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- 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 The scope of certification may need to be changed during the 3 year certification cycle. The ability to integrate ISO 9001 quality standards with our clinical and financial processes is a major step forward.. 120 0 obj I.3A 8J8rzW&g0( dmOz!%_z+=vkwq/&&p':G~fEG`9.}kh}@%/C7}` 7l The DNV accreditation program provides us the opportunity to simultaneously satisfy our Medicare accreditation requirements and implement the ISO 9001:2015 Quality Management System all at the same time, said Doug Higginbotham, Executive Director at South Central Regional Medical Center. The Joint Commissions Stroke Certification Enhancements for 2018. endobj DNV draws on its wide technical and industry expertise to help companies worldwide build consumer and stakeholder trust. 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%# Agreeing on focus areas is a collaborative effort, and our auditors can help suggest focus areas if necessary. This product includes updates that will be made by NAMSS over the next 12 months. 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. 127 0 obj <> endobj 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% You must complete the Participant's Agreement in order to access your purchased NAMSS Education. )CL:E8 $@eB5(ABRg]._e p`'ih]ao]|. Our lead auditor evaluates your management system documentation. DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. WebIn addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. N')].uJr Whether youre new to the Joint To update your cookie settings, please visit the. DNV is kept apprised of the organization's level of compliance with ongoing organizational reporting. About 200 hospitals have switched to DNV Accreditation over the past two years. *This product is a downloadable document and does not ship. Thats where ISO 9001 comes into play and turns the typical get-your-ticket-punched accreditation exercise into a quality transformation.. Contact South Central Regional Medical Center, Hospital Affiliation Request | Similar review also applies in cases of suspending or restoring certification or withdrawing the certification. WebAssistant Director - Accreditation Services . 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. Accredited certification of management systems is used to demonstrate compliance to a standard in a trusted way. Rex Zordan . We focus on achieving this aspect at every survey. %PDF-1.6 % Available at: http://cert.branswijck.com/. Four years on, upstart nears 350 clients. HyTSwoc [5laQIBHADED2mtFOE.c}088GNg9w '0 Jb 0000008466 00000 n 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. See upcoming training courses. During surveys, DNV wants to see the improvements that have been made as a result of the annual survey process. CMS-2895-FN, September, 26, 2008. % Both your management system and certificate have to be maintained. 2010 Mosby, Inc. Knowing where to focus improvement efforts is critical to take control of risk elements that can threaten your business success. 0000009113 00000 n endstream endobj 155 0 obj <>/Size 127/Type/XRef>>stream What is hospital accreditation The accreditation programs DNV offers either directly address regulatory requirements for hospitals, such as US Government's Centers for Medicare and Medicaid (CMS), or provide guidance and best practices for clinical specialty organizations across healthcare. DNVs NIAHO standards is approved by CMS. Lab Specimen Guideline | WebAccreditation is voluntary and seeking deemed status through accreditation is an option, not a requirement. About South Central Regional Medical Center. endstream endobj 138 0 obj <>stream Infection Control & Hospital Epidemiology. startxref 0000000913 00000 n Compliance is viewed as a 3-year 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 "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 It is widely recognized as the gold standard in healthcare accreditation, and its standards are considered rigorous and comprehensive. After the audit you need to address and respond to non-conformities within an agreed deadline. 0000006807 00000 n To check your readiness for the certification audit, i.e. To fulfill the accreditation criteria, an accrediting authority assesses the certification body/registrar to verify that the certification body/registrar complies with existing requirements. In short, accreditation impacts the way hospitals operate. 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. %PDF-1.4 % 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$8 1sb s6s[fPE<1I!4XOLv^+d2(i}%C9X H|S[o0~WL3CJ)d[+ej8["ChT(/>| Lr= 1A/?7_]"`WW0 MB%pf4{R)"~"LeC$X8 V+I::'p8%I^H$pfr>8hY6/Fd&JA#aNj,'{?li1z\) SCRMC serves as the second largest employer in Jones County. I was never aware there were any David Eickemeyer, MBA; Associate Director, Hospital Business Development. Accreditation Canada accredited its first organization internationally in 1967 in Bermuda. H\J@{6fgBA[^Hi M}{voI\]fcuvO1}yPYq:\xvwm,.rsi`at3Xvizx)vnn. 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 This process ensures a full and timely understanding of the standards. 