Ability to Perform Clinical Prilieges

Question 1

The Joint Commission TJC
Ability to Perform

Answer 1

The applicant’s ability to perform requested privileges:
1. Must be evaluated and the evaluation documented
2. Applicant must submit a statement that no health problems exist that could effect performance
3. On initial appt, the statement should be confirmed by a director of training program, the chief of services, or the chief of staff at another hospital where the applicant holds privileges, or MD/DO approved by the medical staff
4. If there are doubts about an applicant’s ability to perform, the medical staff can require an evaluation by an external and/or internal source.
5. Health status is evaluated prior to recommending privileges

Question 2

NCQA
Ability to Perform

Answer 2

There is a current, signed attestation statement from the applicant regarding the reasons for any inability to perform the essential functions of the position, with or without accommodation, and the lack of present illegal drug use

Question 3

ACHC
Ability to Perform

Answer 3

Information regarding ability to perform privileges requested is considered for each applicant and reapplicant during the review and approval process. For reapplicants, this can come from peers familiar with their practice, or reviews by the credentials committee, department chair, or medical executive committee. References should include a statement regarding the physicians physical and mental health in relation to privileges requested

Question 3

DNV
Ability to Perform

Answer 3

1. Not specifically addressed in the standards, the Surveyor Guidance section regarding Surgical Services, instructs surveyors to validate the hospitals method for reviewing practitioner’s surgical privileges to determine if the process includes required verification of practitioner training, experience, health status, and performance.
2. Surveyor must confirm that the organization provides a roster of each practitioner’s surgical privileges that is available in the surgical suite and surgery scheduling
3. A list of current surgeons suspended from performing surgery who have restricted privileges must also be retained in there areas.
4. Surgical privileges shall correspond with the established competencies

Question 4

URAC
Ability to Perform

Answer 4

Application includes disclosure of any physical, mental, or substance abuse problems that could, without reasonable accommodation, impede the practitioner’s ability to provider care according to accepted standards of professional performance or pose a threat to the health or safety of patients

Question 5

AAAHC
Ability to Perform

Answer 5

The application includes information concerning the applicant’s current physical, mental health, or chemical dependency problems that would interfere with the ability to provide high-quality patient care or services. The organization reviews at initial and reappointment and privileging

Question 6

Medicare Hospital COPS
Ability to Perform

Answer 6

Not specifically addressed in the regulations, the interpretative guidelines regarding surgical services, instruct surveyors as follows “Review the hospitals method for reviewing the surgical privileges of practitioners. This method should require a written assessment of the practitioners training, experience, health status, and performance.