dnv accreditation vs joint commission

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% Based on a positive outcome, he/she will recommend certification. dnvaccreditation. 8618 0 obj <> endobj Accreditation | Findings, including non-conformities, and conclusions are presented at the end of the audit in a closing meeting and included in the audit report. 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 All Rochester Regional Health labor and delivery hospitals. DNV is kept apprised of the organization's level of compliance with ongoing organizational reporting. Vendor Login | Rex Zordan . ISO standards ensure that products and services are safe, reliable and of good quality. In case of expanding the scope the process will restart at section 2 with a documentation review (if needed) and will further follow the normal process from section 4 with a (scope extension) certification audit. 0000003710 00000 n ".*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~ Mitigating and preventing hepatitis B virus exposures during hemodialysis across a large regional health system. At this stage you have completed the initial certification and can move on to maintenance of your certification. DNV prides itself in the ability to relate to frontline staff and leadership, thus putting them at ease. The password to view the NAMSS Comparison of Accreditation Standards is: Q7r&Km DNVs accreditation program is the only one to integrate the ISO 9001 Quality Management System with the Medicare Conditions of Participation. Hospitals are no longer stuck in a cycle of addressing the same issue every three years. 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. )CL:E8 $@eB5(ABRg]._e p`'ih]ao]|. 0000000016 00000 n hYmo6+bwRPI-@fulAMTcg5~w'I :^xXoay-uL3,%a8J#!%@aY%I>)ddJ:ph+*jX 9Q43F:\RzvYV:ibv2gTM]oWjQ)|V?AtYuy[uq]{ 121 0 obj The scope of certification may need to be changed during the 3 year certification cycle. cuup}c~*_3:!RvpgI(@6a^@IiPo}f$@ L9qdzD AY:RR' 4PQqhxitI3\! 8667 0 obj <>stream DNV Accreditation is based on the companys innovative NIAHO standards. 0 In 2020, Rochester Regional Health participated in 123 regulatory surveys in our acute care settings, outpatient settings and specialty programs from compliance agencies like DNV Healthcare, The Joint Commission and the Department of Health. WebAccredited certification of management systems is used to demonstrate compliance to a standard in a trusted way. 2010 Mosby, Inc. Accepted manuscript, pp. 1 27. Delia Constanzo . The certification decision is taken after an independent DNV GL internal review. endstream endobj startxref WebAssistant Director - Accreditation Services . N')].uJr After the three years are up, your certification will be extended through a re-certification audit. Below are several components of our psychiatric hospital accreditation program. The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. An integrated health services organization serving the people of Western New York. DNV: Det Norske Veritas: DNV: Der Norske Veritas: DNV: District of North Vancouver (British ISO is the International Organization for Standardization. Fundao So Francisco Xavier / Hospital Mrcio Cunha. 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. SCRMCs current service area includes a patient population of 120,000 residents in 4 countiesJones, Jasper, Smith and Wayne Counties. 156 0 obj <>stream WebWe have a variety of resources to help you explore and master the accreditation process. 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. 0000008466 00000 n In addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. {(oFA`=My$RqH+#~/aDh4:G}_.Q8f(fVJ7*7/oG|t6FG\kpvaGx2?yxz RlG@-e0&9zWez|U( v 1350 0 obj <>stream Our leading medical education and research are at the forefront of healthcare innovation. DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. 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. 0000039232 00000 n DNV is a global independent certification, assurance and risk management provider, operating in more than 100 countries. <>/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 >> Accessed August 5, 2009. hTkSI?ssMl 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. 0000007461 00000 n 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 International Standards Organization (ISO) Web site. To update your cookie settings, please visit the. Det Norske Veritas (DNV) is a global quality DNV draws on its wide technical and industry expertise to help companies worldwide build consumer and stakeholder trust. endstream endobj 139 0 obj <>stream anDkDMMmnZWh|rQl( Unlike previous approaches to accreditation, DNV focuses on what works best for each hospital and therefore opens the door to innovation. This is a list of the hospitals accredited to the international standard by DNV. 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. Knowing where to focus improvement efforts is critical to take control of risk elements that can threaten your business success. 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. 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\) "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 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. 0000003960 00000 n 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. 2y.-;!KZ ^i"L0- @8(r;q7Ly&Qq4j|9 Accreditation verifies the certification body/registrars competence. SCRMC serves as the second largest employer in Jones County. `0 d``_}C!\ |S0\`0[znV$5*c"00z`PwzS\u@_w{wSZ3@`|4iE"'-*5wIsr]gI qyO'WAm)U1Ys96S=ffXTjMJ5P)TTOVyN9xddiV,ey-E% Reflective of an organizations performance with respect to Joint Commission standards and elements of performance (EPs).Transparent all components of the process are fully disclosed to accredited and certified organizations.Easily understood by all involved parties.More items Provides a framework for organizational structure and management Accreditation involves preparing for a survey and maintaining a high level of quality and compliance with the latest standards. Joint Commission accreditation provides guidance to an organizations quality improvement efforts. Rochester Regional Health is a national leader with the most Beacon Awards from the American Association of Critical Care Nurses, recognizing hospital units that have integrated evidence-based practices to improve patient and family outcomes. 0000006234 00000 n The trademarks DNV GL, DNV, the Horizon Graphic and Det Norske Veritas are the properties of companies in the Det Norske Veritas group. WebAccreditation is voluntary and seeking deemed status through accreditation is an option, not a requirement. Published by Elsevier Inc. All rights reserved. Our lead auditor will verify that you have properly addressed the nonconformities. All rights reserved. The purpose of the initial visit is twofold: Based on this, the scope and audit plan are agreed upon. hbbd``b` @)H0A@"*HpE$> oL,F6~0 d About South Central Regional Medical Center. What happens if an organisation fails to maintain their management system and certification? AORN statement on nurse-to-patient ratios. See upcoming training courses. 