[fy^Mx_6vbvX,'Mqtr)yzQn.^%~&PdXfbpqxu5Y)Vwuq_DO1ou{)v]tiply/m}+s[(E}Zyc"F%x.%i%NW?VE\gcuJ[Q[Ka/.W. 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. After the three years are up, your certification will be extended through a re-certification audit. 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. 0000001372 00000 n NIAHO is the National Integrated Accreditation for Healthcare Organizations and encourages collaboration between different hospital departments. The important role of the Joint Commission AORN J. Rochester General Hospital Maternity Care,Unity Hospital Maternity Care,United Memorial Medical Center Maternity Care. 0000020794 00000 n 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. 0000005251 00000 n 0000008466 00000 n Hospitals are no longer stuck in a cycle of addressing the same issue every three years. WebAssistant Director - Accreditation Services . Knowing where to focus improvement efforts is critical to take control of risk elements that can threaten your business success. Therefore, accredited certification consists of a 3-step cycle: To tailor the audit, we need to know what is important to your organisation. nQt}MA0alSx k&^>0|>_',G! What happens if an organisation fails to maintain their management system and certification? Find the location that's most convenient for you! 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. H\J@{6fgBA[^Hi M}{voI\]fcuvO1}yPYq:\xvwm,.rsi`at3Xvizx)vnn. For more information about DNV, visit www.dnvcert.com/healthcare. HSMo0+TR E9dR-,Q WebThis approval provides hospitals with another accreditation option in addition to the Joint Commission and the American Osteopathic Association. More than 2,100 individuals are employed throughout health system and approximately 125 providers representing 28 medical specialties provide care to patients. All Rochester Regional Health labor and delivery hospitals. DNV has a client drop box feature where questions regarding the standards can be asked directly to our specialists and surveyors. 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 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. 2019 HIMSS Annual Conference: Clinical Optimization: One Approach to Integration, 2019 Breakthroughs Conference: Clinical Optimization: A Panel Discussion. Psychiatric Hospitals are accredited for a three year period, subject to annual survey to verify continuing compliance with NIAHO. 0000004698 00000 n DNV conducts a survey every year instead of every three years. Select from the topics below to get started. v4?fBHQ [C. <>/Pages 117 0 R /StructTreeRoot 177 0 R /ViewerPreferences<>/PageLayout/OneColumn/Type/Catalog/MarkInfo<>/Lang( E N - U S)/Metadata 262 0 R >> CMS-2895-FN, September, 26, 2008. All surveyors have a healthcare background and specialize in one of three areas: clinical care, physical environment, or quality management. The Joint Commissions Stroke Certification Enhancements for 2018. 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. South Central Regional Medical Center was the first hospital in Mississippi to be accredited by DNV Healthcare. We evaluate how well your management system supports your focus areas. 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. In short, accreditation impacts the way hospitals operate. The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. LAUREL, MS, South Central Regional Medical Center (SCRMC) announces the successful completion of its new accreditation process that has been awarded by DNV. The ability to integrate ISO 9001 quality standards with our clinical and financial processes is a major step forward.. 0000002012 00000 n Accreditation Canada accredited its first organization internationally in 1967 in Bermuda. xbbg`b``3E0 ) Our Privacy Policy | Find the residency program, fellowship, or training program that's right for you, or explore our research and clinic trials. These audits confirm your companys on-going compliance with specified requirements of the standard while re-evaluating performance in focus areas. ISO is the International Organization for Standardization. Infection Control & Hospital Epidemiology. Joint Commission Online, August 12, 2009. When found compliant, we issue the certificate. We focus on achieving this aspect at every survey. V)gB0iW8#8w8_QQj@&A)/g>'K t;\ $FZUn(4T%)0C&Zi8bxEB;PAom?W= doi:10.1017/ice.2020.295. %PDF-1.6 % This is applicable in situations where an organisation persistently and seriously fails to maintain compliance with the management system standard or due to other situations, as defined in the procedure for suspension and withdrawal of certificates. 630-792-5509 | rzordan@jointcommission.org. DNV Accreditation is based on the companys innovative NIAHO standards. Because there would be a time gap between Joint Commission and DNV accreditation, Rosen worked with the state Department of Health and the local CMS n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. 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 HtTKo0Wh( 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. 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. Have questions Contact us DNV Healthcare Before the actual certification audit, we will normally make a preliminary visit to your organisation. Accessed April 27, 2010. Fundao So Francisco Xavier / Hospital Mrcio Cunha. WebAccredited hospitals. DNV has accredited about 300 hospitals with another 80 or so awaiting accreditation, according to Horine. 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. 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. 