Credentialing and Assigning Clinical Responsibilities under the Behavioral Health Standards
Credentialing and assigning clinical responsibilities to LIPS was one of the top five compliance issues for BH organizations in 2012. In fact, it ranked number two (second only to treatment planning) with 20% of BH organizations receiving findings in this area.
For organizations surveyed under the BH standards, the requirements for credentialing and assigning clinical responsibilities to licensed independent practitioners (LIPs) are in the Human Resources chapter in standard HR.02.01.03. (Note that the BH standards do not use the term "privileging" as is used in the Hospital manual but rather "assigning clinical responsibilities").
Keep in mind that HR.02.01.03 applies only to that designated group of practitioners that your organization has identified as licensed independent practitioners (LIPs) to whom you will grant clinical responsibilities. TJC defines a LIP as "a practitioner permitted by law and the organization to provide care, treatment, or services without direction or supervision within the scope of the practitioner's license and consistent with assigned clinical responsibilities".
There are different requirements to meet when initially assigning clinical responsibilities versus renewing clinical responsibilities for LIPs:
Requirements for Initial Assignment of Clinical Responsibilities
- Primary source verification of licensure, certification, or registration (EP 1)
- Valid picture ID issued by state or federal agency (EP 2)
- Primary source documentation of training (EP 3)
- Written statement from LIP that no health problems exist that would affect ability to perform clinical responsibilities (EP 10)
- Review of the following information:
- Challenges to licensure or registration (EP 11)
- Relinquishment of licensure or registration (EP 12)
- Limitation, reduction, or loss of clinical responsibilities (EP 14)
- Liability actions resulting in a final judgment against the LIP (EP 15)
- Query to National Practitioner Data Bank (NPDB) for physicians, dentists (EP 16)
- Peer recommendation(s) as required by the organization (EP 36)
- Approval of the clinical responsibilities in writing by the governing body (EP 23)
Requirements for Renewal of Clinical Responsibilities (every two years)
At the time of renewal of clinical responsibilities, many of the same requirements apply as did for initial assignment of clinical responsibilities:
- Primary source verification of renewal of licensure/certification/registration
- Written statement from LIP that no health problems exist that would affect ability to perform clinical responsibilities
- Review of the following information:
- Challenges to licensure or registration
- Relinquishment of licensure or registration
- Limitation, reduction, or loss of clinical responsibilities
- Liability actions resulting in a final judgment against the LIP
- Query to NPDB for physicians, dentists
- Approval of the clinical responsibilities in writing by the governing body
In addition, the following requirements must be met when renewing clinical responsibilities:
· The organization must review information from the following sources:
o Performance improvement activities pertaining to the LIP's performance, judgment, clinical or technical skills (EP 7)
o Results of peer review (EP 8)
o Any clinical performance that was outside of acceptable standards (EP 9)
So, where do BH organizations run into problems with these requirements?
At the recent TJC Behavioral Healthcare Conference, Merlin Wessels Associate Director of the Standards Interpretation Group presented the most common survey findings:
Problem # 1: License not verified from the primary source.
· Allowing a copy of the license to be used instead of obtaining primary source verification
· Having a lapse in verifying renewal of the license
Strategy: Make sure you have a solid "tickler system" in place for verifying license renewal from the primary source before the expiration date.
Problem # 2: Lack of peer review
- No peer review process yet established by the organization
- The LIP is the only practitioner of that type within the organization
Strategy: If you have a "one of a kind" LIP, you can use a peer recommendation or peer review from a peer external to your organization.
Problem # 3: Written health statement not done
Strategy: This one is an easy fix. Build the statement into the application paperwork: "I attest that I have no mental or physical health problems that could affect my ability to perform the clinical responsibilities I have requested".
Problem # 4: No Query to the National Practitioner Data Bank
Common issue: Many BH organizations don't realize that the NPDB must be queried every two years. They think that this query just needs to be done initially. Not true. It must be done both initially and at time of renewal of clinical responsibilities.
Strategy: Once you have done an initial baseline query to the NPDB for a LIP, you can then take advantage of their Proactive Disclosure Service (PDS) when renewing clinical responsibilities. This essentially means that you don't have to keep checking with NPDB. Rather, they notify you of any new information they receive on that LIP. No updates from NPDB means no new information. TJC has clarified that there does not need to be documentation in the record that no further communication has been received from NPDB.
Problem # 5: Governing body didn't approve clinical responsibilities in writing
Common issue: Many BH organizations simply overlook this requirement to have the governing body do the final approval of clinical responsibilities.
Strategy: Approval by the governing body can be via a letter or by signature of a governing body representative on the approval form. In addition, governing body approval can be delegated to a committee or an individual (e.g. CEO) within the organization.
Continuous Readiness Strategy: Take the time now to tie up the loose ends in your process for assigning clinical responsibilities to LIPs. It's worth the effort to have all the right steps in place and avoid these common survey pitfalls on your next survey!