You will then receive an email that contains a secure link for resetting your password, If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password. The scope of certification is agreed at an early stage in the certification process. {(oFA`=My$RqH+#~/aDh4:G}_.Q8f(fVJ7*7/oG|t6FG\kpvaGx2?yxz RlG@-e0&9zWez|U( v Each issued certificate has a three-year life period. DET NORSKE VERITAS (DNV) Compliance is viewed as a 3-year The outcome is still a certificate if the management system is found compliant but with added dimension to your improvement journey. 0000005823 00000 n Find the location that's most convenient for you! 127 0 obj <> endobj When found compliant, we issue the certificate. %%EOF 630-792-5787 | lberkeley@jointcommission.org. All rights reserved. endstream endobj 155 0 obj <>/Size 127/Type/XRef>>stream ISO is the International Organization for Standardization. <>/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 >> After the three years are up, your certification will be extended through a re-certification audit. N')].uJr It is widely recognized as the gold standard in healthcare accreditation, and its standards are considered rigorous and comprehensive. Why? )CL:E8 $@eB5(ABRg]._e p`'ih]ao]|. BPHC Accreditation Initiative . In the few years since DNV Healthcare became the first new 23, Sections 1-6 1-7 commission and graduated commission, What are the defects of existing curriculum, Joint commission oxygen cylinder storage 2019, DNV Managing Risk DNV corporate presentation Elzbieta BitnerGregersen, JOINT COMMISSION PANEL DISCUSSION REGARDING RECENT JOINT COMMISSION, COMPARISON AND CONTRAST COMPARISON CONTRAST Comparison points out, Aligning Accreditation and Quality The DNV Perspective The, Introduction to IDSADI 15926 Resources Ian Glendinning DNV, DNV Healthcare Top Survey Findings Medical Staff National, SOLAS requirements DNV interpretations Jan Tore Grimsrud February, Mobile Technology in Ships Inspections Thomas Mestl DNV, RBI Intro some activities at DNV Fatigue Workshop, INTRODUCING INTUMAXEP 1115 XHP DNV CERTIFICATE NO F16685, CBCD Cloned Buggy Code Detector Jingyue Li DNV, DNV a Norwegian company in Korea with focus, DNV GL studie LNG in de scheepvaart verlagen, KNEE JOINT ANKLE JOINT HIP JOINT Prof Ahmed, Shoulder Joint Shoulder Glenohumeral Joint The shoulder joint, Elbow Joint Elbow Joint Type Synovial hinge joint, SYNOVIAL JOINT Dr Iram Tassaduq SYNOVIAL JOINT Joint. In short, accreditation impacts the way hospitals operate. Medical Student H&P | [lW7wI/_./-";)n*R+lx-I$,4|t*0#__ l) WebThe important role of the Joint Commission. 0000003710 00000 n 0000039232 00000 n Infection Control & Hospital Epidemiology. Lesho, E., Hix, J., Bronstein, M., Shastry, S., Hanna, J., Scroggins, G., & Grieff, M. (2019). Accessed August 5, 2009. 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. DNV has a client drop box feature where questions regarding the standards can be asked directly to our specialists and surveyors. WebIntro to DNV and NIAHO. ".*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$iq-kUh_4<7\R+vi)e35elpG[piiqN#@t9Z]Y?})#=[8GOCb+1QKU,HY WWcVr y"=uOsb%V xOy^N?+OHG'9%[qdF]guPa("2Hbs=Kt0 :J~O|JGn n~ Det Norske Veritas (DNV) NIAHO Accreditation Requirements Interpretive Guidelines & Surveyor Guidance Revision 7, 2008. The decision to grant initial certification, renew certification or to expand or reduce the scope of certification, is made by competent and authorized personnel in DNV who are different from those carrying out the audit. The Joint Commission on the Accreditation of Healthcare Organizations. Learn how to plan your visit or hospital stay, pay your bill, contact us, and more information about visiting any of our facilities. The Joint Commission (TJC) is a non-profit organization that accredits and certifies over 22,000 healthcare organizations and programs in the United States. v4?fBHQ [C. If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. Public Records Policy | 0000020794 00000 n Based on a positive outcome, he/she will recommend certification. The password to view the NAMSS Comparison of Accreditation Standards is: Q7r&Km The International Standards Organization (ISO) Web site. Psychiatric Hospitals are accredited for a three year period, subject to annual survey to verify continuing compliance with NIAHO. Midland Memorial happy with DNV shift. Our Risk Based Certification approach tailors the process to evaluate your select business risks in addition to compliance with the standards requirements. wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 Unlike previous approaches to accreditation, DNV focuses on what works best for each hospital and therefore opens the door to innovation. Delia Constanzo . We currently have 26 Beacon Awards across our system. Hover over the "Register" button in the top right corner to see the price, 1 Question|Unlimited attempts|1/1 points to pass|Graded as Pass/Fail. Available at: www.iso.org/iso/home. In comparison, the Joint Commission has This commitment to safe, reliable and high-quality care is also demonstrated through our regulatory compliance and accreditations, awards and recognition and participation in national conferences and journals. 