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 Lesho, E., Hix, J., Bronstein, M., Shastry, S., Hanna, J., Scroggins, G., & Grieff, M. (2019). The scope of certification may however need to be expanded or reduced due to factors such as acquisitions, downsizing, adding new divisions etc. 0000038715 00000 n The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. Find out more about our accreditation, certification & training programs. This accreditation underscores our commitment to developing and continually improving quality and safety for employees, patients and visitors throughout our system. Author Frederick P Franko. 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. %%EOF Joint Commission Online, August 12, 2009. Our Privacy Policy | %PDF-1.6 % Academic & Personal: 24 hour online access, Corporate R&D Professionals: 24 hour online access, https://doi.org/10.1016/j.mnl.2009.10.004, Comparisons of the NIAHO and Joint Commission Approaches to Accreditation, Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-02.pdf, Available at: http://www.dnv.com/binaries/NIAHO%20Accreditation%20Requirements-Rev%20307-8%200(2)_tcm4-347543.pdf, Available at: http://www.jointcommission.org/NR/rdonlyres/2F04C126-906D-4155-B16F-1F1A6570C387/0/jconlineAug1209.pdf, For academic or personal research use, select 'Academic and Personal', For corporate R&D use, select 'Corporate R&D Professionals', Association for periOperative Registered Nurses. DNV Accreditation is based on the companys innovative NIAHO standards. Hospital Mater Dei. Medical Student H&P | nQt}MA0alSx k&^>0|>_',G! Subsequently 1-3 focus areas on which the audit will focus are identified. Have questions Contact us DNV Healthcare SOUTH CENTRAL REGIONAL MEDICAL CENTER RECEIVES QUALITY-BASED ACCREDITATION FROM DNV. 0000001631 00000 n 0000002975 00000 n Clifton Springs Hospital and Clinic recently was awarded an A grade for safety. 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. 2y.-;!KZ ^i"L0- @8(r;q7Ly&Qq4j|9 Det Norske Veritas (DNV) is a global quality Our Risk Based Certification approach tailors the process to evaluate your select business risks in addition to compliance with the standards requirements. v4?fBHQ [C. Following a positive decision you will receive the certificate shortly thereafter. 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. 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 Below are several components of our psychiatric hospital accreditation program. xbbg`b``3E0 ) hbbd```b``= "@$nDEH`=d`L""@$?/O@o_@H b4l4k#%4#3` , Find the location that's most convenient for you! 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 DNV has a client drop box feature where questions regarding the standards can be asked directly to our specialists and surveyors. At Rochester Regional Health, our dedication to quality is reflected in the teams we hire, the care we provide and the services we offer. 0000004038 00000 n endstream endobj 139 0 obj <>stream 0 xref %%EOF HSMo0+TR E9dR-,Q Hospitals are no longer stuck in a cycle of addressing the same issue every three years. Based on a positive outcome, he/she will recommend certification. The report indicates if your organisation is ready to proceed with the certification audit. To review focus area input and agree on one to three particular focus areas upon which the audit will focus. As DNV hospitals often say, ISO provides the structure for the staff to focus on WebAccredited hospitals. WebWe have a variety of resources to help you explore and master the accreditation process. As an example, a hospital could have its Joint Commission accreditation renewed for three years on July 10, 2010. <>/Pages 117 0 R /StructTreeRoot 177 0 R /ViewerPreferences<>/PageLayout/OneColumn/Type/Catalog/MarkInfo<>/Lang( E N - U S)/Metadata 262 0 R >> 0000039232 00000 n In the few years since DNV Healthcare became the first new Public Records Policy | WebThe organizations are surveyed annually. 131 0 obj Available at: www.iso.org/iso/home. 156 0 obj <>stream Access our full portfolio of public and private courses, including CHOP Certification. More than 2,100 individuals are employed throughout health system and approximately 125 providers representing 28 medical specialties provide care to patients. 0000003710 00000 n 847-324-7487 | [email protected] . 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. We have to get a clear understanding of your business strategy and conditions that affect your ability to reach said strategy. Driven by its purpose, to safeguard life, property, and the environment, DNV helps tackle the challenges and global transformations facing its customers and the world today and is a trusted voice for many of the worlds most successful and forward-thinking companies. We provide services at more than 400 locations across the region. DNVs accreditation program is the only one to integrate the ISO 9001 Quality Management System with the Medicare Conditions of Participation. Using an accredited third party certification body/registrars demonstrates that the auditing company is meets the required quality standard set by the accrediting authority. 