ACCREDITING BODIES

Question 1

TJC (The Joint Commission)

Answer 1

Primary hospital accrediting body with comprehensive credentialing requirements:

Key Accreditation Functions:
-Provides deemed status for Medicare participation
-Sets credentialing/privileging standards for hospitals
-Conducts on-site surveys
-Issues accreditation decisions

Unique Requirements:
-Measures to the day for appointment cycles (not to exceed 3 years)
-Only accreditor requiring applicant identity verification
-Medical Executive Committee (MEC) is only required committee
-OPPE cannot exceed 12 months
-FPPE required for all initial privileges

Verification Requirements:

Primary Source Required for:
-Medical education
-Training/residency
-Current licensure (at appointment, reappointment, renewal, revision, expiration)
-Board certification (if required by organization)

Designated Equivalent Sources Accepted:
-AMA/AOA for education/training
-ABMS for board certification
-ECFMG for international education
-FSMB for licensure actions
-NCCPA/AAPA for PA credentials

Privileging Standards:
-Hospital-specific privileges
-Evidence-based criteria
-Current competency verification
-Resource availability consideration
-Disaster privileges process defined

Timeframe Requirements:
-3-year maximum appointment cycle
-120-day maximum for temporary privileges
-72 hours for disaster privilege verification
-OPPE review within 12 months
-License verification at expiration

Documentation Standards:
-Written criteria for privileges
-Defined medical staff categories
-Current clinical competence evidence
-Peer recommendations
-Performance monitoring data

Key phrase: “Hospital accreditation gold standard”

Distinguishing Features:
-Only accreditor requiring applicant ID verification
-Measures reappointment cycle to the day
-Uses term “Licensed Independent Practitioners” (LIPs)
-Requires FPPE for all initial privileges
-Only mandates MEC committee

Question 2

National Committee for Quality Assurance (NCQA)

Answer 2

Primary managed care accrediting body with standardized credentialing requirements:

Key Accreditation Functions:
-Accredits managed care organizations/health plans
-Sets credentialing standards for practitioners
-Evaluates quality through data sets/programs
-No privileging requirements (credentialing only)

Unique Requirements:
-Measures to the month for appointment cycles (not day)
-Only requires verifying highest level of education
-Considers residency highest level (not fellowship)
-Semi-annual delegation reporting required
-Provisional credentialing limited to 60 days

Verification Requirements:

Primary Source Required for:
-Current licensure
-Highest level education/training
-Board certification (if claimed)
-DEA/CDS registration
-5-year malpractice history
-Medicare/Medicaid sanctions

Approved Sources Accepted:
-AMA/AOA for education/training/board certification
-State licensing boards (with annual documentation)
-Sealed transcripts (with inspection evidence)
-ECFMG for international graduates
-FCVS for closed residency programs

Work History Requirements:
-5 years minimum relevant history
-Month/year for each position
-Gaps >6 months need verbal/written clarification
-Gaps >1 year need written clarification

Timeframe Requirements:
-36-month recredentialing cycle
-180 days MCO verification window
-120 days CVO verification window
-365 days MCO attestation window
-305 days CVO attestation window
-30 days to review sanction reports

Monitoring Requirements:
-Ongoing license sanctions monitoring
-Complaint review every 6 months
-Medicare/Medicaid exclusion monitoring
-Quality issues tracking between cycles

Key phrase: “Managed care credentialing authority”

Distinguishing Features:
-Only verifies highest level education
-Measures reappointment cycle to month
-Allows provisional credentialing
-Focuses on individual practitioners
-No privileging requirements

Question 3

DNV (Det Norske Veritas)

Answer 3

Hospital accrediting body with ISO 9001 integration:

Key Accreditation Functions:
-Provides deemed status for Medicare participation
-Integrates ISO 9001 quality standards
-Annual unannounced surveys
-Focuses on continuous improvement

Unique Requirements:
-Medical staff bylaws define most processes
-Requires validation of continuing education
-Medicare/Medicaid exclusions verified at initial, reappointment, and temps
-2 peer recommendations required at initial appointment
-Surveyor must validate surgical privilege review process

Verification Requirements:

Primary Source Required for:
-Education (at initial appointment)
-Current licensure (initial and reappointment)
-DEA (initial appointment)
-Current competence (initial and temporary privileges)
-Specific training verification

Approved Sources Accepted:
-AMA/AOA for training/education/licensure
-ECFMG for international graduates
-Does not use term “designated equivalent sources”

Privileging Standards:
-Must correspond with established competencies
-Cannot rely solely on board certification
-Automatic suspension criteria in bylaws
-Surgical privileges roster required in OR
-Process for emergency/disaster privileges

Timeframe Requirements:
-Not to exceed 3 years (as defined by state law)
-120 days maximum for temporary privileges
-Periodic practitioner performance review

Documentation Standards:
-Roster of surgical privileges in OR
-List of suspended/restricted practitioners
-Written grievance procedures
-Performance data documentation
-Continuing education validation

Key phrase: “ISO-integrated healthcare accreditation”

Distinguishing Features:
-Integration with ISO 9001
-Annual surveys (vs triennial)
-Emphasis on continuous improvement
-Focus on organizational systems
-Specific surgical privilege requirements”