0000000016 00000 n LAUREL, MS, South Central Regional Medical Center (SCRMC) announces the successful completion of its new accreditation process that has been awarded by DNV. Rochester General Hospital Maternity Care,Unity Hospital Maternity Care,United Memorial Medical Center Maternity Care. We have taken an entirely different approach to accreditation, and hospitals are really responding, says DNV Healthcare USA Inc. President Patrick Horine. To update your cookie settings, please visit the. Learn About Accreditation Survey hVO0W4u~yHZVm6)am|;#\zn$2N'*P1!$''BoD/We/Tze Using an accredited third party certification body/registrars demonstrates that the auditing company is meets the required quality standard set by the accrediting authority. DOI: https://doi.org/10.1016/j.mnl.2009.10.004, The International Organization for Standardization (ISO), To read this article in full you will need to make a payment. View our list of disease-specific and specialty program certifications. The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. Our lead auditor evaluates your management system documentation. Using an accredited third party certification body/registrars DNVs philosophy is to assist Psychiatric Hospitals through compliance with the NIAHO Hospital Accreditation Program and Appendix B standards, encouraging a safe and therapeutic milieu which allows patients to be treated safely and effectively. Similar review also applies in cases of suspending or restoring certification or withdrawing the certification. Antibiotic Susceptibility | To check your readiness for the certification audit, i.e. %,,`0,XA!rd{ey` F7 The trademarks DNV GL, DNV, the Horizon Graphic and Det Norske Veritas are the properties of companies in the Det Norske Veritas group. This process ensures a full and timely understanding of the standards. 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. DNV prides itself in the ability to relate to frontline staff and leadership, thus putting them at ease. Our leading medical education and research are at the forefront of healthcare innovation. 2019 HIMSS Annual Conference: Clinical Optimization: One Approach to Integration, 2019 Breakthroughs Conference: Clinical Optimization: A Panel Discussion. This accreditation underscores our commitment to developing and continually improving quality and safety for employees, patients and visitors throughout our system. 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 0000003466 00000 n H|S[o0~WL3CJ)d[+ej8["ChT(/>| Lr= 1A/?7_]"`WW0 MB%pf4{R)"~"LeC$X8 V+I::'p8%I^H$pfr>8hY6/Fd&JA#aNj,'{?li1z\) WebAccredited certification of management systems is used to demonstrate compliance to a standard in a trusted way. The Joint Commissions Stroke Certification Enhancements for 2018. Brazil. This product includes updates that will be made by NAMSS over the next 12 months. endobj endstream endobj startxref Access our full portfolio of public and private courses, including CHOP Certification. endstream endobj 1331 0 obj <>stream 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 The certification decision is taken after an independent DNV GL internal review. Four years on, upstart nears 350 clients. The certification audit consists of informal interviews, examinations, observations of the system in operation and review of relevant documentation. 0000012414 00000 n if6&a<=h19;G;:1/SVyB~szQxLgF/94|249#5}Z.+2P#Ncj&qd>ezUL!U&^bezdif++ 0F5/*36Xkm2EI5 y|d04_4_4U. 38cWuc5Sgp:|z] b#THp.'y9Q"dC) XyBlY0,REC-;BfKg%k Gn#A &5B.69e@CqL2{8ZJaC3}vS~ ~l }A}BB-P^I1d}F +R5:>BK5F#A05Vvm{H74` &ixTeG'8T qm|/.mF}K"&Et:rPdj'wj,QmfKh!ynoiwazxC4;oVO ^W[]|rzG k% DNVs accreditation program, called NIAHO (Integrated Accreditation of Healthcare Organizations), involves annual hospital surveys instead of every three years and encourages hospitals to openly share information across departments and to discover improvements in clinical workflows and safety protocols. Have questions Contact us DNV Healthcare WebAccreditation is voluntary and seeking deemed status through accreditation is an option, not a requirement. 