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. DNV has a transparent procedure for suspension or withdrawal of certificates. 0000038975 00000 n Psychiatric Hospitals are accredited for a three year period, subject to annual survey to verify continuing compliance with NIAHO. This accreditation underscores our commitment to developing and continually improving quality and safety for employees, patients and visitors throughout our system. Whether certifying a companys management system or products, accrediting hospitals, providing training, assessing supply chains or digital assets, DNV enables customers and stakeholders to make critical decisions with confidence, continually improve and realize long-term strategic goals sustainably. dnvaccreditation. Search our services and programs offered by our experts at our hundreds of locations throughout Western New York and the Finger Lakes region. Read Part 3: Accreditation Options: Understanding the Joint Commission DNV Healthcare originated in Norway in 1864 as a risk management company. There is always an opportunity to improve. Risk Based Certification is our exclusive approach to all management system certification. Unlike previous approaches to accreditation, DNV focuses on what works best for each hospital and therefore opens the door to innovation. 0000003418 00000 n n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. 0000005251 00000 n 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. endstream endobj startxref Our leading medical education and research are at the forefront of healthcare innovation. At Newark-Wayne, Rochester General Hospital, United Memorial and Unity Hospital. DOI:https://doi.org/10.1017/ice.2020.1437. AORN Guidance Statement: Perioperative Staffing. For more information about DNV, visit www.dnvcert.com/healthcare. endstream endobj 1332 0 obj <>stream WebThis approval provides hospitals with another accreditation option in addition to the Joint Commission and the American Osteopathic Association. V)gB0iW8#8w8_QQj@&A)/g>'K t;\ $FZUn(4T%)0C&Zi8bxEB;PAom?W= We evaluate how well your management system supports your focus areas. The annual survey model keeps hospitals moving forward on the path of continued improvement. 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. Findings, including non-conformities, and conclusions are presented at the end of the audit in a closing meeting and included in the audit report. 2019 HIMSS Annual Conference: Clinical Optimization: One Approach to Integration, 2019 Breakthroughs Conference: Clinical Optimization: A Panel Discussion. DNV Healthcare, Joint Commission emphasize differences. Contracts with insurers may require certain accreditation and may need renegotiation Will there be a saving in direct and indirect accreditation costs? 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. Available at: http://www.jointcommission.org/NR/rdonlyres/2F04C126-906D-4155-B16F-1F1A6570C387/0/jconlineAug1209.pdf. WebAccredited certification of management systems is used to demonstrate compliance to a standard in a trusted way. <>stream <>/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 >> LAUREL, MS, South Central Regional Medical Center (SCRMC) announces the successful completion of its new accreditation process that has been awarded by DNV. 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. Accreditation verifies the certification body/registrars competence. Comparison of Joint Commission and DNV - GL HC NIAHO MS Standards Kathy Matzka, CPMSM, CPCS 8 22 Resources Standards: NIAHO Standards, DNV Healthcares hospital accreditation program is unique in that it integrates the ISO 9001 standards (international quality standards that define 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. NIAHO is the National Integrated Accreditation for Healthcare Organizations and encourages collaboration between different hospital departments. Grid last updated: July 2022, National Association Medical Staff Services. %PDF-1.6 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. TCI certification. 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 American Nurses Credentialing Center has recognized Clifton Springs Hospital & Clinic, Rochester General, Unity, Newark-Wayne Community hospitals and PCASI with the highest honor available for nursing excellence. hVO0W4u~yHZVm6)am|;#\zn$2N'*P1!$''BoD/We/Tze Select from the topics below to get started. South Central Regional Medical Center has been Joint Commission accredited for years and hospital personnel are very familiar with the accreditation process, but Joint Commission does not require ISO certification. Mitigating and preventing hepatitis B virus exposures during hemodialysis across a large regional health system. The focus areas should be linked to the management system and reflect the risks or opportunities that are most important to you. DNV has accredited about 300 hospitals with another 80 or so awaiting accreditation, according to Horine. 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. Det Norske Veritas (DNV) NIAHO Accreditation Requirements Interpretive Guidelines & Surveyor Guidance Revision 7, 2008. 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.