0000003960 00000 n Our surveyors employ a variety of methods for assessment, including staff interviews, medical record review, organizational document review, building and offsite visits, as well as patient interviews and feedback. Comparison of The Joint Commission and DNV GL The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. 0000038715 00000 n Lesho, E., Hix, J., Bronstein, M., Shastry, S., Hanna, J., Scroggins, G., & Grieff, M. (2019). anDkDMMmnZWh|rQl( Accreditation options: Understanding DNV GL Main Accreditation Organizations For U.s Hospital Accreditation Pricing | The Joint Commission The important role of the Joint Commission AORN J. Grid last updated: July 2022, National Association Medical Staff Services. 1338 0 obj <>/Filter/FlateDecode/ID[]/Index[1327 24]/Info 1326 0 R/Length 69/Prev 861584/Root 1328 0 R/Size 1351/Type/XRef/W[1 2 1]>>stream As with all accreditation programs, surveyors from the organization will visit the hospital on regular annual intervals to monitor the organizations progress in implementing the new requirements. Available at: www.iso.org/iso/home. endstream endobj 8619 0 obj <>/Metadata 315 0 R/Outlines 731 0 R/Pages 8594 0 R/StructTreeRoot 1070 0 R/Type/Catalog>> endobj 8620 0 obj <>/ExtGState<>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 8621 0 obj <>stream Learn how to plan your visit or hospital stay, pay your bill, contact us, and more information about visiting any of our facilities. `0 d``_}C!\ |S0\`0[znV$5*c"00z`PwzS\u@_w{wSZ3@`|4iE"'-*5wIsr]gI qyO'WAm)U1Ys96S=ffXTjMJ5P)TTOVyN9xddiV,ey-E% For more information about DNV, visit www.dnvcert.com/healthcare. Comparisons of the NIAHO and Joint Commission Approaches Four years on, upstart nears 350 clients. 630 ISO standards ensure that products and services are safe, reliable and of good quality. Accreditation | 127 0 obj <> endobj Because there would be a time gap between Joint Commission and DNV accreditation, Rosen worked with the state Department of Health and the local CMS The DNV accreditation program provides us the opportunity to simultaneously satisfy our Medicare accreditation requirements and implement the ISO 9001:2015 Quality Management System all at the same time, said Doug Higginbotham, Executive Director at South Central Regional Medical Center. All rights reserved. Innovative hospitals have started embracing ISO as a way to identify and focus on the most successful approaches to patient care, billing and other critical aspects of running a modern hospital system. %,,`0,XA!rd{ey` F7 121 0 obj Compliance is viewed as a 3-year 0000009113 00000 n Medical Student SOAP Note | Academic & Personal: 24 hour online access, Corporate R&D Professionals: 24 hour online access, https://doi.org/10.1016/j.mnl.2009.10.004, Comparisons of the NIAHO and Joint Commission Approaches to Accreditation, Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-02.pdf, Available at: http://www.dnv.com/binaries/NIAHO%20Accreditation%20Requirements-Rev%20307-8%200(2)_tcm4-347543.pdf, Available at: http://www.jointcommission.org/NR/rdonlyres/2F04C126-906D-4155-B16F-1F1A6570C387/0/jconlineAug1209.pdf, For academic or personal research use, select 'Academic and Personal', For corporate R&D use, select 'Corporate R&D Professionals', Association for periOperative Registered Nurses. %%EOF At Rochester Regional Health, our dedication to quality is reflected in the teams we hire, the care we provide and the services we offer. Thats where ISO 9001 comes into play and turns the typical get-your-ticket-punched accreditation exercise into a quality transformation.. endstream endobj 1332 0 obj <>stream 0000009720 00000 n We focus on achieving this aspect at every survey. DNV conducts a survey every year instead of every three years. I've just been hired on at a hospital that is Det Norske Veritas (DNV) accredited as opposed to the Joint Commission. It is widely recognized as the gold standard in healthcare accreditation, and its standards are considered rigorous and comprehensive. Subsequently 1-3 focus areas on which the audit will focus are identified. Metrics and Performance The certification audit consists of informal interviews, examinations, observations of the system in operation and review of relevant documentation. 8618 0 obj <> endobj DNV Accessed April 23, 2010. Accessed August 5, 2009. 