These surveys, often routine or planned to certify our specialty programs, look at our communication processes, governance, processes, standardization, safety precautions and outcomes. 0000006234 00000 n The International Standards Organization (ISO) Web site. 0000002447 00000 n Available at: http://www.jointcommission.org/NR/rdonlyres/2F04C126-906D-4155-B16F-1F1A6570C387/0/jconlineAug1209.pdf. This helps hospitals create a corrective action plan to improve their process and prevent that variance from occurring again. Four years on, upstart nears 350 clients. 121 0 obj The purpose of the initial visit is twofold: Based on this, the scope and audit plan are agreed upon. The trademarks DNV GL, DNV, the Horizon Graphic and Det Norske Veritas are the properties of companies in the Det Norske Veritas group. 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 DNV: Det Norske Veritas: DNV: Der Norske Veritas: DNV: District of North Vancouver (British 0 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. nQt}MA0alSx k&^>0|>_',G! wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 anDkDMMmnZWh|rQl( DNV has accredited about 300 hospitals with another 80 or so awaiting accreditation, according to Horine. 127 0 obj <> endobj Access our full portfolio of public and private courses, including CHOP Certification. Our lead auditor evaluates your management system documentation. Because while undergoing the accreditation process, a hospital makes critical decisions about how it provides services, manages medications and allocates resources. Please enter a term before submitting your search. 0000003960 00000 n The scope of certification may however need to be expanded or reduced due to factors such as acquisitions, downsizing, adding new divisions etc. Det Norske Veritas (DNV) NIAHO Accreditation Requirements Interpretive Guidelines & Surveyor Guidance Revision 7, 2008. The password to view the NAMSS Comparison of Accreditation Standards is: Q7r&Km Learning happens when staff are comfortable and not intimidated by the process. Learn how to plan your visit or hospital stay, pay your bill, contact us, and more information about visiting any of our facilities. Lab Specimen Guideline | Contact South Central Regional Medical Center, Hospital Affiliation Request | Available at: http://cert.branswijck.com/. Search our services and programs offered by our experts at our hundreds of locations throughout Western New York and the Finger Lakes region. 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) About South Central Regional Medical Center. DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. Centers for Medicare and Medicaid Services. Find the residency program, fellowship, or training program that's right for you, or explore our research and clinic trials. Our Risk Based Certification approach tailors the process to evaluate your select business risks in addition to compliance with the standards requirements. HyTSwoc [5laQIBHADED2mtFOE.c}088GNg9w '0 Jb n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. [lW7wI/_./-";)n*R+lx-I$,4|t*0#__ l) Certification by DNV Healthcare is key step toward establishing your hospital's reputation for excellence. ".*RK6"zf9ss~3 AARJA=Z\&6c@+|dk{GKY B_],IEmmq_rS}gX;L9nL%)5Ek&$;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~ AORN Guidance Statement: Perioperative Staffing. )CL:E8 $@eB5(ABRg]._e p`'ih]ao]|. 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. Vendor Login | We have taken an entirely different approach to accreditation, and hospitals are really responding, says DNV Healthcare USA Inc. President Patrick Horine. endstream endobj startxref WebAccredited certification of management systems is used to demonstrate compliance to a standard in a trusted way. Through its broad experience and deep expertise, DNV advances safety and sustainable performance, sets industry benchmarks, drives innovative solutions. Each issued certificate has a three-year life period. These audits confirm your companys on-going compliance with specified requirements of the standard while re-evaluating performance in focus areas. Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-02.pdf. doi:10.1017/ice.2020.295. DNVs accreditation program is the only one to integrate the ISO 9001 Quality Management System with the Medicare Conditions of Participation. <>stream 0000007824 00000 n Risk Based Certification is our exclusive approach to all management system certification. DNV has a transparent procedure for suspension or withdrawal of certificates. Medical Student H&P | 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 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. SCRMCs current service area includes a patient population of 120,000 residents in 4 countiesJones, Jasper, Smith and Wayne Counties. 0000005251 00000 n ISO is recognized by businesses around the world as the benchmark for continual quality improvement. DNV draws on its wide technical and industry expertise to help companies worldwide build consumer and stakeholder trust. {(oFA`=My$RqH+#~/aDh4:G}_.Q8f(fVJ7*7/oG|t6FG\kpvaGx2?yxz RlG@-e0&9zWez|U( v 0000009113 00000 n Grid last updated: July 2022, National Association Medical Staff Services. endstream endobj 138 0 obj <>stream There is always an opportunity to improve. Rex Zordan . Joint Commission Online, August 12, 2009. During this process, we assess your management systems degree of compliance with the requirements of the elected standard and performance in identified focus areas. 