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
How far back does the JC require evaluation of malpractice history?
Back to Medical School
According to JC, what source may be used to verify malpractice history?
NPDB
What accreditation bodies require privileges to be distributed to essential department personnel?
Joint Commission - CMS
Telemedicine according to JC what two options are available for credentialing at the originating site?
full credentialing/use of distant site credentialing
According to the JC, a fair hearing and appeals process as described in the medical staff bylaws is available to whom?
Medical staff members and non-members holding clinical privileges
According to the Joint Commission a peer recommendation should address what 6 competencies?
medical knowledge, technical skills, clinical judgement, interpersonal skills, communication skills, professionalism.
According to JC what two verifications must be performed before granting of privileges to satisfy an urgent patient care need?
current licensure/current competence
What is JC appointment timeframe?
3 years (used to be 2)
Who requires CME?
JC
Who says the governing board must ensure competence?
JC
Does JC require work history verification?
No
Who requires that all licensed independent practitioners must be credentialed and privileged through the organized medical staff structure?
JC
JC approved designated sources for verification against a physicians medical license?
FSMB, State Medical Boards
Who requires participation in CME be considered in decisions about reappointment to membership on the medical staff or renewal or revision of individual clinical privileges?
JC
Does JC consider CME in decision making at initial appointment?
No
According to JC what should be used to verify current competence?
Hospital verification
Which JC terminology references the new and revised elements of the accreditation and survey process?
New pathways
In what circumstances does JC permit the granting of temporary privileges?
1) To fulfill an important patient care need 2) when a new applicant with a complete, “clean” application that raises no concerns is awaiting review and approval of the medical executive committee and board
JC requirements for professional practice questions?
voluntary and involuntary limitation, reduction or loss of clinical privileges
According to JC what document may be obtained to verify current competence?
Hospital verification
Per JC what must decisions on membership and granting of privileges consider?
Criteria directly related to the quality of healthcare treatment and services
JOINT COMMISSION: define credentialing as:
the process of obtaining, verifying, and assessing the qualifications of a health care practitioner who seeks to provide patient care in or for a hospital
JC evaluates the following information before granting privileges
Challenges to any licensure or registration, voluntary & involuntary relinquishment of any license registration voluntary & involuntary limitation, reduction, or loss of clinical privileges; any evidence of unusual pattern or an excessive # of professional liability actions resulting in a final judgement against the practitioners.
Nondiscrimination according to JC
consideration of gender, race, creed, and national origin cannot be used in making privileging decisions
Medicare/Medicaid Sanctions/Exclusions Requirement by JC
not addressed
Current competence is determined by the JC how?
thorough peer references, it is recommended but not required that hospitals base evaluations on the six areas of general competencies adopted by ACGME and ABMS
Complaints - The Joint Commission - 1/10/2017 (CAMH)
There must be a process for evaluation of the credibility of a complaint, allegation or concern against a privileged provider. For telemedicine services, complaints about the distant site LIP from patients, other LIPs, or staff are reported to the distant site by the originating site.
Compliance with Law - The Joint Commission 01/10/2017 CAMH
A governance standard holds the hospital’s governing body responsible to comply with applicable law and regulation. Leaders are responsible to be aware of and comply with local, state, and federal regulations related to credentialing and privileging of practitioners.
Continuing Medical Education: The Joint Commission 01/10/2017 CAMH
LIPs and other practitioners privileged through the medical staff process must participate in CE. Participation must be documented and considered in decisions about reappointment, renewal or revision of individual clinical privileges. Documentation of attendance can be done in several different ways, including but not limited to: obtaining copies of program certificates, obtaining a copy of the information submitted with a license renewal application when CME’s are required by the state obtaining an attestation statement from the licensed independent practitioner which attests to his/her attendance at CME programs that relate to their area of practice with the stipulation that proof of attendance and program content will be submitted upon request.
CVOs/: The Joint Commission: CAMH 1/10/2017
The CAMH states that organizations that use information from a CVO should have confidence in the completeness, accuracy, and timeliness of that information and outlines nine principles to evaluate such an agency. Among the necessary aspects are disclosure of data and information available, processes utilized, limitations of information available, identification of primary source information versus information obtained from a secondary source, overview of quality control measures, related to data integrity, security, transmission, accuracy, etc.
Criminal Background Checks: The Joint Commission: 01/10/2017 CAMH
Applies to hospital employees: a criminal background check is obtained and documented for the applicants as required by law and regulation or hospital policy.
Current Competence: The Joint Commission 01/10/2017 CAMH
The medical staff is responsible for the ongoing evaluation of the competency of privileged practitioners. The hospital verifies in writing and from the primary source, whenever feasible, or from a CVO, information concerning the current competence the provider’s ability to perform privileges requested must be evaluated and documented. The organization must review data from professional practice review by other organizations where the applicant currently has privileges, if such data is available. Information from ongoing professional practice evaluation information is used in the decision to maintain, revise, or revoke existing privileges prior to or at the time of renewal. A period of focused professional practice evaluation is implemented for all initially requested privileges. Medical staff defines circumstances requiring monitoring and evaluation of a practitioner’s performance.
