dnv accreditation vs joint commission

HlSn0}W*vHUYii& 3kj`{YiDsqHI)P(J|\*|H X(PnFc'G]=/L$)$M[x6i; `9aDv}~2$eY@5 f'N^O_SFda55,EgsHwJWP'* xi.qDU_4%4reA)4zq0l>vf_R3;hxxlqn=hK`I8BL!eAS$O=pJI`2xKtQ_hv6 bG2u.S?)UIraqn/S#5gCi3+D WmBK%# 630-792-5509 | rzordan@jointcommission.org. endstream endobj startxref This accreditation underscores our commitment to developing and continually improving quality and safety for employees, patients and visitors throughout our system. Thats where ISO 9001 comes into play and turns the typical get-your-ticket-punched accreditation exercise into a quality transformation.. Det Norske Veritas (DNV) is a global quality These surveys, often routine or planned to certify our specialty programs, look at our communication processes, governance, processes, standardization, safety precautions and outcomes. ".*RK6"zf9ss~3 AARJA=Z\&6c@+|dk{GKY B_],IEmmq_rS}gX;L9nL%)5Ek&$;mcUeEP*wb\yaA.eW:OS3hoRqgi^Ygv`l!7/vou$VZ(T&d$iq-kUh_4<7\R+vi)e35elpG[piiqN#@t9Z]Y?})#=[8GOCb+1QKU,HY WWcVr y"=uOsb%V xOy^N?+OHG'9%[qdF]guPa("2Hbs=Kt0 :J~O|JGn n~ 2y.-;!KZ ^i"L0- @8(r;q7Ly&Qq4j|9 The documentation review report summarizes any findings from this process. DNV is kept apprised of the organization's level of compliance with ongoing organizational reporting. HyTSwoc [5laQIBHADED2mtFOE.c}088GNg9w '0 Jb Accreditation Field Report: Midland Memorial Available at: www.iso.org/iso/home. This process ensures a full and timely understanding of the standards. endstream endobj 8619 0 obj <>/Metadata 315 0 R/Outlines 731 0 R/Pages 8594 0 R/StructTreeRoot 1070 0 R/Type/Catalog>> endobj 8620 0 obj <>/ExtGState<>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 8621 0 obj <>stream DET NORSKE VERITAS (DNV) xb```f``ue` ea *(ltSa{+ 9QQ (MHKX*?6Y ,8v'83rXrE0C;;[70^} Ua vHCO4@ZT Dr g$ All rights reserved. Vendor Login | This is a list of the hospitals accredited to the international standard by DNV. All Rochester Regional Health labor and delivery hospitals. DNV Healthcares hospital accreditation program is unique in that it integrates the ISO 9001 standards (international quality standards that define <>/XObject<>/ExtGState<>/ProcSet[/PDF/Text/ImageC]/Font<>>>/MediaBox[ 0 0 612 792]/Contents 168 0 R /Parent 117 0 R /Type/Page/CropBox[ 0 0 612 792]/Rotate 0/Annots 145 0 R /Tabs/S/Group 166 0 R >> The scope of certification is agreed at an early stage in the certification process. Digital monitoring of medium-voltage cable networks, Offshore classification fleet in service, Electric grid performance and reliability, Reliability, availability and maintainability (RAM), Ship management, operations and ship design, procedure for suspension and withdrawal of certificates. Det Norske Veritas (DNV) vs JC? - General Nursing Talk Comparison of The Joint Commission and DNV GL Hospital Accreditation Pricing | The Joint Commission Below are several components of our psychiatric hospital accreditation program. As an example, a hospital could have its Joint Commission accreditation renewed for three years on July 10, 2010. Metrics and Performance There is always an opportunity to improve. The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. Public Records Policy | to review your manual, check procedures, to see your facilities, and briefly check the implementation of your management system. By earning accreditation, SCRMC has demonstrated it meets or exceeds patient safety standards (Conditions of Participation) set forth by the U.S. Centers for Medicare and Medicaid Services. 8618 0 obj <> endobj 0000006234 00000 n 0000012414 00000 n Author Frederick P Franko. 2010 Mosby, Inc. 0000038975 00000 n The certification audit consists of informal interviews, examinations, observations of the system in operation and review of relevant documentation. Lesho, E., Hix, J., Bronstein, M., Shastry, S., Hanna, J., Scroggins, G., & Grieff, M. (2019). Grid last updated: July 2022, National Association Medical Staff Services. Our surveyors employ a variety of methods for assessment, including staff interviews, medical record review, organizational document review, building and offsite visits, as well as patient interviews and feedback. 