0000005823 00000 n WebThis background is fascinating in view of The Joint Commissions (TJC) history. Unlike previous approaches to accreditation, DNV focuses on what works best for each hospital and therefore opens the door to innovation. Lab Specimen Guideline | Rex Zordan . To check your readiness for the certification audit, i.e. Lesho, E., Clifford, R., Vore, K., Zenits, B., Alcantara, J., Gargano, B., Phillips, M., Boyd, S., Eckert-Davis, L., Sosa, C, Vargas, R. Riedy, D., Stamps, D., Bhavsar, H., Fede J., Laguio-vila, M., Bronstein, M. Sustainably reducing device utilization and device-related infections with DeCATHlongs, device alternatives, and decision support. Learn About Accreditation Survey Accreditation Using an accredited third party certification body/registrars Senior Account Executive . What is hospital accreditation The accreditation programs DNV offers either directly address regulatory requirements for hospitals, such as US Government's Centers for Medicare and Medicaid (CMS), or provide guidance and best practices for clinical specialty organizations across healthcare. DNVs NIAHO standards is approved by CMS. Employee Login | Find the residency program, fellowship, or training program that's right for you, or explore our research and clinic trials. South Central Regional Medical Center was the first hospital in Mississippi to be accredited by DNV Healthcare. DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. Deemed Status DNV has a client drop box feature where questions regarding the standards can be asked directly to our specialists and surveyors. This product includes updates that will be made by NAMSS over the next 12 months. We are honored to provide behavioral healthcare facilities the same option provided to their hospital partners - a choice in their accreditation.PsychiatricHospital Accreditation Program Components Whether youre new to the Joint wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 2019 HIMSS Annual Conference: Clinical Optimization: One Approach to Integration, 2019 Breakthroughs Conference: Clinical Optimization: A Panel Discussion. 2010 Mosby, Inc. <>/Pages 117 0 R /StructTreeRoot 177 0 R /ViewerPreferences<>/PageLayout/OneColumn/Type/Catalog/MarkInfo<>/Lang( E N - U S)/Metadata 262 0 R >> Download the Standards created and offered by DNV Healthcare, 0000004698 00000 n 0000003466 00000 n This is much more than an accreditation program, its a catalyst for our ongoing commitment to patient safety and clinical quality.. Findings, including non-conformities, and conclusions are presented at the end of the audit in a closing meeting and included in the audit report. WebThe organizations are surveyed annually. Although the costs of Joint Commission and DNV are about the same, according to health experts, there are some big differences between the two: The organization surveys the hospitals that use their commissioning services annually, while the Joint Commission extends its survey periods from 18 months to three years. David Eickemeyer, MBA; Associate Director, Hospital Business Development. SCRMCs current service area includes a patient population of 120,000 residents in 4 countiesJones, Jasper, Smith and Wayne Counties. Det Norske Veritas (DNV) vs JC? - General Nursing Talk Learning happens when staff are comfortable and not intimidated by the process. Please enter a term before submitting your search. hbbd```b``= "@$nDEH`=d`L""@$?/O@o_@H b4l4k#%4#3` , Read Part 3: Accreditation Options: Understanding the Joint Commission DNV Healthcare originated in Norway in 1864 as a risk management company. hb```b``c`201 +s0 These surveys, often routine or planned to certify our specialty programs, look at our communication processes, governance, processes, standardization, safety precautions and outcomes. endstream endobj 128 0 obj <>/Metadata 20 0 R/PieceInfo<>>>/Pages 19 0 R/PageLayout/OneColumn/StructTreeRoot 22 0 R/Type/Catalog/LastModified(D:20081002145347)/PageLabels 17 0 R>> endobj 129 0 obj <>/ColorSpace<>/Font<>/ProcSet[/PDF/Text/ImageC/ImageI]/ExtGState<>>>/Type/Page>> endobj 130 0 obj <> endobj 131 0 obj <> endobj 132 0 obj <> endobj 133 0 obj [/Indexed 148 0 R 255 149 0 R] endobj 134 0 obj <> endobj 135 0 obj <> endobj 136 0 obj <> endobj 137 0 obj <>stream )CL:E8 $@eB5(ABRg]._e p`'ih]ao]|. org 22, Questions to Consider Will our reputation in the community suffer if we change? 0000002012 00000 n Accessed April 27, 2010. To fulfill the accreditation criteria, an accrediting authority assesses the certification body/registrar to verify that the certification body/registrar complies with existing requirements. Comparison of Joint Commission and DNV - GL HC NIAHO MS Standards Kathy Matzka, CPMSM, CPCS 8 22 Resources Standards: NIAHO Standards, What happens if an organisation fails to maintain their management system and certification? DNV accredited hospitals hTkSI?ssMl South Central Regional Medical Center has been Joint Commission accredited for years and hospital personnel are very familiar with the accreditation process, but Joint Commission does not require ISO certification. 