Designated Equivalent Sources: the Joint Commission 01/10/2017 CAMH
Designated equivalent sources may be used to verify certain credentials in lieu of using the primary source. Designated equivalent sources include but are not limited to: - AMA Physician masterfile for a physician’s U.S. or Puerto Rican medical school graduation and residency completion. - ABMS for a physician’s board certification - ECFMG for a physician’s graduation from a foreign medical school- - AOA physician database for a physician’s predoctoral education accredited by the AOA bureau of professional education, post doctoral education accredited by the AOA bureau of professional education, post doctoral education approved by the AOA council on postdoctoral training and osteopathic specialty board certification. - FSMB for all actions against a physician’s medical license. - AAPA profile for PA education and NCCPA certification.
Disaster or Emergency Management Plan Privileges: The Joint Commission 01/10/2017 CAMH
During disasters, disaster privileges may be granted to volunteer LIPs when the Emergency operations plan has been activated in response to a disaster and the hospital is unable to meet immediate patient needs. If the organizations usual credentialing and privileging processes can’t be performed due to the disaster, a modified credentialing and privileging process can be used on a case-by-case basis. Medical staff bylaws must identify the individual(s) responsible for granting disaster privilege. The medical staff must have a documented mechanism for oversight of the professional performance of volunteer practitioners who receive disaster privileges, which can be accomplished through direct observation, mentoring, and/or clinical record review. There must be a mechanism to identify volunteer practitioners functioning under disaster privileges. In order to be considered for disaster privileges as an LIP, volunteers the organization must obtain, at a minimum, present a valid government-issued photo ID from a state or federal agency, such as a drivers license or passport, and at least one of the following: current picture hospital ID card with professional designation; current license to practice; PSV of license; identification indicating the volunteer is a member of a disaster medical assistance team, the medical reserve corps, the emergency system for advance registration of volunteer health professionals, or another recognized federal, state, or municipal entity; identification indicating that the individual has been granted authority to render patient care, treatment, and services during disaster by a federal, state, or municpal entity; or identification by a current hospital employee or medical staff member with personal knowledge of ability of the volunteer to act independently during a disaster. Primary source verification of license must begin as soon as the immediate situation is under control or within 72 hours from the time the volunteer LIP begins working at the hospital, whichever occurs first. The organization must make a decision within 72 hours related to the continuation of the disaster privileges initially granted based on information obtained in the medical staff’s oversight of the volunteer. It is not necessary to obtain PSV of licensure if the volunteer LIP has not provided care treatment, or services under the disaster privileges.
Drug Enforcement Agency Certificate (DEA) or State Controlled Dangerous Substances Certificate: The Joint Commission 01/10/2017 CAMH
Before recommending privileges, the medical staff evaluates challenges to any licensure or registration.
Education - The Joint Commission: 01/10/2017 CAMH
On recommendations of the medical staff and approval by the governing body, the hospital establishes criteria that determine a practitioner’s ability to provide patient care, treatment, and services within the scope of the privileges requested including verification of relevant education. Verification for MDs and DO can come from:
- the school
- American Medical Association (AMA) Physician Masterfile (as of 1996) for all US or Puerto Rican Medical School grauation.
- Education Commission for Foreign Medical Graduates (ECFMG) for foreign medical school
- The American Osteopathic Association (AOA) Physician Masterfile
- The AAPA profile can be used for verification of PA education and NCCPA certification.
Felony Convictions: The Joint Commission 01/10/2017 CAMH
Not specifically addressed.
Licensure/Licensure Sanctions: The Joint Commission 01/10/2017 CAMH:
Licensure is verified with the primary source at the time of appointment and initial granting of clinical privileges; at reappointment, removal or revision of clinical privileges and on expiration. Before recommending privileges, the medical staff evaluates challenges to or voluntary/involuntary relinquishment of any license or registration. FSMB is recognized as a designated equivalent source for information regarding licensure actions.
Verbal Orders-JC
The hospital identifies, in writing, the staff who are authorized to receive and record verbal orders. Documentation of verbal orders includes the date and names of individual’s who gave, received, recorded and implemented the orders. Additional CMS Deemed Status Requirements - Verbal orders are authenticated within 48 hours. Documentation of verbal orders includes the time the verbal order was received.
Verification
TJC does not specifically require verification of medical malpractice insurance. They only have to view the certificate of insurance or COI.
Verification Time Limit
Verification time limit for licensure per NCQA CVO standards 120 days.