0000001631 00000 n xbbg`b``3E0 ) WebWe have a variety of resources to help you explore and master the accreditation process. Accessed August 5, 2009. for Medicaid and State Operations/Survey and Innovative hospitals have started embracing ISO as a way to identify and focus on the most successful approaches to patient care, billing and other critical aspects of running a modern hospital system. Country-wide, more than 5000 hospitals are permitted to provide Medicarefinanced services solely Accreditation options: Understanding DNV GL DEPARTMENT OF HEALTH & HUMAN SERVICES <>stream Webparticipation was based on Joint Commission accreditation issued prior to that date will continue to participate in Medicare via deemed status until the normal expiration date of its accreditation. %PDF-1.6 % Comparisons of the NIAHO and Joint Commission Approaches WebDNV Healthcare introduces a hospital accreditation program for stand-alone Psychiatric Hospitals, part of our dedication to helping hospitals improve quality, patient safety and healthcare delivery. endstream endobj 139 0 obj <>stream Infection Control & Hospital Epidemiology,40(9), 1066-1069. doi:10.1017/ice.2019.164. DNV Healthcare introduces a hospital accreditation program for stand-alone Psychiatric Hospitals, part of our dedication to helping hospitals improve quality, patient safety and healthcare delivery. Lesho, E., Walsh, E., Gutowski, J., Reno, L., Newhart, D, Yu, S., Bress, J., Bronstein, M. A Cluster-Control Approach to a SARS-CoV-2 Outbreak on a Stroke Ward with Infection Control Considerations for Dementia and Vascular Units. 8667 0 obj <>stream hTkSI?ssMl 1 27. wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 Findings, including non-conformities, and conclusions are presented at the end of the audit in a closing meeting and included in the audit report. Reflective of an organizations performance with respect to Joint Commission standards and elements of performance (EPs).Transparent all components of the process are fully disclosed to accredited and certified organizations.Easily understood by all involved parties.More items 0000002012 00000 n 630-792-5787 | lberkeley@jointcommission.org. Because while undergoing the accreditation process, a hospital makes critical decisions about how it provides services, manages medications and allocates resources. Based on a positive outcome, he/she will recommend certification. We are honored to provide behavioral healthcare facilities the same option provided to their hospital partners - a choice in their accreditation.PsychiatricHospital Accreditation Program Components endstream endobj 1331 0 obj <>stream Each issued certificate has a three-year life period. Blood use Prescribing of medications Surgical Case Review Specific departmental indicators Moderate Sedation Outcomes Anesthesia events Appropriateness of care for noninvasive procedures/interventions Utilization data Significant deviations from established standards of practice Timely and legible completion of patients medical records Variants analyzed for statistical significance 19, Addressed by TJC, Not NIAHO Verification of applicant identity Use of CVO (DNV does allow is addressed under telemedicine) Health status (DNV only under surgical privileges) Applicant required to provide info re: previously successful or currently pending challenges to licensure or voluntary relinquishment, felony convictions Leadership standards place additional responsibilities on MS Residency program requirements 20, Addressed by NIAHO, not TJC Receipt of database profile from OIG Medicare/Medicaid Exclusions initial/reappointment/temporary privileges 21, Resources Standards: NIAHO Standards, Interpretive Guidelines, or Accreditation Process www. Please enter a term before submitting your search. Similar review also applies in cases of suspending or restoring certification or withdrawing the certification. Hospital accreditation HSMo0+TR E9dR-,Q 4NuH.z)z06q?Rt|E"vzQV-\\-U=^4/M6z`| Y, 2mKe59\^9xg6`?,^eaQ)PHwzX=ixf#`x[aA;B|A3 $z(Gc(A%aC@)4"44SY S20L: 2("ukvVhMg9a,"J0$8 1sb s6s[fPE<1I!4XOLv^+d2(i}%C9X SOUTH CENTRAL REGIONAL MEDICAL CENTER RECEIVES QUALITY-BASED ACCREDITATION FROM DNV. WebCommission, Healthcare Facilities Accreditation Program (HFAP) and Det Norske Veritas Healthcare, Inc. (DNV) for hospitals; gives deeming authority to NCQA for Medicare Advantage health plans Accrediting Organizations Targets for Accreditation Types of Standards Accreditation Categories NCQA Joint Commission Health plans Employee Login | Frustrated with The Joint Commission, Midland Memorial Hospital (TX) made the shift to DNV this year, says accreditation specialist Lisa Williams, PT, MS, HACP.The hospital had already been looking at the Centers for Medicare & Medicaid Services' conditions of participation in We have taken an entirely different approach to accreditation, and hospitals are really responding, says DNV Healthcare USA Inc. President Patrick Horine. View our list of disease-specific and specialty program certifications. Although the costs of Joint Commission and DNV are about the same, according to health experts, there are some big differences between the two: The organization surveys the hospitals that use their commissioning services annually, while the Joint Commission extends its survey periods from 18 months to three years. In comparison, the Joint Commission has After the three years are up, your certification will be extended through a re-certification audit. Main Accreditation Organizations For U.s Accreditation verifies the certification body/registrars competence. 