8667 0 obj <>stream SCRMC serves as the second largest employer in Jones County. The password to view the NAMSS Comparison of Accreditation Standards is: Q7r&Km endstream endobj startxref Risk Based Certification is our exclusive approach to all management system certification. DEPARTMENT OF HEALTH & HUMAN SERVICES 0000012451 00000 n 630-792-5787 | lberkeley@jointcommission.org. HtTKo0Wh( The focus areas should be linked to the management system and reflect the risks or opportunities that are most important to you. xb```f``ue` ea *(ltSa{+ 9QQ (MHKX*?6Y ,8v'83rXrE0C;;[70^} Ua vHCO4@ZT Dr g$ cuup}c~*_3:!RvpgI(@6a^@IiPo}f$@ L9qdzD AY:RR' 4PQqhxitI3\! Accreditation Canada accredited its first organization internationally in 1967 in Bermuda. <>stream WebAccredited certification of management systems is used to demonstrate compliance to a standard in a trusted way. WebThis electronic reference tool provides plain-language interpretations of the credentialing standards for The Joint Commission, NCQA, Healthcare Facilities Accreditation hbbd``b` @)H0A@"*HpE$> oL,F6~0 d 0000001631 00000 n The report indicates if your organisation is ready to proceed with the certification audit. About South Central Regional Medical Center. We felt that by moving from Joint Commission accreditation to DNV accreditation we were taking our organization to an all new level, he said. If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. Find the location that's most convenient for you! hYmo6+bwRPI-@fulAMTcg5~w'I :^xXoay-uL3,%a8J#!%@aY%I>)ddJ:ph+*jX 9Q43F:\RzvYV:ibv2gTM]oWjQ)|V?AtYuy[uq]{ WebIn addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. This is applicable in situations where an organisation persistently and seriously fails to maintain compliance with the management system standard or due to other situations, as defined in the procedure for suspension and withdrawal of certificates. Search our services and programs offered by our experts at our hundreds of locations throughout Western New York and the Finger Lakes region. 0000039232 00000 n V)gB0iW8#8w8_QQj@&A)/g>'K t;\ $FZUn(4T%)0C&Zi8bxEB;PAom?W= This is the authorities way of auditing the auditors, such as certification bodies like DNV. South Central is a public, not for profit hospital owned by Jones County, MS, who has an economic impact to our local community annually of almost $200 million. dnvaccreditation. Accreditation Field Report: Midland Memorial The decision to grant initial certification, renew certification or to expand or reduce the scope of certification, is made by competent and authorized personnel in DNV who are different from those carrying out the audit. "F$H:R!zFQd?r9\A&GrQhE]a4zBgE#H *B=0HIpp0MxJ$D1D, VKYdE"EI2EBGt4MzNr!YK ?%_&#(0J:EAiQ(()WT6U@P+!~mDe!hh/']B/?a0nhF!X8kc&5S6lIa2cKMA!E#dV(kel }}Cq9 In 2020, Rochester Regional Health participated in 123 regulatory surveys in our acute care settings, outpatient settings and specialty programs from compliance agencies like DNV Healthcare, The Joint Commission and the Department of Health. Organizations seeking CMS approval may choose to be surveyed either by an accrediting body, such as the Joint Commission, DNV, and HFAP, or by state surveyors on behalf of CMS. Felicio Rocho Hospital. Delia Constanzo . DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. Based on a positive outcome, he/she will recommend certification. This 2.5-day course is a basic course designed to train healthcare professionals in the principles and requirements of DNV's approach to hospital accreditation. Det Norske Veritas (DNV) is a global quality Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-02.pdf. WebThis approval provides hospitals with another accreditation option in addition to the Joint Commission and the American Osteopathic Association. Accreditation Guide | The Joint Commission At Newark-Wayne, Rochester General Hospital, United Memorial and Unity Hospital. DET NORSKE VERITAS (DNV) Vendor Login | We felt that by moving from Joint Commission accreditation to DNV accreditation we were taking our organization to an all new level, he said. 120 0 obj In comparison, the Joint Commission has 0000007461 00000 n [lW7wI/_./-";)n*R+lx-I$,4|t*0#__ l) DOI:https://doi.org/10.1017/ice.2020.1437. for Medicaid and State Operations/Survey and Psychiatric Hospitals are accredited for a three year period, subject to annual survey to verify continuing compliance with NIAHO. Available at: http://cert.branswijck.com/. The outcome is still a certificate if the management system is found compliant but with added dimension to your improvement journey. 0000012414 00000 n endstream endobj 1328 0 obj <>/Metadata 142 0 R/OCProperties<>/OCGs[1339 0 R 1340 0 R 1341 0 R]>>/Outlines 204 0 R/Pages 1318 0 R/StructTreeRoot 287 0 R/Type/Catalog>> endobj 1329 0 obj <>/ExtGState<>/Font<>/Properties<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1330 0 obj <>stream Using an accredited third party certification body/registrars demonstrates that the auditing company is meets the required quality standard set by the accrediting authority. endstream endobj startxref n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. x- [ 0}y)7ta>jT7@t`q2&6ZL?