Medical School - JC
The JC requires verification from the medical school. Accepted “designated equivalent sources” are: The American Medical Association (AMA) Physician Masterfile for all United States and Puerto Rico medical school education. The American Osteopathic Association (AOA) Physician database. The Educational Commission for Foreign Medical Graduates (ECFMG) for foreign medical schools. Note: when an organization cannot obtain verification from the primary source, the Joint Commission standards permit use of a “reliable secondary source”. Such a source can be another hospital that has a doucmented primary source verification of the credential: correspondence with medical school or documented phone call with medical school.
Postgraduate Training: JC
Postgraduate training (e.g internships, residencies and fellowships) the jc requires verification from the primary source. This requirement encompasses internship, residency, and fellowship programs, as well as other relevant experience (eg military training). Accepted “designated equivalent sources” for United States and Puerto Rico postgraduate training are the American Medical Association (AMA) Physician Master file and the American Osteopathic Association (AMA) Physician masterfile and the American Osteopathic Association (AOA) Physician Database. Note: in certain instances, foreign institutions will not or cannot verify training. In that case, efforts to obtain primary source verification should be documented. The organization may be able to verify training and experience through individuals who trained with the applicant who are now practicing in the United States. Note: when an organization cannot obtain verification from the primary source, the Joint commission standards permit use of a “reliable secondary source”. Such a source can be another hospital that has a documented primary source verification of the credential.
Board Certification: JC
The JC standards do not specifically require verification of board certification. If the organization’s policies or bylaws, rules and regulations require certification, however, the joint commission expects, this credential to be verified in accordance with the organization’s regulations, the verification may be obtained directly from the specialty board. The American Board of Medical Specialties (ABMS) and the American or Osteopathic Association (AOA).
Current Licensure - JC
primary source verification is required from the state licensing board when granting clinical privileges (both initially and when considering requests for additional privileges). Verification of licensure is also required at expiration.
Sanctions Against Licensure - JC
Before granting privileges, the leadership evaluates the following: information regarding challenges to any licensure or registration. Voluntary and involuntary relinquishment of any licensure or registration. The standards are silent regarding the specific method to accomplish this requirement. One way would be to request that the applicant provide the required information. This information also may be obtained or confirmed through the licensing board (s), the federation of state medical boards (FSMB), and/or the National Practitioner Data Bank (NPDB).
Professional Liability/Malpractice Coverage - JC
Primary source verification is not required. If the organization’s governance documents require malpractice coverage, then the Joint Commission expects the organization to have a method of verifying such coverage. Verification of coverage may come directly from the carrier or in the form of a copy of the applicant’s current malpractice/professional liability policy binder that shows dates and amount of coverage.
Malpractice History - JC
Before granting privileges, the organization evaluates professional liability actions resulting in a final judgement against the applicant. The standards are silent regarding the specific method to accomplish this requirement. One way would be to request that the applicant provide information regarding involvement in professional liability action (as required by the organization’s policies). At minimum, the applicant would be required to report final judgements. This information also may be obtained or confirmed through a query to the professional liability carrier and/or the national practitioner data bank (NPDB).
Current Competence: JC
There is a defined process for ensuring competence of all licensed independent practitioners granted privileges. This process includes verification and evaluation of the following: current licensure, successful completion of training related to privileges requested, applicant’s written statement that no health issues are present that could affect his or her ability to perform the privileges requested - Peer and/or faculty recommendations concerning the practitioner’s ability to perform the requested privileges - information from performance improvement activities related to professional performance, judgement, and clinical or technical skills - information from peer review activities.
Medicare/Medicaid Sanctions - JC
The Joint Commission standards do not specifically address obtaining information on Medicare/Medicaid sanctions. However, query of the national practitioner data bank (npdb) is required. The NPDB confirmation also provides information on medicare/medicaid sanctions. The OIG recommends that healthcare organizations check the OIG list of excluded individuals/entities (LEIE) before hiring, contracting or privileging healthcare practitioners.
DEA Certificate or State Controlled CDS - JC
The organization evaluates any challenges to registration, along with the voluntary and involuntary relinquishment of any registration. The standards are silent regarding the specific methodology to use in complying with this requirement. One source for this information may be though the applicant responding to questions regarding any challenges to registration (state, district or federal) or the voluntary an involuntary relinquishment of such registration. This information also may be obtained or verified through viewing a copy of the current DEA or CDS certificates or through contact with the issuing body or a recognized verification agency with equivalent information, such as the National Practitioner Data Bank, National Technical Information Service, AMA/Masterfile, or AOA Official Osteopathic Physician Profile Report.