630-792-5787 | lberkeley@jointcommission.org. Why? WebThis approval provides hospitals with another accreditation option in addition to the Joint Commission and the American Osteopathic Association. LAUREL, MS, South Central Regional Medical Center (SCRMC) announces the successful completion of its new accreditation process that has been awarded by DNV. What happens if an organisation fails to maintain their management system and certification? 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. This is a list of the hospitals accredited to the international standard by DNV. The scope of certification is agreed at an early stage in the certification process. trailer WebIntro to DNV and NIAHO. Fundao So Francisco Xavier / Hospital Mrcio Cunha. Before the audit starts, you provide input on what operational processes are most crucial to your business success. ISO standards ensure that products and services are safe, reliable and of good quality. If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. 0000001372 00000 n Senior Account Executive . The outcome is still a certificate if the management system is found compliant but with added dimension to your improvement journey. 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. 0000002012 00000 n WebThe important role of the Joint Commission. 8618 0 obj <> endobj Accreditation verifies the certification body/registrars competence. org 22, Questions to Consider Will our reputation in the community suffer if we change? 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 Knowing where to focus improvement efforts is critical to take control of risk elements that can threaten your business success. 1327 0 obj <> endobj COVID-19 Updates: Get the latest information from our experts: Vaccines Testing Visitor & Mask Guidelines Closings. This collaborative approach is crucial in continuing to improve and be a quality improvement hospital. Author Frederick P Franko. Det Norske Veritas (DNV) is a global quality The scope of certification may need to be changed during the 3 year certification cycle. The Joint Commission on the Accreditation of Healthcare Organizations. 0000013305 00000 n 2010 Mosby, Inc. 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. I've just been hired on at a hospital that is Det Norske Veritas (DNV) accredited as opposed to the Joint Commission. It is widely recognized as the gold standard in healthcare accreditation, and its standards are considered rigorous and comprehensive. Brazil. To update your cookie settings, please visit the. The ability to integrate ISO 9001 quality standards with our clinical and financial processes is a major step forward.. WebThis electronic reference tool provides plain-language interpretations of the credentialing standards for The Joint Commission, NCQA, Healthcare Facilities Accreditation H\J@{6fgBA[^Hi M}{voI\]fcuvO1}yPYq:\xvwm,.rsi`at3Xvizx)vnn. %PDF-1.6 % 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. Following a positive decision you will receive the certificate shortly thereafter. 0000008466 00000 n Have questions Contact us DNV Healthcare See upcoming training courses. startxref At this stage you have completed the initial certification and can move on to maintenance of your certification. 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. 0000000016 00000 n We use cookies to help provide and enhance our service and tailor content. 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 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. % hVO0W4u~yHZVm6)am|;#\zn$2N'*P1!$''BoD/We/Tze Accepted manuscript, pp. In the few years since DNV Healthcare became the first new hb```b``c`201 +s0 0 Infection Control & Hospital Epidemiology. DNV prides itself in the ability to relate to frontline staff and leadership, thus putting them at ease. WebThe more variables and inter-dependencies in you organization, the more relevant ISO becomes. At least one periodic audit per year is required. South Central was the first DNV accredited healthcare organization in Mississippi. We felt that by moving from Joint Commission accreditation to DNV accreditation we were taking our organization to an all new level, he said. About 200 hospitals have switched to DNV Accreditation over the past two years. Det Both your management system and certificate have to be maintained. 0000012451 00000 n BPHC Accreditation Initiative . 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. Infection Control & Hospital Epidemiology,40(9), 1066-1069. doi:10.1017/ice.2019.164. We provide services at more than 400 locations across the region. 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. Using an accredited third party certification body/registrars 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. 131 0 obj 0000002975 00000 n Available at: www.iso.org/iso/home. The certification audit consists of informal interviews, examinations, observations of the system in operation and review of relevant documentation. Find out more about our accreditation, certification & training programs. Thats where ISO 9001 comes into play and turns the typical get-your-ticket-punched accreditation exercise into a quality transformation.. 