0000003466 00000 n During surveys, DNV wants to see the improvements that have been made as a result of the annual survey process. Our Risk Based Certification approach tailors the process to evaluate your select business risks in addition to compliance with the standards requirements. DET NORSKE VERITAS (DNV) 121 0 obj endstream endobj startxref 8667 0 obj <>stream 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. DNV is kept apprised of the organization's level of compliance with ongoing organizational reporting. ISO standards ensure that products and services are safe, reliable and of good quality. TCI certification. South Central was the first DNV accredited healthcare organization in Mississippi. endobj 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. We have taken an entirely different approach to accreditation, and hospitals are really responding, says DNV Healthcare USA Inc. President Patrick Horine. 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. WebThe important role of the Joint Commission. The Joint Commission (TJC) is a non-profit organization that accredits and certifies over 22,000 healthcare organizations and programs in the United States. 0000012451 00000 n 2010 Mosby, Inc. Webknown as DNV Accreditation, they came equipped with the experience of TUVs previous effort to become deemed and their National Integrated Accreditation for Healthcare The International Standards Organization (ISO) Web site. 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 Contact South Central Regional Medical Center, Hospital Affiliation Request | 120 0 obj 127 30 The trademarks DNV GL, DNV, the Horizon Graphic and Det Norske Veritas are the properties of companies in the Det Norske Veritas group. ".*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~ The certification decision is taken after an independent DNV GL internal review. Infection Control & Hospital Epidemiology,40(9), 1066-1069. doi:10.1017/ice.2019.164. Antibiotic Susceptibility | 1 27. startxref DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. com Jointcomission. 0000013305 00000 n 0000006234 00000 n endstream endobj 1332 0 obj <>stream 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. 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. Rex Zordan . %,,`0,XA!rd{ey` F7 We use cookies to help provide and enhance our service and tailor content. 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) During this process, we assess your management systems degree of compliance with the requirements of the elected standard and performance in identified focus areas. <>/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 >> Available at: www.iso.org/iso/home. 630-792-5787 | lberkeley@jointcommission.org. hbbd```b``= "@$nDEH`=d`L""@$?/O@o_@H b4l4k#%4#3` , SCRMC serves as the second largest employer in Jones County. 847-324-7487 | msweeney@aaahc.org . N')].uJr hb```b``c`201 +s0 I've just been hired on at a hospital that is Det Norske Veritas (DNV) accredited as opposed to the Joint Commission. WebAccredited certification of management systems is used to demonstrate compliance to a standard in a trusted way. SCRMCs current service area includes a patient population of 120,000 residents in 4 countiesJones, Jasper, Smith and Wayne Counties. Similar review also applies in cases of suspending or restoring certification or withdrawing the certification. Infection Control & Hospital Epidemiology (2020), 41, 13441347. The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. Top management should be involved at this stage. trailer Our lead auditor will verify that you have properly addressed the nonconformities. 0000009720 00000 n Risk Based Certification is our exclusive approach to all management system certification. COVID-19 Updates: Get the latest information from our experts: Vaccines Testing Visitor & Mask Guidelines Closings. Upon certification, we will create a periodic audit schedule for regular audits over the three-year period. WebIntro to DNV and NIAHO. 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. Based on a positive outcome, he/she will recommend certification. 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. 127 0 obj <> endobj We provide services at more than 400 locations across the region. PMID: 12085409 Joint Commission on Accreditation of Healthcare Organizations* / history AORN Guidance Statement: Perioperative Staffing. 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. In comparison, the Joint Commission has An integrated health services organization serving the people of Western New York. The password to view the NAMSS Comparison of Accreditation Standards is: Q7r&Km Learn how to plan your visit or hospital stay, pay your bill, contact us, and more information about visiting any of our facilities. Author Frederick P Franko. Midland Memorial happy with DNV shift. "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 Delia Constanzo . DNVs philosophy is to assist Psychiatric Hospitals through compliance with the NIAHO Hospital Accreditation Program and Appendix B standards, encouraging a safe and therapeutic milieu which allows patients to be treated safely and effectively. Accreditation | Det Norske Veritas (DNV) is a global quality 0 630 A successful management system is one that is improved on a continual basis. 