_yxg)zLU*uSkSeO4?c. R -25 S>Vd`rn~Y&+`;A4 A9 =-tl`;~p Gp| [`L` "AYA+Cb(R, *T2B- In the few years since DNV Healthcare became the first new 2y.-;!KZ ^i"L0- @8(r;q7Ly&Qq4j|9 2022 NAMSS Comparison of Accreditation Standards WebAccreditation and certification are important accomplishments and we are here to help your organization throughout the entire process. The DNV program is consistent with our long-term commitment to quality and patient safety, says Dr. Teresa Camp-Rogers, Chief Quality Officer at SCRMC. DOI: https://doi.org/10.1016/j.mnl.2009.10.004, The International Organization for Standardization (ISO), To read this article in full you will need to make a payment. An integrated health services organization serving the people of Western New York. Det CMS-2895-FN, September, 26, 2008. 847-324-7487 | msweeney@aaahc.org . N')].uJr endstream endobj 139 0 obj <>stream WebThe more variables and inter-dependencies in you organization, the more relevant ISO becomes. Making the Switch: Washington Hospital Turns to DNV Have questions Contact us DNV Healthcare DNV Healthcare introduces a hospital accreditation program for stand-alone Psychiatric Hospitals, part of our dedication to helping hospitals improve quality, patient safety and healthcare delivery. All Rochester Regional Health labor and delivery hospitals. We currently have 26 Beacon Awards across our system. 0000013305 00000 n Contracts with insurers may require certain accreditation and may need renegotiation Will there be a saving in direct and indirect accreditation costs? DNV The documentation review report summarizes any findings from this process. WebThe JCAHO and its accreditation programs are described, the history of the Medicare-JCAHO relationship is reviewed, and why the federal Medicare program has relied on accreditation as an indicator of the quality of participating hospitals is examined. 0000006807 00000 n Webknown as DNV Accreditation, they came equipped with the experience of TUVs previous effort to become deemed and their National Integrated Accreditation for Healthcare Accepted manuscript, pp. 0000002447 00000 n The Joint Commissions Stroke Certification Enhancements for 2018. endobj DNV Healthcare, Joint Commission emphasize differences Country-wide, more than 5000 hospitals are permitted to provide Medicarefinanced services solely Medical Student H&P | com Jointcomission. Contact South Central Regional Medical Center, Hospital Affiliation Request | Infection Control & Hospital Epidemiology. 0000004038 00000 n You must complete the Participant's Agreement in order to access your purchased NAMSS Education. DNV is a global independent certification, assurance and risk management provider, operating in more than 100 countries. Hospital Mater Dei. Clifton Springs Hospital and Clinic recently was awarded an A grade for safety. Before the audit starts, you provide input on what operational processes are most crucial to your business success. Our lead auditor evaluates your management system documentation. The ability to integrate ISO 9001 quality standards with our clinical and financial processes is a major step forward.. SCRMC has three years from the date of its accreditation to achieve compliance with ISO 9001, the worlds most trusted quality management system used by performance-driven organizations around the world to advance their quality and sustainability objectives. doi:10.1017/ice.2020.295. After the audit you need to address and respond to non-conformities within an agreed deadline. v4?fBHQ [C. Accreditation verifies the certification body/registrars competence. 0000007824 00000 n 2002 Jun;75(6):1179-82. doi: 10.1016/s0001-2092(06)61621-9. endstream endobj 1331 0 obj <>stream *This product is a downloadable document and does not ship. The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. To review focus area input and agree on one to three particular focus areas upon which the audit will focus. 156 0 obj <>stream TCI certification. %PDF-1.6 % Joint Commission %%EOF % 630-792-5509 | rzordan@jointcommission.org. The Joint Commission Lon Berkeley . After each survey there is a detailed report which is easy to follow and describes, with objective evidence, where your organization is not in compliance with the standard. xref Similar review also applies in cases of suspending or restoring certification or withdrawing the certification. Following a positive decision you will receive the certificate shortly thereafter. Admin, South Central Family Medicine & Urgent Care, Directions to South Central Regional Medical Center, Where to Get the Best Care and When to Go. This helps hospitals create a corrective action plan to improve their process and prevent that variance from occurring again. 