0000012414 00000 n This decision is made based on a review of the certification process and associated documentation. DNV is kept apprised of the organization's level of compliance with ongoing organizational reporting. When found compliant, we issue the certificate. [fy^Mx_6vbvX,'Mqtr)yzQn.^%~&PdXfbpqxu5Y)Vwuq_DO1ou{)v]tiply/m}+s[(E}Zyc"F%x.%i%NW?VE\gcuJ[Q[Ka/.W. com Jointcomission. 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. 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. Country-wide, more than 5000 hospitals are permitted to provide Medicarefinanced services solely For more information about DNV, visit www.dnvcert.com/healthcare. All rights reserved. 156 0 obj <>stream xref This accreditation underscores our commitment to developing and continually improving quality and safety for employees, patients and visitors throughout our system. 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 All surveyors have a healthcare background and specialize in one of three areas: clinical care, physical environment, or quality management. Accessed April 23, 2010. <>/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 >> This product includes updates that will be made by NAMSS over the next 12 months. 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. Admin, South Central Family Medicine & Urgent Care, Directions to South Central Regional Medical Center, Where to Get the Best Care and When to Go. 847-324-7487 | msweeney@aaahc.org . 0000001631 00000 n The Joint Commissions Stroke Certification Enhancements for 2018. DNV conducts a survey every year instead of every three years. At Newark-Wayne, Rochester General Hospital, United Memorial and Unity Hospital. 0000003710 00000 n Infection Control & Hospital Epidemiology (2020), 41, 13441347. Therefore, accredited certification consists of a 3-step cycle: To tailor the audit, we need to know what is important to your organisation. xbbg`b``3E0 ) Public Records Policy | More than 2,100 individuals are employed throughout health system and approximately 125 providers representing 28 medical specialties provide care to patients. Our lead auditor will verify that you have properly addressed the nonconformities. Accessed August 5, 2009. Whether youre new to the Joint 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. WebIn addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. xb```f``ue` ea *(ltSa{+ 9QQ (MHKX*?6Y ,8v'83rXrE0C;;[70^} Ua vHCO4@ZT Dr g$ Project Director, CHC Accreditation . The documentation review can be performed prior to or conducted as part of the initial visit. Agreeing on focus areas is a collaborative effort, and our auditors can help suggest focus areas if necessary. SOUTH CENTRAL REGIONAL MEDICAL CENTER RECEIVES QUALITY-BASED ACCREDITATION FROM DNV. 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. WebAssistant Director - Accreditation Services . We felt that by moving from Joint Commission accreditation to DNV accreditation we were taking our organization to an all new level, he said. 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. 0000003418 00000 n DNV is a global independent certification, assurance and risk management provider, operating in more than 100 countries. 0000006807 00000 n Learn About Accreditation Survey The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. V)gB0iW8#8w8_QQj@&A)/g>'K t;\ $FZUn(4T%)0C&Zi8bxEB;PAom?W= 1350 0 obj <>stream x- [ 0}y)7ta>jT7@t`q2&6ZL?_yxg)zLU*uSkSeO4?c. R -25 S>Vd`rn~Y&+`;A4 A9 =-tl`;~p Gp| [`L` "AYA+Cb(R, *T2B- At Rochester Regional Health, our dedication to quality is reflected in the teams we hire, the care we provide and the services we offer. You must complete the Participant's Agreement in order to access your purchased NAMSS Education. DET NORSKE VERITAS (DNV) H|S[o0~WL3CJ)d[+ej8["ChT(/>| Lr= 1A/?7_]"`WW0 MB%pf4{R)"~"LeC$X8 V+I::'p8%I^H$pfr>8hY6/Fd&JA#aNj,'{?li1z\) 0000004038 00000 n endstream endobj 8619 0 obj <>/Metadata 315 0 R/Outlines 731 0 R/Pages 8594 0 R/StructTreeRoot 1070 0 R/Type/Catalog>> endobj 8620 0 obj <>/ExtGState<>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 8621 0 obj <>stream 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. Upon certification, we will create a periodic audit schedule for regular audits over the three-year period. HSMo0+TR E9dR-,Q %PDF-1.4 % The report indicates if your organisation is ready to proceed with the certification audit. PMID: 12085409 Joint Commission on Accreditation of Healthcare Organizations* / history N')].uJr endstream endobj startxref Subsequently 1-3 focus areas on which the audit will focus are identified. dnvaccreditation. 0000038715 00000 n 0000020794 00000 n In addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. 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 Regional Medical Center operates as a 285-bed hospital, an alcohol and drug inpatient detox facility, a wound care center with hyperbaric oxygen chambers, a cancer center, 22 medical clinics, two large nursing homes, a wellness and rehabilitation center, a home care and hospice division, a full service ambulance service, an emergency department which has 42,000 patient visits annually, and numerous other programs and services. 