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 South Central was the first DNV accredited healthcare organization in Mississippi. xref Medical Student SOAP Note | 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. Top management should be involved at this stage. Therefore, accredited certification consists of a 3-step cycle: To tailor the audit, we need to know what is important to your organisation. 0000038715 00000 n 1350 0 obj <>stream WebThe more variables and inter-dependencies in you organization, the more relevant ISO becomes. DNV Healthcare, Joint Commission emphasize differences. AORN Guidance Statement: Perioperative Staffing. Subsequently 1-3 focus areas on which the audit will focus are identified. endstream endobj startxref 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. org 22, Questions to Consider Will our reputation in the community suffer if we change? In addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. Vendor Login | 0 Infection Control & Hospital Epidemiology,40(9), 1066-1069. doi:10.1017/ice.2019.164. SOUTH CENTRAL REGIONAL MEDICAL CENTER RECEIVES QUALITY-BASED ACCREDITATION FROM DNV. (Are minimal standards sufficient in todays healthcare climate? ) %%EOF 156 0 obj <>stream "F$H:R!zFQd?r9\A&GrQhE]a4zBgE#H *B=0HIpp0MxJ$D1D, VKYdE"EI2EBGt4MzNr!YK ?%_&#(0J:EAiQ(()WT6U@P+!~mDe!hh/']B/?a0nhF!X8kc&5S6lIa2cKMA!E#dV(kel }}Cq9 630 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. Our Privacy Policy | We felt that by moving from Joint Commission accreditation to DNV accreditation we were taking our organization to an all new level, he said. To review focus area input and agree on one to three particular focus areas upon which the audit will focus. COVID-19 Updates: Get the latest information from our experts: Vaccines Testing Visitor & Mask Guidelines Closings. The purpose of the initial visit is twofold: Based on this, the scope and audit plan are agreed upon. doi:10.1017/ice.2020.295. endstream endobj 1328 0 obj <>/Metadata 142 0 R/OCProperties<>/OCGs[1339 0 R 1340 0 R 1341 0 R]>>/Outlines 204 0 R/Pages 1318 0 R/StructTreeRoot 287 0 R/Type/Catalog>> endobj 1329 0 obj <>/ExtGState<>/Font<>/Properties<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1330 0 obj <>stream Web DNV GL Healthcare (DNV GL) The Compliance Team (TCT) The Joint Commission (JC) There are currently another seven AOs approved under CLIA, which are: American Association of Blood Banks (AABB) American Association for Laboratory Accreditation (A2LA) American Osteopathic Association (AOA) 847-324-7487 | msweeney@aaahc.org . Provides a framework for organizational structure and management Accreditation involves preparing for a survey and maintaining a high level of quality and compliance with the latest standards. Joint Commission accreditation provides guidance to an organizations quality improvement efforts. 0000004038 00000 n Agreeing on focus areas is a collaborative effort, and our auditors can help suggest focus areas if necessary. Webknown as DNV Accreditation, they came equipped with the experience of TUVs previous effort to become deemed and their National Integrated Accreditation for Healthcare 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 For more information about DNV, visit www.dnvcert.com/healthcare. % I've just been hired on at a hospital that is Det Norske Veritas (DNV) accredited as opposed to the Joint Commission. Hospital Mater Dei. 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. Rex Zordan . This is much more than an accreditation program, its a catalyst for our ongoing commitment to patient safety and clinical quality.. Select from the topics below to get started. All rights reserved. Because while undergoing the accreditation process, a hospital makes critical decisions about how it provides services, manages medications and allocates resources. endstream endobj 1332 0 obj <>stream 2002 Jun;75(6):1179-82. doi: 10.1016/s0001-2092(06)61621-9. 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- HyTSwoc [5laQIBHADED2mtFOE.c}088GNg9w '0 Jb The report indicates if your organisation is ready to proceed with the certification audit. 1327 0 obj <> endobj As DNV hospitals often say, ISO provides the structure for the staff to focus on The focus areas should be linked to the management system and reflect the risks or opportunities that are most important to you. Findings, including non-conformities, and conclusions are presented at the end of the audit in a closing meeting and included in the audit report. 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. 