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 WebIn addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. At least one periodic audit per year is required. Employee Login | The documentation review report summarizes any findings from this process. DNV Healthcares hospital accreditation program is unique in that it integrates the ISO 9001 standards (international quality standards that define This is the authorities way of auditing the auditors, such as certification bodies like DNV. Hospital Mater Dei. %%EOF 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- Admin, South Central Family Medicine & Urgent Care, Directions to South Central Regional Medical Center, Where to Get the Best Care and When to Go. Contracts with insurers may require certain accreditation and may need renegotiation Will there be a saving in direct and indirect accreditation costs? Grid last updated: July 2022, National Association Medical Staff Services. SOUTH CENTRAL REGIONAL MEDICAL CENTER RECEIVES QUALITY-BASED ACCREDITATION FROM DNV. hTkSI?ssMl See upcoming training courses. Please enter a term before submitting your search. 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 Centers for Medicare and Medicaid Services. 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 DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. Mitigating and preventing hepatitis B virus exposures during hemodialysis across a large regional health system. )CL:E8 $@eB5(ABRg]._e p`'ih]ao]|. Today, 300 follow DNV Accreditation procedures, and 80 more are in the process hYmo6+bwRPI-@fulAMTcg5~w'I :^xXoay-uL3,%a8J#!%@aY%I>)ddJ:ph+*jX 9Q43F:\RzvYV:ibv2gTM]oWjQ)|V?AtYuy[uq]{ 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. Why? Felicio Rocho Hospital. `0 d``_}C!\ |S0\`0[znV$5*c"00z`PwzS\u@_w{wSZ3@`|4iE"'-*5wIsr]gI qyO'WAm)U1Ys96S=ffXTjMJ5P)TTOVyN9xddiV,ey-E% If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. hVO0W4u~yHZVm6)am|;#\zn$2N'*P1!$''BoD/We/Tze You must complete the Participant's Agreement in order to access your purchased NAMSS Education. We felt that by moving from Joint Commission accreditation to DNV accreditation we were taking our organization to an all new level, he said. Published by Elsevier Inc. All rights reserved. The scope of certification is agreed at an early stage in the certification process. Find out more about our accreditation, certification & training programs. This collaborative approach is crucial in continuing to improve and be a quality improvement hospital. We have to get a clear understanding of your business strategy and conditions that affect your ability to reach said strategy. (Are minimal standards sufficient in todays healthcare climate? ) At this stage you have completed the initial certification and can move on to maintenance of your certification. This decision is made based on a review of the certification process and associated documentation. xb```f``ue` ea *(ltSa{+ 9QQ (MHKX*?6Y ,8v'83rXrE0C;;[70^} Ua vHCO4@ZT Dr g$ All rights reserved. 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. 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 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. %%EOF All rights reserved. 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. endstream endobj 1331 0 obj <>stream 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. 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$8 1sb s6s[fPE<1I!4XOLv^+d2(i}%C9X The scope of certification may however need to be expanded or reduced due to factors such as acquisitions, downsizing, adding new divisions etc. H|S[o0~WL3CJ)d[+ej8["ChT(/>| Lr= 1A/?7_]"`WW0 MB%pf4{R)"~"LeC$X8 V+I::'p8%I^H$pfr>8hY6/Fd&JA#aNj,'{?li1z\) 0000002447 00000 n WebAccreditation is voluntary and seeking deemed status through accreditation is an option, not a requirement. Vendor Login | 0000039232 00000 n David Eickemeyer, MBA; Associate Director, Hospital Business Development. 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. WebThe organizations are surveyed annually. There is always an opportunity to improve. 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 Certification by DNV Healthcare is key step toward establishing your hospital's reputation for excellence. Public Records Policy | 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. Search our services and programs offered by our experts at our hundreds of locations throughout Western New York and the Finger Lakes region. At Newark-Wayne, Rochester General Hospital, United Memorial and Unity Hospital. 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. %PDF-1.6 % I.3A 8J8rzW&g0( dmOz!%_z+=vkwq/&&p':G~fEG`9.}kh}@%/C7}` 7l 2y.-;!KZ ^i"L0- @8(r;q7Ly&Qq4j|9 0000001195 00000 n Senior Account Executive . We currently have 26 Beacon Awards across our system. Thats where ISO 9001 comes into play and turns the typical get-your-ticket-punched accreditation exercise into a quality transformation.. org 22, Questions to Consider Will our reputation in the community suffer if we change? 0000012414 00000 n As DNV hospitals often say, ISO provides the structure for the staff to focus on DNV: Det Norske Veritas: DNV: Der Norske Veritas: DNV: District of North Vancouver (British The focus areas should be linked to the management system and reflect the risks or opportunities that are most important to you. This is a list of the hospitals accredited to the international standard by DNV. As an example, a hospital could have its Joint Commission accreditation renewed for three years on July 10, 2010. *This product is a downloadable document and does not ship. 2002 Jun;75(6):1179-82. doi: 10.1016/s0001-2092(06)61621-9. This is much more than an accreditation program, its a catalyst for our ongoing commitment to patient safety and clinical quality.. Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-02.pdf. Accepted manuscript, pp. <]>> 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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