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THE JOINT COMMISSION MEDICAL STAFF STANDARDS. AOA-HFAP STANDARDS, CMS CoPS, AND NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) CREDENTIALING STANDARDS PREPAREDNESS
Is your medical staff ready for your upcoming survey? Make sure by taking advantage of the following services:
Review of medical staff bylaws for compliance with standards relating to the medical staff
Kathy can perform a complete review of medical staff bylaws and documents and map them to all elements of performance in accreditation standards. This mapping document can be used to document compliance with standards and identify areas of noncompliance. Kathy can also draft bylaws language and recommended process changes needed to meet standards.
Credentials file audit for compliance with Joint Commission, AOA-HFAP, CMS Regs, or NCQA credentialing standards
In the busy credentialing office, it is very easy for things to “fall through the cracks”. Will your provider credentialing files stand up under rigorous surveyor examination? Have you had turnovers in your credentialing office since your last survey? If so, you may benefit from an independent audit of medical staff credentialing files. With over 20 years experience in credentialing, Kathy can provide a comprehensive review of credentials files to determine compliance with primary source verification requirements of accreditation standards, state law, and medical staff bylaws. Don’t be surprised on your next survey!
Education/training/coaching of medical and support staff regarding survey process and interviews
Medical staff’s preparedness can make or break your survey. Make sure your medical staff knows what to expect during the credentialing interview and survey. Due to decreasing reimbursement, many employers are forced to cut back or stop paying for continuing education for their employees and medical staff officers. See Educational Programs for a list of programs offered, or a program can be developed to meet your needs.
Development and implementation of pre- and post-survey compliance plans
Kathy can help with development, implementation and follow-up of compliance plans to meet medical staff standards including development of procedures and drafting of bylaws changes.