1 27. 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. After the three years are up, your certification will be extended through a re-certification audit. 0 Our leading medical education and research are at the forefront of healthcare innovation. 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 DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. To check your readiness for the certification audit, i.e. 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? We evaluate how well your management system supports your focus areas. The Joint Commission Lon Berkeley . Similar review also applies in cases of suspending or restoring certification or withdrawing the certification. In short, accreditation impacts the way hospitals operate. 0000007461 00000 n Hospital Mater Dei. Mitigating and preventing hepatitis B virus exposures during hemodialysis across a large regional health system. "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 I was never aware there were any Compliance is viewed as a 3-year AORN statement on nurse-to-patient ratios. %%EOF 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. 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. Comparison of The Joint Commission and DNV- GL HCs National Integrated Accreditation for Healthcare Organizations (NIAHO) MS Standards Kathy Matzka, CPMSM, CPCS 1, History TJC 1952 began Unique statutory hospital deeming authority 1965 Medicare statute July 15, 2008, the Medicare Improvements for Patients and Providers Act of 2008 became law 11/09 CMS approval 4, 546 Hospital and CAH in 2011 4, 429 Hospital and CAH in 2013 (90% of accredited hospitals) 4, 032 Hospital and CAH in 2016 (88% of accredited hospitals) NIAHO 12/19/07 Application to CMS 09/08 CMS approval 94 Hospital and CAH on 7/14/10 393 Hospital and CAH on 4/17/2016 2, Process TJC NIAHO Three year survey Annual Survey Standards directly Most MS standards related to the CMS as directly related to the well as self-defined CMS ISO 9001 quality management 3, Scoring Process TJC NIAHO Three-point scale: 0 = insufficient compliance 1 = partial compliance 2 = satisfactory compliance Icons Documentation required Situational decision rules apply Direct impact requirements apply Category A requirement Category C requirement (based on # of times does not meet standard) Measurement of Success needed Standards Scored as Meets requirements Nonconformity Category I Conditional level Egregious non-compliance Nonconformity Category I Noncompliant Nonconformity Category II Occasional or isolated lapse in compliance Immediate Jeopardy Immediate threat to patient safety No aggregate scoring 4, Appointment Timeframe TJC Two years NIAHO Three years if state law does not address 5, Continuing Medical Education TJC NIAHO LIPs and other practitioners All with privileges participate in privileged through the medical CE that is at least in part staff process must participate related to their clinical in CE privileges Participation must be CME considered in decisions documented and considered in about reappointment or decisions about reappointment, renewal or revision of clinical renewal, or revision of privileges individual clinical privileges Action on an individuals application for appointment /reappointment or initial or subsequent clinical privileges is withheld until the information is available and verified 6, Current Competence TJC The hospital verifies in writing and from the primary source, whenever feasible, or from a CVO, information concerning the current competence Evaluate data from other organizations where the applicant currently has privileges, if available NIAHO Initial - MS qualifications include verification of current competence Reap - Review of individual performance data for variation from benchmark Variations to peer review for determination of validity, written explanation of findings and, if appropriate, an action plan to include improvement strategies 7, Malpractice History TJC NIAHO MS evaluates Review of involvement in a any professional liability action at initial and action, including final reappointment judgments and settlements involving a practitioner Must evaluate any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant 8, Peer Recommendations TJC NIAHO Required at initial, reap, consideration of termination, or revision/revocation of clinical privileges Address the relevant training and experience, current competence, and any effects of health status on privileges being requested Include evaluation of the applicants medical knowledge, technical and clinical skills, clinical judgment, communication skills, interpersonal skills, and professionalism Obtained from a practitioner in the same professional discipline as the applicant with personal knowledge of the applicants ability to practice List of appropriate sources Two peer recommendations required at initial appointment 9, Clinical Privileges TJC NIAHO PSV for current licensure or All permitted by the certification organization and by law to PSV of relevant training provide patient care services Evidence of physical ability to independently have delineated perform the requested privilege clinical privileges If available, data from If available and/or