Contents . 1Introduction . 1How Audits are Performed . 1File Selection . 1Audits for New Applicants . 2Figure 1 - Audit Tool for New Applicants . 3Figure 2 - Summary Tool New Applicant Audits . 4Audits for Reapplicants . 6Figure 3- Audit Tool for Re-Applicants . 7Figure 4- Summary Tool Re-Applicant Audits . 8Expirables Audits . 9Figure 5- Audit Tool for Expirables . 9Figure 6 - Summary of Expirables Audit. 10Keeping Track of Files that have been Audited . 11Figure 7- Tracking Tool for File Audits . 11Reporting Results . 11Follow up Deficiencies. 12Policy on Confidentiality, Access To, Retention, And Content of Credentials Files andRecords of Medical Staff Committees and Departments . 13Policy for Retention of Credentials File Documents for Practitioners No Longer on Staff. 19Exercise: How Much Time to Audit YOUR Files . 22

IntroductionAlthough time consuming, credentialing audits are a good idea. Even the mostexperienced professionals make mistakes and overlook things – it’s part of humannature. In some cases, an element, such as primary source verification of licensure, iscompleted but the documentation does not get placed in the credentials file. Orperhaps an issue requiring follow-up is identified, but is forgotten when a more urgentissue presents itself. Audits are also helpful in monitoring the work of a new employee.Today’s healthcare market in which over 30 states have recognized the tort of negligentcredentialing or have applied broad common law principles of negligence tocredentialing issues, is another reason to perform credentials chart audits.How Audits are PerformedWhile credentials file audits are typically performed by the department manager orperson responsible for oversight of the MSP responsible for credentialing, some medicalstaff managers like to get everyone in the department involved in an audit committee.Here is a basic outline of how credentials file audits are performed:1. A set number of files are identified for review.2. The auditor reviews each file and completes a checklist3. The results of the audits are then compiled into a master report.Results of the audit can be used internally in the medical staff office, shared withhospital administration, and/or reported at the hospital performance improvementcommittee.There are different types of audits with individual focuses.File SelectionIn random sampling, each file has an equal and known chance of being selected. Whenthere is a large medical staffs, it is often difficult to audit every file, so a random sampleis selected.Systematic sampling, also known as “Nth selection” is often used instead of randomsampling. After calculating the required sample size, every Nth record is selected.Systematic sampling is frequently used to select a specified number of records from acomputer file.Kathy Matzka, CPMSM, CPCS, LLCCredentials File Audits1

Stratified sampling occurs when you choose a stratum, or a subset, of records thatshare at least one common characteristic. Examples of stratums might be members of acertain specialty or those who were appointed within a certain timeframe.Audits for New ApplicantsThe audit tool in Figure 1 - Audit Tool for New Applicants is specifically constructed tofocus on initial applicants to the medical staff. It includes an audit of all the informationrequired for initial appointment. This audit form can be used for screening all initialappointments to the medical staff to assure that nothing is being missed.Final results can be tallied on the tool in Figure 2 - Summary Tool New Applicant Audits.Notice in the completed example, there are some problems with documentation in thecredentials files of two applicants, both of whom are physician assistants. Byhighlighting the areas of non-compliance, you can easily see where improvement isneeded. Figure 2 can also be printed and used in place of Figure 1 if reviews are beingconducted by only one person instead of by a committee or group of people.Kathy Matzka, CPMSM, CPCS, LLCCredentials File Audits2