1350 0 obj <>stream The scope of certification may need to be changed during the 3 year certification cycle. Each issued certificate has a three-year life period. Comparison of The Joint Commission and DNV- GL HCs National Integrated Accreditation for Healthcare Organizations (NIAHO) MS Standards Kathy Matzka, CPMSM, CPCS 1, History TJC 1952 began Unique statutory hospital deeming authority 1965 Medicare statute July 15, 2008, the Medicare Improvements for Patients and Providers Act of 2008 became law 11/09 CMS approval 4, 546 Hospital and CAH in 2011 4, 429 Hospital and CAH in 2013 (90% of accredited hospitals) 4, 032 Hospital and CAH in 2016 (88% of accredited hospitals) NIAHO 12/19/07 Application to CMS 09/08 CMS approval 94 Hospital and CAH on 7/14/10 393 Hospital and CAH on 4/17/2016 2, Process TJC NIAHO Three year survey Annual Survey Standards directly Most MS standards related to the CMS as directly related to the well as self-defined CMS ISO 9001 quality management 3, Scoring Process TJC NIAHO Three-point scale: 0 = insufficient compliance 1 = partial compliance 2 = satisfactory compliance Icons Documentation required Situational decision rules apply Direct impact requirements apply Category A requirement Category C requirement (based on # of times does not meet standard) Measurement of Success needed Standards Scored as Meets requirements Nonconformity Category I Conditional level Egregious non-compliance Nonconformity Category I Noncompliant Nonconformity Category II Occasional or isolated lapse in compliance Immediate Jeopardy Immediate threat to patient safety No aggregate scoring 4, Appointment Timeframe TJC Two years NIAHO Three years if state law does not address 5, Continuing Medical Education TJC NIAHO LIPs and other practitioners All with privileges participate in privileged through the medical CE that is at least in part staff process must participate related to their clinical in CE privileges Participation must be CME considered in decisions documented and considered in about reappointment or decisions about reappointment, renewal or revision of clinical renewal, or revision of privileges individual clinical privileges Action on an individuals application for appointment /reappointment or initial or subsequent clinical privileges is withheld until the information is available and verified 6, Current Competence TJC The hospital verifies in writing and from the primary source, whenever feasible, or from a CVO, information concerning the current competence Evaluate data from other organizations where the applicant currently has privileges, if available NIAHO Initial - MS qualifications include verification of current competence Reap - Review of individual performance data for variation from benchmark Variations to peer review for determination of validity, written explanation of findings and, if appropriate, an action plan to include improvement strategies 7, Malpractice History TJC NIAHO MS evaluates Review of involvement in a any professional liability action at initial and action, including final reappointment judgments and settlements involving a practitioner Must evaluate any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant 8, Peer Recommendations TJC NIAHO Required at initial, reap, consideration of termination, or revision/revocation of clinical privileges Address the relevant training and experience, current competence, and any effects of health status on privileges being requested Include evaluation of the applicants medical knowledge, technical and clinical skills, clinical judgment, communication skills, interpersonal skills, and professionalism Obtained from a practitioner in the same professional discipline as the applicant with personal knowledge of the applicants ability to practice List of appropriate sources Two peer recommendations required at initial appointment 9, Clinical Privileges TJC NIAHO PSV for current licensure or All permitted by the certification organization and by law to PSV of relevant training provide patient care services Evidence of physical ability to independently have delineated perform the requested privilege clinical privileges If available, data from If available and/or required by professional practice review the MS, a review of individual from other organization where performance data variation the applicant currently has from criteria determined by the privileges medical staff to identify need Recommendations from for training or proctoring that peers/faculty may be required On renewal, review of the applicants performance within the hospital 10, Telemedicine TJC NIAHO 3 choices The originating