Touching a touchy subject: Age

On a regular basis, we are asked about the advisability of developing a policy requiring a physician to pass a medical examination once he or she reaches a certain age (62, 65, 68, etc.) in order to be able to continue to maintain clinical privileges at a hospital. And our first response is always, “Absolutely, […]

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Do Not Text and Order

The Joint Commission (TJC) has again clarified its position on the use of secure text messaging for patient care orders. Specifically, in contrast to its position in May 2016, TJC, in collaboration with the Centers for Medicare & Medicaid Services (CMS), is now stating that the use of secure text orders is not permitted. Although […]

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The Challenge of Incident Reports

Incident reports, unusual occurrence reports, risk management reports — whatever you call them — are a challenge, and whether or not they will be “peer review protected” depends upon your individual state law. There are, however, some basic steps you can take to be sure that if there is any protection available, you will have […]

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Understanding the Federal Health Care Quality Improvement Act (HCQIA) and State Peer Review Privileges in Day-to-Day Activities

When most people think of the Health Care Quality Improvement Act of 1986 (HCQIA), they think of reporting obligations to the National Practitioner Data Bank. But HCQIA, just as your state peer review privilege, has practical application to your day-to-day quality improvement activities as well. Did you know that HCQIA originated as a part of […]

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Colliding Worlds, Peer Review and Medical Necessity

QMCG Executive Director Catherine Ballard and Bricker & Eckler attorney Steve Kleinman presented the “Colliding Worlds, Peer Review and Medical Necessity” webinar on April 27, 2016. The live webinar, hosted by NAMSS, provided insightful information related to physician peer review, explanation of medical necessity review, and the similarities and benefits of both. The webinar also […]

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Sharing Quality Information Within a System

It used to be that we all knew that a medical staff credentials file, or quality file, contained peer review-protected information, and that it would only be used as part of the medical staff process. But that was yesterday. Today, more and more demands are being made on medical staff services to share their information […]

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New Quality Measures for Cardiac Catheterization Services in Ohio: Our Recommendations

On September 21, 2015, the Ohio Department of Health (ODH) posted draft rules for public comment regarding adult cardiac catheterization services. The draft rules propose new quality performance measures and reporting requirements for all cardiac catheterization services. Public comment is due by October 21, 2015. At this time, we recommend a review of your cardiac […]

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Correcting CNHA Errors #1

Final CHNA rules issued December 31, 2014 identify and confirm extensive requirements for a Community Health Needs Assessment (CHNA) required of all 501(c)(3) hospitals. This is the first in a three-part series of e-mail alerts on correcting CHNA errors and the consequences of such errors. Minor CHNA Omissions and Errors The IRS recognizes that minor […]

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Correcting CNHA Errors #2

Final CHNA rules issued December 31, 2014 identify and confirm extensive requirements for a Community Health Needs Assessment (CHNA) required of all 501(c)(3) hospitals. This is the second in a three-part series of e-mail alerts on correcting CHNA errors and the consequences of such errors. Omissions and errors that rise above minor but are neither […]

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Correcting CNHA Errors #3

Final CHNA rules issued December 31, 2014 identify and confirm extensive requirements for a Community Health Needs Assessment (CHNA) required of all 501(c)(3) hospitals. This is the last in a three-part series of e-mail alerts on correcting CHNA errors and the consequences of such errors. Failures that are willful or egregious These are failures caused […]

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