120 0 obj The documentation review can be performed prior to or conducted as part of the initial visit. WebOne of the large number of accreditation schemes in the United States, the Joint Commission (TJC) currently being the best known, has created Joint Commission International, or JCI. The Joint Commission Lon Berkeley . ISO is the International Organization for Standardization. Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-02.pdf. Why? What happens if an organisation fails to maintain their management system and certification? )CL:E8 $@eB5(ABRg]._e p`'ih]ao]|. Accreditation Joint Commission Online, August 12, 2009. Psychiatric Hospitals are accredited for a three year period, subject to annual survey to verify continuing compliance with NIAHO. Delia Constanzo . startxref Admin, South Central Family Medicine & Urgent Care, Directions to South Central Regional Medical Center, Where to Get the Best Care and When to Go. The focus areas should be linked to the management system and reflect the risks or opportunities that are most important to you. %PDF-1.6 % 0000020794 00000 n Our lead auditor will verify that you have properly addressed the nonconformities. DNV is a global independent certification, assurance and risk management provider, operating in more than 100 countries. %%EOF Through its broad experience and deep expertise, DNV advances safety and sustainable performance, sets industry benchmarks, drives innovative solutions. DNV has a transparent procedure for suspension or withdrawal of certificates. See upcoming training courses. DNVs accreditation program is the only one to integrate the ISO 9001 Quality Management System with the Medicare Conditions of Participation. 0000039232 00000 n The Joint Commission (TJC) is a non-profit organization that accredits and certifies over 22,000 healthcare organizations and programs in the United States. 0000002975 00000 n Before the actual certification audit, we will normally make a preliminary visit to your organisation. x- [ 0}y)7ta>jT7@t`q2&6ZL?_yxg)zLU*uSkSeO4?c. R -25 S>Vd`rn~Y&+`;A4 A9 =-tl`;~p Gp| [`L` "AYA+Cb(R, *T2B- 0 Whether youre new to the Joint As with all accreditation programs, surveyors from the organization will visit the hospital on regular annual intervals to monitor the organizations progress in implementing the new requirements. The scope of certification may need to be changed during the 3 year certification cycle. This 2.5-day course is a basic course designed to train healthcare professionals in the principles and requirements of DNV's approach to hospital accreditation. Lesho, E., Clifford, R., Vore, K., Zenits, B., Alcantara, J., Gargano, B., Phillips, M., Boyd, S., Eckert-Davis, L., Sosa, C, Vargas, R. Riedy, D., Stamps, D., Bhavsar, H., Fede J., Laguio-vila, M., Bronstein, M. Sustainably reducing device utilization and device-related infections with DeCATHlongs, device alternatives, and decision support. This electronic reference tool provides plain-language interpretations of the credentialing standards for The Joint Commission, NCQA, Healthcare Facilities Accreditation Program, DNV, URAC, the Accreditation Association for Ambulatory Health Care, as well as the Medicare Conditions of Participation. com Jointcomission. 0000007824 00000 n WebDNV offers a number of standards - Hospital Accreditation, Stroke Center, Orthopedic Service Line, Infection Risk and more. Comparisons of the NIAHO and Joint Commission Approaches to ISO standards ensure that products and services are safe, reliable and of good quality. % 0000008466 00000 n 630 Midland Memorial happy with DNV shift. 1338 0 obj <>/Filter/FlateDecode/ID[]/Index[1327 24]/Info 1326 0 R/Length 69/Prev 861584/Root 1328 0 R/Size 1351/Type/XRef/W[1 2 1]>>stream The certification decision is taken after an independent DNV GL internal review. This helps hospitals create a corrective action plan to improve their process and prevent that variance from occurring again. All rights reserved. Using an accredited third party certification body/registrars demonstrates that the auditing company is meets the required quality standard set by the accrediting authority. Rochester General Hospital Maternity Care,Unity Hospital Maternity Care,United Memorial Medical Center Maternity Care. This product includes updates that will be made by NAMSS over the next 12 months. Biocor Hospital De Doencas Cardiovasculares LTDA. In recent years, DNV