site can fully privilege and credential the practitioner according to MS standards or Use credentialing information from the distant site if the distant site is a Joint Commission-accredited organization or Use credentialing and privileging decision from the Joint Commission-accredited distant site Medical staff at both sites make recommendation for services to be provided via telemedicine For non-deeming, can be via contract only if TJC accredited entity 2 choices The originating site can fully privilege and credential the practitioner according to MS standards or Use credentialing and privileging decision from telemedicine entity or distant site Medicare participating hospital When services provided by a contracted entity, GB must identify criteria for selection and procurement of services and how to evaluate the entity 11, Temporary Privileges TJC NIAHO 120 days for new applicant with complete file awaiting MEC approval Time as specified in bylaws for patient care need On recommendation of MS President or designee No successful challenges to licensure or registration; involuntary termination of MS appointment; involuntary limitation, reduction, denial, or loss of clinical privileges Not exceed 120 days Locum tenens not to exceed 6 months On recommendation of a MEC member, MS president or medical director (as defined by MS Urgent patient care need Complete application w/o negative or adverse information before action by the medical staff or governing body 12, Temporary Privileges TJC NIAHO Patient care need verify Current licensure Current competence New Applicant verify Current licensure Relevant training or experience Current competence Ability to perform the privileges requested Other criteria required by medical staff bylaws NPDB In all cases verify education (AMA/AOA Profile OK current competence primary verification of State professional licenses professional references (including current competence) Database profiles from AMA, AOA, NPDB, and OIG Medicare/Medicaid Exclusions 13, Allied Health Professionals TJC NIAHO LIPs through MS process Non-LIP APRNs and PAs HR or MS if not providing a medical level of care If State law allows, MS may include DPM, OD, DC, PA, CRNA, NM, APRN, DMD, PHD or other designated professionals approved by MS and Board and eligible for appointment 14, Executive Committee TJC NIAHO 10 EPs outlining responsibilities, structure, function If MS has an executive committee, a majority of the members of the committee shall be doctors of medicine or osteopathy CEO and the nurse executive of the organization or designee shall attend each meeting on an ex-officio basis, with or without vote 15, TJC Notifications NIAHO The decision to grant, A current roster listing deny, revise, or each practitioners revoke privilege(s) is specific surgical disseminated and privileges must be made available to all available in the appropriate internal surgical suite and external persons scheduling area or entities, as defined Include surgeons with by the hospital and suspended surgical applicable law privileges or whose surgical privileges have been restricted 16, Surgical Privileges TJC NIAHO Included in general category for privileges All practitioners performing surgery have surgical privileges established by the department of surgery and medical staff and approved by the governing body Privileges for general surgery and surgical subspecialties defined with established criteria approved by MS Privileges correspond with established competencies of each practitioner 17, Automatic Suspension TJC NIAHO The medical staff bylaws include description of indications for automatic suspension or summary suspension of a practitioners medical staff membership or clinical privileges description of when automatic suspension or summary suspension procedures are implemented The medical staff will define the criteria and have a mechanism for consideration of automatic suspension of clinical privileges of a practitioner at a minimum when: revocation/restriction of professional license DEA certificate has been revoked, suspended or on probation Failure to maintain the minimum specified amount of professional liability insurance non-compliance with written medical record delinquency or deficiency requirements Mechanism for immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioners Medicare or Medicaid status 18, QA/PI Data TJC FPPE OPPE Medical Assessment Blood Medication Operative and other procedure(s) Appropriateness of clinical practice patterns Significant departures from established patterns of clinical practice Use of criteria for autopsies Sentinel event data Patient safety data NIAHO Practitioner specific performance data is required and must be ratebased with comparative peer or national data available for comparison.