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. Contracts with insurers may require certain accreditation and may need renegotiation Will there be a saving in direct and indirect accreditation costs? Using an accredited third party certification body/registrars demonstrates that the auditing company is meets the required quality standard set by the accrediting authority. The certification audit consists of informal interviews, examinations, observations of the system in operation and review of relevant documentation. endstream endobj 1332 0 obj <>stream CMS-2895-FN, September, 26, 2008. Accreditation can directly affect the quality of hospital care. WebAccredited hospitals. Accreditation Canada accredited its first organization internationally in 1967 in Bermuda. In comparison, the Joint Commission has Psychiatric Hospitals are accredited for a three year period, subject to annual survey to verify continuing compliance with NIAHO. 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. Each issued certificate has a three-year life period. Because while undergoing the accreditation process, a hospital makes critical decisions about how it provides services, manages medications and allocates resources. Both your management system and certificate have to be maintained. 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) Compliance is viewed as a 3-year To check your readiness for the certification audit, i.e. Rochester General Hospital Maternity Care,Unity Hospital Maternity Care,United Memorial Medical Center Maternity Care. NIAHO is the National Integrated Accreditation for Healthcare Organizations and encourages collaboration between different hospital departments. The Joint Commission Lon Berkeley . to review your manual, check procedures, to see your facilities, and briefly check the implementation of your management system. HyTSwoc [5laQIBHADED2mtFOE.c}088GNg9w '0 Jb As an example, a hospital could have its Joint Commission accreditation renewed for three years on July 10, 2010. 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. *This product is a downloadable document and does not ship. PMID: 12085409 Joint Commission on Accreditation of Healthcare Organizations* / history hbbd```b``= "@$nDEH`=d`L""@$?/O@o_@H b4l4k#%4#3` , I've just been hired on at a hospital that is Det Norske Veritas (DNV) accredited as opposed to the Joint Commission. Why? 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. 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 630-792-5787 | lberkeley@jointcommission.org. We evaluate how well your management system supports your focus areas. 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. 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. 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- It is widely recognized as the gold standard in healthcare accreditation, and its standards are considered rigorous and comprehensive. Senior Account Executive . 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. 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 0000001372 00000 n endobj 0000003466 00000 n HtTKo0Wh( 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. 0 DOI:https://doi.org/10.1017/ice.2020.1437. Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-02.pdf. At Newark-Wayne, Rochester General Hospital, United Memorial and Unity Hospital. Please enter a term before submitting your search. In the few years since DNV Healthcare became the first new 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. WebThe important role of the Joint Commission. Whether youre new to the Joint All rights reserved. SOUTH CENTRAL REGIONAL MEDICAL CENTER RECEIVES QUALITY-BASED ACCREDITATION FROM DNV. There is always an opportunity to improve. Find the residency program, fellowship, or training program that's right for you, or explore our research and clinic trials. Country-wide, more than 5000 hospitals are permitted to provide Medicarefinanced services solely 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. xbbg`b``3E0 ) Therefore, accredited certification consists of a 3-step cycle: To tailor the audit, we need to know what is important to your organisation. Certification by DNV Healthcare is key step toward establishing your hospital's reputation for excellence. 630-792-5509 | rzordan@jointcommission.org. org 22, Questions to Consider Will our reputation in the community suffer if we change? Clifton Springs Hospital and Clinic recently was awarded an A grade for safety. 0000009720 00000 n 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 Webknown as DNV Accreditation, they came equipped with the experience of TUVs previous effort to become deemed and their National Integrated Accreditation for Healthcare DNV conducts a survey every year instead of every three years. wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 endstream endobj 138 0 obj <>stream Public Records Policy | The outcome is still a certificate if the management system is found compliant but with added dimension to your improvement journey. This accreditation underscores our commitment to developing and continually improving quality and safety for employees, patients and visitors throughout our system. Before the audit starts, you provide input on what operational processes are most crucial to your business success. Infection Control & Hospital Epidemiology,40(9), 1066-1069. doi:10.1017/ice.2019.164. Comparison of Joint Commission and DNV - GL HC NIAHO MS Standards Kathy Matzka, CPMSM, CPCS 8 22 Resources Standards: NIAHO Standards, HSMo0+TR E9dR-,Q 0000000913 00000 n These audits confirm your companys on-going compliance with specified requirements of the standard while re-evaluating performance in focus areas. endobj 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, Joint Commission emphasize differences. This product includes updates that will be made by NAMSS over the next 12 months. If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. WebThe more variables and inter-dependencies in you organization, the more relevant ISO becomes. 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 %PDF-1.4 % 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. 2002 Jun;75(6):1179-82. doi: 10.1016/s0001-2092(06)61621-9. The documentation review report summarizes any findings from this process. Author Frederick P Franko. The report indicates if your organisation is ready to proceed with the certification audit. The important role of the Joint Commission AORN J. Antibiotic Susceptibility | This accreditation underscores our commitment to developing and continually improving quality and safety for employees, patients and visitors throughout our system. H\J@{6fgBA[^Hi M}{voI\]fcuvO1}yPYq:\xvwm,.rsi`at3Xvizx)vnn. 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? 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. Employee Login | 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. 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.