have been challenging TJC in the USA. More than 2,100 individuals are employed throughout health system and approximately 125 providers representing 28 medical specialties provide care to patients. Agreeing on focus areas is a collaborative effort, and our auditors can help suggest focus areas if necessary. Unlike previous approaches to accreditation, DNV focuses on what works best for each hospital and therefore opens the door to innovation. At least one periodic audit per year is required. An integrated health services organization serving the people of Western New York. The report indicates if your organisation is ready to proceed with the certification audit. anDkDMMmnZWh|rQl( At Newark-Wayne, Rochester General Hospital, United Memorial and Unity Hospital. Brazil. {(oFA`=My$RqH+#~/aDh4:G}_.Q8f(fVJ7*7/oG|t6FG\kpvaGx2?yxz RlG@-e0&9zWez|U( v WebAddressed by TJC, Not NIAHO Verification of applicant identity Use of CVO (DNV does allow is addressed under telemedicine) Health status (DNV only under surgical The purpose of the initial visit is twofold: Based on this, the scope and audit plan are agreed upon. Search our services and programs offered by our experts at our hundreds of locations throughout Western New York and the Finger Lakes region. The important role of the Joint Commission endobj DNV conducts a survey every year instead of every three years. WebAccreditation is voluntary and seeking deemed status through accreditation is an option, not a requirement. Medical Student SOAP Note | LAUREL, MS, South Central Regional Medical Center (SCRMC) announces the successful completion of its new accreditation process that has been awarded by DNV. Mitigating and preventing hepatitis B virus exposures during hemodialysis across a large regional health system. At Rochester Regional Health, our dedication to quality is reflected in the teams we hire, the care we provide and the services we offer. DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. nQt}MA0alSx k&^>0|>_',G! WebThe JCAHO and its accreditation programs are described, the history of the Medicare-JCAHO relationship is reviewed, and why the federal Medicare program has relied on accreditation as an indicator of the quality of participating hospitals is examined. endstream endobj 1332 0 obj <>stream 0000006807 00000 n To review focus area input and agree on one to three particular focus areas upon which the audit will focus. Infection Control & Hospital Epidemiology. %%EOF Accessed April 23, 2010. We focus on achieving this aspect at every survey. All surveyors have a healthcare background and specialize in one of three areas: clinical care, physical environment, or quality management. endstream endobj 155 0 obj <>/Size 127/Type/XRef>>stream In addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. Certification by DNV Healthcare is key step toward establishing your hospital's reputation for excellence. endstream endobj 128 0 obj <>/Metadata 20 0 R/PieceInfo<>>>/Pages 19 0 R/PageLayout/OneColumn/StructTreeRoot 22 0 R/Type/Catalog/LastModified(D:20081002145347)/PageLabels 17 0 R>> endobj 129 0 obj <>/ColorSpace<>/Font<>/ProcSet[/PDF/Text/ImageC/ImageI]/ExtGState<>>>/Type/Page>> endobj 130 0 obj <> endobj 131 0 obj <> endobj 132 0 obj <> endobj 133 0 obj [/Indexed 148 0 R 255 149 0 R] endobj 134 0 obj <> endobj 135 0 obj <> endobj 136 0 obj <> endobj 137 0 obj <>stream Organizations seeking CMS approval may choose to be surveyed either by an accrediting body, such as the Joint Commission, DNV, and HFAP, or by state surveyors on behalf of CMS. Download the Standards created and offered by DNV Healthcare, 131 0 obj Accessed August 5, 2009. 0000003418 00000 n Learning happens when staff are comfortable and not intimidated by the process. Since accreditation is a must-have credential for just about every hospital in this country, why not make it more valuable, and get more out of it? I.3A 8J8rzW&g0( dmOz!%_z+=vkwq/&&p':G~fEG`9.}kh}@%/C7}` 7l We use cookies to help provide and enhance our service and tailor content. Our Risk Based Certification approach tailors the process to evaluate your select business risks in addition to compliance with the standards requirements. dnvaccreditation. hb```b``c`201 +s0 xref 2019 HIMSS Annual Conference: Clinical Optimization: One Approach to Integration, 2019 Breakthroughs Conference: Clinical Optimization: A Panel Discussion. DNV draws on its wide technical and industry expertise to help companies worldwide build consumer and stakeholder trust. 