Ability to Perform Clinical Privileges Requested (NAMSS Comparison)

Question 1

The applicant’s ability to perform privileges requested must be evaluated and this evaluation documented in the credentials files. The applicant must submit a statement that no health problems exist that could affect the exercise of clinical privileges. On initial appointment this statement should be confirmed by a director of a training program, the chief of services, or the chief of staff at another hospital where the applicant holds privileges, or an MD / DO approved by the medical staff.

a. NCQA
b. TJC (CAMH)
c. AAAHC

Answer 1

TJC (CAMH)

Question 2

CR3, Element C factors 1-6 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

a. NCQA
b. DNV (NIAHO)
c. Medicare CoP

Answer 2

NCQA

Question 3

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

a. TJC (CAMH)
b. ACHC (HFAP)
c. URAC

Answer 3

ACHC (HFAP)

Question 4

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

a. URAC
b. AAAHC
c. DNV (NIAHO)

Answer 4

DNV (NIAHO)

Question 5

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

a. URAC
b. AAAHC
c. Medicare CoP

Answer 5

URAC

Question 6

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.

a. AAAHC
b. TJC (CAMH)
c. ACHC (HFAP)

Answer 6

AAAHC

Question 7

Although not specifically addressed in the Regulations, the Interpretative Guidelines for §482.51(a)(4) regarding Surgical Services, instruct surveyors as follows: Review the hospital’s method of reviewing the surgical privileges of practitioners. This method should require a written assessment of the practitioner’s training, experience, health status, and performance

a. Medicare CoP
b. URAC
c. DNV (NIAHO)

Answer 7

Medicare CoP

Question 8

If there is doubt about an applicant’s ability to perform privileges requested, the medical staff can require an evaluation by an external and/or internal source. Health status is evaluated prior to recommending privileges.

a. ACHC (HFAP)
b. NCQA
c. TJC (CAMH)

Answer 8

TJC (CAMH)