STATUS CME

Why should medical directors familiarize themselves with their hospital’s medical staff bylaws?

Because the medical staff bylaws tell them how they’re going to be compensated

In order to understand how to utilize the electronic health record efficiently

Because they outline the basis for medical staff privileges along with other guidelines and processes related to the medical staff

They outline all routine hospital operations policies

True or False: At hospital reappointment, each provider’s privileges must be evaluated to verify current competence

True

False

What is the main difference between OPPE and FPPE?

OPPE is only performed when the Medical Executive Committee requests it

OPPE must be conducted annually whereas FPPE must be conducted multiple times a year

OPPE does not apply to providers that only work part-time but FPPE can be performed on any provider

OPPE is required for all medical staff but FPPE is only enacted under certain circumstances

What does OPPE typically NOT include?

Evaluation of provider treatment plans

Group level data instead of data specific to that provider

Patient care outcomes

Compliance with core measures and other quality indicators

True or False: If a provider is evaluated under an FPPE, that is reportable to the National Practitioner Databank

True

False

According to the CMS Conditions of Participation for CAHs

The care provided by advanced practice providers (including nurse practitioners and physician assistants), must be evaluated by a physician who is a member or a contractor of, the CAH

The care provided by advanced practice providers (including nurse practitioners and physician assistants), must be on an outpatient basis only

Advanced practice providers are allowed to admit patients and administer treatment for adult patients only

An advanced practice provider may be listed as “first call” on the On Call Calendar as a specialist for ER call, as long as their collaborating physician is a specialist

If a physician acts as a collaborator for an advanced practice provider, they should:

Check their state laws for specific collaboration requirements

Check their medical staff bylaws for specific hospital requirements

If required, ensure their collaborative agreement includes scope of practice, clinical protocols and prescriptive authority

All of the above

It is a Federal Code of Regulation for Critical Access Hospitals to:

Demonstrate that they can care for all types of patients in their community, regardless of acuity level

Have an On Call roster of specialty physicians that includes a minimum of five distinct specialties

Have written protocols that are evidence-based guidelines for the care of patients with emergency conditions

Have at minimum, an emergency department, an Obstetrics/Labor & Delivery department, and a surgical services department

Medical Directors are typically involved in:

Community Outreach initiatives

Emergency Preparedness plans

Relationship building with EMS

All of the above

Clinical protocols and standing orders:

Are evidence-based so they don’t need to be approved by a physician

Should be reviewed by physicians, usually on an annual or bi-annual basis

Allow nursing staff to diagnose and treat low acuity patients

Can be written and authorized by any member of the medical staff at any time