8644 0 obj <>/Filter/FlateDecode/ID[<80A28E873128684998433581F605455E>]/Index[8618 50]/Info 8617 0 R/Length 123/Prev 1023342/Root 8619 0 R/Size 8668/Type/XRef/W[1 3 1]>>stream Read Part 3: Accreditation Options: Understanding the Joint Commission DNV Healthcare originated in Norway in 1864 as a risk management company. After the audit you need to address and respond to non-conformities within an agreed deadline. WebAccreditation and certification are important accomplishments and we are here to help your organization throughout the entire process. 0000038715 00000 n *This product is a downloadable document and does not ship. Both your management system and certificate have to be maintained. <>/Pages 117 0 R /StructTreeRoot 177 0 R /ViewerPreferences<>/PageLayout/OneColumn/Type/Catalog/MarkInfo<>/Lang( E N - U S)/Metadata 262 0 R >> 0000002447 00000 n WebThis background is fascinating in view of The Joint Commissions (TJC) history. The International Standards Organization (ISO) Web site. Contact South Central Regional Medical Center, Hospital Affiliation Request | WebIn addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. 0000005823 00000 n CMS-2895-FN, September, 26, 2008. After each survey there is a detailed report which is easy to follow and describes, with objective evidence, where your organization is not in compliance with the standard. Rochester Regional Health is a national leader with the most Beacon Awards from the American Association of Critical Care Nurses, recognizing hospital units that have integrated evidence-based practices to improve patient and family outcomes. DNV attracts attention from health care organizations WebAssistant Director - Accreditation Services . cuup}c~*_3:!RvpgI(@6a^@IiPo}f$@ L9qdzD AY:RR' 4PQqhxitI3\! The DNV program is consistent with our long-term commitment to quality and patient safety, says Dr. Teresa Camp-Rogers, Chief Quality Officer at SCRMC. DNV Healthcare - Accreditation Organization for If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. During surveys, DNV wants to see the improvements that have been made as a result of the annual survey process. doi:10.1017/ice.2020.295. Our lead auditor evaluates your management system documentation. South Central was the first DNV accredited healthcare organization in Mississippi. Meeting DNV Accreditation Standards BPHC Accreditation Initiative . This is applicable in situations where an organisation persistently and seriously fails to maintain compliance with the management system standard or due to other situations, as defined in the procedure for suspension and withdrawal of certificates. Top management should be involved at this stage. The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. SCRMC serves as the second largest employer in Jones County. %PDF-1.4 % Our Privacy Policy | Medical Student H&P | WebAccredited certification of management systems is used to demonstrate compliance to a standard in a trusted way. I was never aware there were any Center for Medicaid and State Operations/Survey and Contracts with insurers may require certain accreditation and may need renegotiation Will there be a saving in direct and indirect accreditation costs? Because there would be a time gap between Joint Commission and DNV accreditation, Rosen worked with the state Department of Health and the local CMS Accreditation | SCRMC has three years from the date of its accreditation to achieve compliance with ISO 9001, the worlds most trusted quality management system used by performance-driven organizations around the world to advance their quality and sustainability objectives. 0000001372 00000 n The initial visit can be combined with the documentation review. HtTKo0Wh( This collaborative approach is crucial in continuing to improve and be a quality improvement hospital. Subsequently 1-3 focus areas on which the audit will focus are identified. Comparison of The Joint Commission and Det Norske - WAMSS The certification process - DNV I*Rt>[?Yim*>"1t>hvYJa`h0vh` 2+@,F0)fP`c6e,ITWhLVJCXLFu @B@h6{E@E"% @lT- g Hu.5LL00~gPdpMej8 PClY~p=Tt n`xH108Y * ~ D\z David Eickemeyer, MBA; Associate Director, Hospital Business Development. We felt that by moving from Joint Commission accreditation to DNV accreditation we were taking our organization to an all new level, he said. hbbd```b``= "@$nDEH`=d`L""@$?/O@o_@H b4l4k#%4#3` , %%EOF Learn how to plan your visit or hospital stay, pay your bill, contact us, and more information about visiting any of our facilities. Today, 300 follow DNV Accreditation procedures, and 80 more are in the process v4?fBHQ [C. `0 d``_}C!\ |S0\`0[znV$5*c"00z`PwzS\u@_w{wSZ3@`|4iE"'-*5wIsr]gI qyO'WAm)U1Ys96S=ffXTjMJ5P)TTOVyN9xddiV,ey-E% 847-324-7487 | msweeney@aaahc.org . I've just been hired on at a hospital that is Det Norske Veritas (DNV) accredited as opposed to the Joint Commission. This is much more than an accreditation program, its a catalyst for our ongoing commitment to patient safety and clinical quality.. 