required by professional practice review the MS, a review of individual from other organization where performance data variation the applicant currently has from criteria determined by the privileges medical staff to identify need Recommendations from for training or proctoring that peers/faculty may be required On renewal, review of the applicants performance within the hospital 10, Telemedicine TJC NIAHO 3 choices The originating site can fully privilege and credential the practitioner according to MS standards or Use credentialing information from the distant site if the distant site is a Joint Commission-accredited organization or Use credentialing and privileging decision from the Joint Commission-accredited distant site Medical staff at both sites make recommendation for services to be provided via telemedicine For non-deeming, can be via contract only if TJC accredited entity 2 choices The originating site can fully privilege and credential the practitioner according to MS standards or Use credentialing and privileging decision from telemedicine entity or distant site Medicare participating hospital When services provided by a contracted entity, GB must identify criteria for selection and procurement of services and how to evaluate the entity 11, Temporary Privileges TJC NIAHO 120 days for new applicant with complete file awaiting MEC approval Time as specified in bylaws for patient care need On recommendation of MS President or designee No successful challenges to licensure or registration; involuntary termination of MS appointment; involuntary limitation, reduction, denial, or loss of clinical privileges Not exceed 120 days Locum tenens not to exceed 6 months On recommendation of a MEC member, MS president or medical director (as defined by MS Urgent patient care need Complete application w/o negative or adverse information before action by the medical staff or governing body 12, Temporary Privileges TJC NIAHO Patient care need verify Current licensure Current competence New Applicant verify Current licensure Relevant training or experience Current competence Ability to perform the privileges requested Other criteria required by medical staff bylaws NPDB In all cases verify education (AMA/AOA Profile OK current competence primary verification of State professional licenses professional references (including current competence) Database profiles from AMA, AOA, NPDB, and OIG Medicare/Medicaid Exclusions 13, Allied Health Professionals TJC NIAHO LIPs through MS process Non-LIP APRNs and PAs HR or MS if not providing a medical level of care If State law allows, MS may include DPM, OD, DC, PA, CRNA, NM, APRN, DMD, PHD or other designated professionals approved by MS and Board and eligible for appointment 14, Executive Committee TJC NIAHO 10 EPs outlining responsibilities, structure, function If MS has an executive committee, a majority of the members of the committee shall be doctors of medicine or osteopathy CEO and the nurse executive of the organization or designee shall attend each meeting on an ex-officio basis, with or without vote 15, TJC Notifications NIAHO The decision to grant, A current roster listing deny, revise, or each practitioners revoke privilege(s) is specific surgical disseminated and privileges must be made available to all available in the appropriate internal surgical suite and external persons scheduling area or entities, as defined Include surgeons with by the hospital and suspended surgical applicable law privileges or whose surgical privileges have been restricted 16, Surgical Privileges TJC NIAHO Included in general category for privileges All practitioners performing surgery have surgical privileges established by the department of surgery and medical staff and approved by the governing body Privileges for general surgery and surgical subspecialties defined with established criteria approved by MS Privileges correspond with established competencies of each practitioner 17, Automatic Suspension TJC NIAHO The medical staff bylaws include description of indications for automatic suspension or summary suspension of a practitioners medical staff membership or clinical privileges description of when automatic suspension or summary suspension procedures are implemented The medical staff will define the criteria and have a mechanism for consideration of automatic suspension of clinical privileges of a practitioner at a minimum when: revocation/restriction of professional license DEA certificate has been revoked, suspended or on probation Failure to maintain the minimum specified amount of professional liability insurance non-compliance with written medical record delinquency or deficiency requirements Mechanism for immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioners Medicare or Medicaid status 18, QA/PI Data TJC FPPE OPPE Medical Assessment Blood Medication Operative and other procedure(s) Appropriateness of clinical practice patterns Significant departures from established patterns of clinical practice Use of criteria for autopsies Sentinel event data Patient safety data NIAHO Practitioner specific performance data is required and must be ratebased with comparative peer or national data available for comparison.
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