On November 4, 2022, The Joint Commission changed its standards regarding the reappointment cycle to state, “Reappointment/re-privileging is due no later than three years from the same date from the previous appointment or reappointment, or for a period required by law or regulation if shorter. For example, if the reappointment period is July 1, 2021, through June 30, 2024, the reappointment date would be July 1, 2024.”
This change may be something some of us have secretly hoped for, for years. Changing the reappointment cycle to a 3-year period aligns reappointments and re-privileging with the managed care world and DNV, which have allowed a 3-year cycle for many years.
If you have a combined reappointment process between the hospital and your health plans, this may not be a substantial change for you (assuming you have kept a 2-year cycle if you are Joint Commission accredited facility). However, if you are a facility that does not have a combined process, or a stand-alone facility that provides credentialing services to one hospital, this change to a 3-year period may affect your processes.
Start With a Review of State Requirements
The first step in mitigating this change is to review your state laws and regulations regarding the reappointment cycle. There are some states that mandate specifically that re-privileging and/or re-credentialing must be done no less than every 2 years. Both California and Illinois are examples of states where language will need to be reviewed to ensure continued compliance on the state level, despite the accreditation organization lengthening the timeline. Be sure to review your state statutes. If applicable, leverage your legal team to assess whether your state will allow this change. If not hindered by state statutes, create a project plan to support the process.
Educate Yourself and Others on the Implications
Education falls into the second step in mitigating this change. Educate yourself about the new standards and the standards under which you currently practice. Educate your team, medical staff leaders, and C-suite executives, as necessary, to gain support for changing to a 3-year reappointment cycle. Having solid knowledge of the standards and the effect this change will have on the medical staff is crucial to gaining stakeholder confidence to facilitate a new process.
This change may affect medical staff processes in addition to the reappointment cycle period.
Medical staff bylaws, privileging criteria, and Ongoing Professional Practice Evaluation (OPPE) are areas that require attention if your medical staff changes from a 2-year to a 3-year cycle.
Changing from a two-year reappointment cycle to a three-year reappointment cycle will require a change to your medical staff bylaws if your bylaws reflect a 2-year cycle and your state allows a longer cycle. This will also affect any polices you have regarding the reappointment cycle where the timeframe and/or the reappointment process is referenced. If your delineation of privileges (DOP) reflects a 2-year cycle for required clinical activity and/or documentation of experience, the language and period requested for clinical activity will also need to be revisited. This may also be a suitable time to update DOPs that need attention in other ways.
Creating a summary of the ramifications of this change will help in gaining support from your key stakeholders. While leaders may understand that the reappointment time cycle is changing, they may not understand how it affects things like your bylaws, OPPE, and privileges. These changes should be spelled out. As the expert in these processes, it only makes sense that you, as a medical staff professional and healthcare leader, create this summary and provide your medical staff and administrative leaders with this information. Include the current state of your affairs and processes and how this change will affect your workflows in the Medical Staff Services Department (MSSD) as well as the effect on your medical staff practitioners. Identify the benefits of the changes, including resources, time management for the MSSD, and benefits for the medical staff practitioners.
If your hospital or facility outsources its credentialing function to a Credentialing Verification Organization (CVO), you will need to collaboratively work with the CVO to capture this change in its process, keeping in mind that you will most likely need to revise your service level agreement to reflect a change in the reappointment period.
The Importance of Ongoing Monitoring and Peer Review
The Joint Commission has provided clarification regarding the frequency of OPPE review in its FAQs, noting that review cannot exceed 12 months. Therefore, the need for a robust OPPE process for continuous monitoring of performance is now more important than ever if your reappointment cycle changes to every 3 years. This is a vital part of the change and it’s a great opportunity to evaluate your ongoing monitoring and peer review processes.
Include your quality team and those involved in the OPPE process as you create this new plan and timeline for the change. Reports may need to be changed to reflect the new timeframes, and how these reports are created may need to be adjusted. Understand how your peer review process is managed and aid in making the process better. If you are not involved in your current peer review structure, take this opportunity to educate yourself and provide support and resources if necessary to help in the process.
Communicate, Collaborate, and Consult
If you are an experienced medical staff professional or healthcare leader, you know the value of your colleagues’ experience. Brainstorm with them about this change. They may have a nugget or two that could be a goldmine. When we are in it alone, the process may become daunting, so rally your peers and work on this together. Reach out to your contacts and the experts in the industry, including your state association leaders. Encourage them to provide education in this area. Better yet, offer to provide it at your next state conference.
As the medical staff professional, your organization will look to you to take the lead and assist leadership with making the necessary shift in the medical staff bylaws, reappointment process, privilege forms, and OPPE process. While these changes may be relatively straightforward, you may want to consider whether this is the appropriate time update your credentialing and privileging, peer review, and bylaws documents.
Opportunities such as a change in regulations or accreditation standards is a prime time to take time to make time. Sometimes we must spend time to gain it.
Spending time to assess this change and the impact on your organization now may afford you more time later, when new processes are implemented because of this change.
Ensure the shift does not affect the quality of your credentialing program and provide the guidance to your medical staff and administrative leaders as you formulate these changes. It’s time to shine as a healthcare leader and be proactive about this new Joint Commission standard change.