1350 0 obj <>stream hVO0W4u~yHZVm6)am|;#\zn$2N'*P1!$''BoD/We/Tze 121 0 obj Comparison of The Joint Commission and DNV- GL HCs National Integrated Accreditation for Healthcare Organizations (NIAHO) MS Standards Kathy Matzka, CPMSM, CPCS 1, History TJC 1952 began Unique statutory hospital deeming authority 1965 Medicare statute July 15, 2008, the Medicare Improvements for Patients and Providers Act of 2008 became law 11/09 CMS approval 4, 546 Hospital and CAH in 2011 4, 429 Hospital and CAH in 2013 (90% of accredited hospitals) 4, 032 Hospital and CAH in 2016 (88% of accredited hospitals) NIAHO 12/19/07 Application to CMS 09/08 CMS approval 94 Hospital and CAH on 7/14/10 393 Hospital and CAH on 4/17/2016 2, Process TJC NIAHO Three year survey Annual Survey Standards directly Most MS standards related to the CMS as directly related to the well as self-defined CMS ISO 9001 quality management 3, Scoring Process TJC NIAHO Three-point scale: 0 = insufficient compliance 1 = partial compliance 2 = satisfactory compliance Icons Documentation required Situational decision rules apply Direct impact requirements apply Category A requirement Category C requirement (based on # of times does not meet standard) Measurement of Success needed Standards Scored as Meets requirements Nonconformity Category I Conditional level Egregious non-compliance Nonconformity Category I Noncompliant Nonconformity Category II Occasional or isolated lapse in compliance Immediate Jeopardy Immediate threat to patient safety No aggregate scoring 4, Appointment Timeframe TJC Two years NIAHO Three years if state law does not address 5, Continuing Medical Education TJC NIAHO LIPs and other practitioners All with privileges participate in privileged through the medical CE that is at least in part staff process must participate related to their clinical in CE privileges Participation must be CME considered in decisions documented and considered in about reappointment or decisions about reappointment, renewal or revision of clinical renewal, or revision of privileges individual clinical privileges Action on an individuals application for appointment /reappointment or initial or subsequent clinical privileges is withheld until the information is available and verified 6, Current Competence TJC The hospital verifies in writing and from the primary source, whenever feasible, or from a CVO, information concerning the current competence Evaluate data from other organizations where the applicant currently has privileges, if available NIAHO Initial - MS qualifications include verification of current competence Reap - Review of individual performance data for variation from benchmark Variations to peer review for determination of validity, written explanation of findings and, if appropriate, an action plan to include improvement strategies 7, Malpractice History TJC NIAHO MS evaluates Review of involvement in a any professional liability action at initial and action, including final reappointment judgments and settlements involving a practitioner Must evaluate any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant 8, Peer Recommendations TJC NIAHO Required at initial, reap, consideration of termination, or revision/revocation of clinical privileges Address the relevant training and experience, current competence, and any effects of health status on privileges being requested Include evaluation of the applicants medical knowledge, technical and clinical skills, clinical judgment, communication skills, interpersonal skills, and professionalism Obtained from a practitioner in the same professional discipline as the applicant with personal knowledge of the applicants ability to practice List of appropriate sources Two peer recommendations required at initial appointment 9, Clinical Privileges TJC NIAHO PSV for current licensure or All permitted by the certification organization and by law to PSV of relevant training provide patient care services Evidence of physical ability to independently have delineated perform the requested privilege clinical privileges If available, data from If available and/or required by professional practice review the MS, a review of individual from other organization where performance data variation the applicant currently has from criteria determined by the privileges medical staff to identify need Recommendations from for training or proctoring that peers/faculty may be required On renewal, review of the applicants performance within the hospital 10, Telemedicine TJC NIAHO 3 choices The originating site can fully privilege and credential the practitioner according to MS standards or Use credentialing information from the