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. DNV is a global independent certification, assurance and risk management provider, operating in more than 100 countries. 8618 0 obj <> endobj 0000012451 00000 n 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. Whether youre new to the Joint The annual survey model keeps hospitals moving forward on the path of continued improvement. The scope of certification may need to be changed during the 3 year certification cycle. %PDF-1.4 % 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. 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 Det Accessed August 5, 2009. Available at: http://www.jointcommission.org/NR/rdonlyres/2F04C126-906D-4155-B16F-1F1A6570C387/0/jconlineAug1209.pdf. DNV conducts a survey every year instead of every three years. 2023 Rochester Regional Health. Published by Elsevier Inc. All rights reserved. Mitigating and preventing hepatitis B virus exposures during hemodialysis across a large regional health system. 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 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 0000006234 00000 n A successful management system is one that is improved on a continual basis. 0000004698 00000 n WebIn addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. 0000005251 00000 n 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. 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%# n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. Below are several components of our psychiatric hospital accreditation program. to review your manual, check procedures, to see your facilities, and briefly check the implementation of your management system. Biocor Hospital De Doencas Cardiovasculares LTDA. We evaluate how well your management system supports your focus areas. 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. SCRMCs current service area includes a patient population of 120,000 residents in 4 countiesJones, Jasper, Smith and Wayne Counties. xbbg`b``3E0 ) Find the residency program, fellowship, or training program that's right for you, or explore our research and clinic trials. 1 27. By 1991, TJC had learned that it was not possible to ensure quality and had moved on to quality improvement and its many iterations, now known as performance improvement. About South Central Regional Medical Center. 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. <]>> During surveys, DNV wants to see the improvements that have been made as a result of the annual survey process. NIAHO is the National Integrated Accreditation for Healthcare Organizations and encourages collaboration between different hospital departments. Lab Specimen Guideline | com Jointcomission. 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. HtTKo0Wh( Read Part 3: Accreditation Options: Understanding the Joint Commission DNV Healthcare originated in Norway in 1864 as a risk management company. The scope of certification may however need to be expanded or reduced due to factors such as acquisitions, downsizing, adding new divisions etc. Centers for Medicare and Medicaid Services. anDkDMMmnZWh|rQl( Find out more about our accreditation, certification & training programs. <>/Pages 117 0 R /StructTreeRoot 177 0 R /ViewerPreferences<>/PageLayout/OneColumn/Type/Catalog/MarkInfo<>/Lang( E N - U S)/Metadata 262 0 R >> Before the audit starts, you provide input on what operational processes are most crucial to your business success. At Newark-Wayne, Rochester General Hospital, United Memorial and Unity Hospital. WebAssistant Director - Accreditation Services . ISO standards ensure that products and services are safe, reliable and of good quality. What happens if an organisation fails to maintain their management system and certification? Country-wide, more than 5000 hospitals are permitted to provide Medicarefinanced services solely DNV draws on its wide technical and industry expertise to help companies worldwide build consumer and stakeholder trust. This accreditation underscores our commitment to developing and continually improving quality and safety for employees, patients and visitors throughout our system. 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. Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-02.pdf. Search our services and programs offered by our experts at our hundreds of locations throughout Western New York and the Finger Lakes region. We have to get a clear understanding of your business strategy and conditions that affect your ability to reach said strategy. Project Director, CHC Accreditation . 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.