Joint Commission Flashcards
The JC standards do not specifically require verification of the board certification. If the medical staff bylaws, policies or rules/regulations require certification, the JC expects certification to be verified in some manner.
If board certification is required it should be verified directly from the specialty board or a designated equivalent source. An equivalent source is the ABMS and AOA.
Education Verification requirements
The JC requires medical education and postgraduate training to be verified from the primary source. The primary source is through tthe medical school or the internship, residency or fellowship program or an accepted designated equivalent source.
Accepted medical school “designated equivalent sources” are AMA for all US & Puerto Rico Medical School education, AOA and ECFMG for foreign medical schools.
Accepted post graduate training “designated equivalent sources” for US & Puerto Rico are the AMA & the AOA.
What are the ACGME six core competencies?
The joint commission expects that hospitals use standardized indicators to measure practitioner’s competency and performance. When a provider has insufficient volume at a facility, one way to measure practitioner’s competency and performance can be to utilize the AGCME six core competencies:
1) Medical/Clinical knowledge
2) Technical & Clinical Skills
3) Clinical Judgement
4) Interpersonal Skills
5) Communication Skills
6) Professionalism
Joint Commission time frame for reappointment
Not to exceed 3 years (used to be two)
According to the Joint Commission the governing body may amend
The Medical Staff Bylaws
According to the Joint Commission…
A fair hearing and appeals process as describe in the medical staff bylaws is available to medical staff members and non-members holding clinical privileges.
According to the Joint Commission a peer recommendation should address what six competencies?
Medical Knowledge, technical & clinical skills, clinical judgement, interpersonal skills, communication skills and professionalism
According to Joint Commission what two options are available for credentialing at the original site?
Full Credentialing, use of the distant sites credentialing (TELEMEDICINE)
According to the Joint Commission what is included in the process of planning and implementing privileges?
Develop and approve procedure list, process the application, evaluate applicant specific information; submit recommendations to governing body for applicant specific delineated privileges, notify the applicant, relevant personnel, monitor the use of privileges.
Who requires applicant ID?
JC
According to the JC, who may amend the medical staff bylaws?
Governing Body