distant site if the distant site is a Joint Commission-accredited organization or Use credentialing and privileging decision from the Joint Commission-accredited distant site Medical staff at both sites make recommendation for services to be provided via telemedicine For non-deeming, can be via contract only if TJC accredited entity 2 choices The originating site can fully privilege and credential the practitioner according to MS standards or Use credentialing and privileging decision from telemedicine entity or distant site Medicare participating hospital When services provided by a contracted entity, GB must identify criteria for selection and procurement of services and how to evaluate the entity 11, Temporary Privileges TJC NIAHO 120 days for new applicant with complete file awaiting MEC approval Time as specified in bylaws for patient care need On recommendation of MS President or designee No successful challenges to licensure or registration; involuntary termination of MS appointment; involuntary limitation, reduction, denial, or loss of clinical privileges Not exceed 120 days Locum tenens not to exceed 6 months On recommendation of a MEC member, MS president or medical director (as defined by MS Urgent patient care need Complete application w/o negative or adverse information before action by the medical staff or governing body 12, Temporary Privileges TJC NIAHO Patient care need verify Current licensure Current competence New Applicant verify Current licensure Relevant training or experience Current competence Ability to perform the privileges requested Other criteria required by medical staff bylaws NPDB In all cases verify education (AMA/AOA Profile OK current competence primary verification of State professional licenses professional references (including current competence) Database profiles from AMA, AOA, NPDB, and OIG Medicare/Medicaid Exclusions 13, Allied Health Professionals TJC NIAHO LIPs through MS process Non-LIP APRNs and PAs HR or MS if not providing a medical level of care If State law allows, MS may include DPM, OD, DC, PA, CRNA, NM, APRN, DMD, PHD or other designated professionals approved by MS and Board and eligible for appointment 14, Executive Committee TJC NIAHO 10 EPs outlining responsibilities, structure, function If MS has an executive committee, a majority of the members of the committee shall be doctors of medicine or osteopathy CEO and the nurse executive of the organization or designee shall attend each meeting on an ex-officio basis, with or without vote 15, TJC Notifications NIAHO The decision to grant, A current roster listing deny, revise, or each practitioners revoke privilege(s) is specific surgical disseminated and privileges must be made available to all available in the appropriate internal surgical suite and external persons scheduling area or entities, as defined Include surgeons with by the hospital and suspended surgical applicable law privileges or whose surgical privileges have been restricted 16, Surgical Privileges TJC NIAHO Included in general category for privileges All practitioners performing surgery have surgical privileges established by the department of surgery and medical staff and approved by the governing body Privileges for general surgery and surgical subspecialties defined with established criteria approved by MS Privileges correspond with established competencies of each practitioner 17, Automatic Suspension TJC NIAHO The medical staff bylaws include description of indications for automatic suspension or summary suspension of a practitioners medical staff membership or clinical privileges description of when automatic suspension or summary suspension procedures are implemented The medical staff will define the criteria and have a mechanism for consideration of automatic suspension of clinical privileges of a practitioner at a minimum when: revocation/restriction of professional license DEA certificate has been revoked, suspended or on probation Failure to maintain the minimum specified amount of professional liability insurance non-compliance with written medical record delinquency or deficiency requirements Mechanism for immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioners Medicare or Medicaid status 18, QA/PI Data TJC FPPE OPPE Medical Assessment Blood Medication Operative and other procedure(s) Appropriateness of clinical practice patterns Significant departures from established patterns of clinical practice Use of criteria for autopsies Sentinel event data Patient safety data NIAHO Practitioner specific performance data is required and must be ratebased with comparative peer or national data available for comparison.

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