Ability to Perform Clinical Privileges (Health Status): JC
The organization obtains a written statement from the applicant that no health problems exist that might affect his or her ability to exercise the requested privileges. Additionally, a peer or faculty recommendation is obtained providing current evidence of the practitioner’s ability to perform the requested privileges. The clinical leadership then evaluates the documentation of the applicant’s health status. Note: the following is an acceptable question that applicant’s may be required to answer. “Do you have a physical, mental, or emotional condition or substance abuse problem that could affect your ability to exercise the clinical privileges requested or that would require an accommodation for you to exercise those privileges safely and competently?”
Clinical Privileges - JC
Requires organizations to grant clinical privileges to licensed independent practitioners (LIP) in accordance with predefined criteria. Criteria include: current licensure, successful completion of training related to privileges requested. Applicant’s written statement that no health issues are present that could impact his or her ability to perform the privileges requested. Peer and/or faculty recommendations concerning the practitioner’s ability to perform the requested privileges. Evidence of the ability to perform the requested privileges. Organizations also are expected to evaluate whether there has been - a voluntary or involuntary termination of medical staff membership at another organization. A voluntary or involuntary limitation, reduction or loss of clinical privileges. The organization delineates clinical privileges according to organization policy and based upon the practitioner’s current credentials and documented competency. The delineation of privileges is to be reflective of the patients served and the site-specific care, treatment, and services provided within the facility.
History of Felony Convictions - JC
The Human Resources chapter’s section on credentialing and privileging is silent regarding obtaining and/or verifying an applicant’s history of felony convictions. However, another section of the Human Resources standards does require information to be obtained on the staff’s criminal background as required by law, regulation, or organizational policy. Therefore, if the practitioner is to be an employee of the organization the organization must conduct criminal background checks as required or as defined by policy. Note: some states do require a criminal background check for individuals privileged in healthcare organizations. *The Joint Commission requires healthcare organizations to comply with all applicable state and federal regulations - ie: licensure requirements, law, rules and regulations.
Identity: JC
The credentialing process includes a mechanism to ensure that the applicant is the person identified in the credentialing documents by viewing a valid picture ID issued by a state or federal agency (eg. drivers license or passport). The Joint Commission requirement is as stated previously . However, the methodology outlined ensures only that the individual pictured is the one in the driver’s license or passport. This process does not ensure that the practitioner is the individual who completed the education and post graduate trainin, or is the subject of the peer references, etc. Therefore, a best practice would be to affix or scan in a passport style photograph of the applicant to professional reference questionnaires. Request that the respondent confirm that the pictured applicant is the individual about whom the reference is written.
Peer - JC
A “peer” is defined as: a practitioner in the same professional discipline with personal knowledge of the applicant’s clinical practice, ability to work as a member of a team, and ethical behavior.
Temporary Privileges: JC
Temporary privileges may be granted for a limited period of time for only two circumstances: to fulfill an important patient care need or for a new application - under the first circumstance (fulfilling an important patient care need), at a minimum the organization must verify current licensure and current competence. The temporary privileges are time-limited, as specified by policies/procedures or regulations. Under the second circumstance (a new applicant), there must be evidence of verification and evaluation of current licensure, relevant training or experience, current competence, evaluation of an applicant’s statement regarding any health conditions that could affect his or her ability to perform the privileges requested. National Practitioner Data Bank query and evaluation of outcome, history of involuntary termination of medical staff membership at other institutions - history of voluntary or involuntary limitation, reduction, denial or loss of clinical privileges.
Approval Process: JC
Leaders of the organization formally approve mechanisms for granting clinical privileges. Therefore, there are policies and procedures outlining the credentialing and privileging process and the mechanisms of granting or denying clinical privileges.
Hearing/Appeals - JC
Procedures describe the methodology for addressing adverse decisions. Practitioners are afforded a fair hearing and appellate review. Hearing and appeals processes are designed to provide a uniform and fair process and include:
- a mechanism for scheduling a hearing and an appeal
- the procedures to be used for a hearing or appeal
- the membership of the hearing panel
- a mechanism to appeal an adverse decision.
- consistent application of hearing and appeals process
Length of Clinical Privileges - JC
Clinical privileges are granted for no more than two years.
Continuing Medical Education: CME - JC
Evidence of CME is not specifically required in the human resources chapter. However, many states require evidence of CME for license renewal. Therefore, the organization must ensure that the practitioner complies with state CME requirements through licensure verification. Further, consideration of CME may be relevant to establishing the applicant’s education/training, current competence for the clinical privileges requested.
Time frame for completion of verification/approval process: JC
The organization’s leadership has defined mechanisms for granting or denying clinical privileges to licensed independent practitioners. Note: It is appropriate to assume that the mechanisms outline a structured procedure for an expeditious process.
All licensed independent practitioners must be credentialed and privileged through the organized medical staff structure at initial appointment, clinical privileges
Practitioners covered according to TJC
Requires verification from the medical school or accepted PSV
verification of medical education according to the TJC
TJC accepted PSV for medical education
The AMA, the AOA and the ECFMG
