ࡱ> q` /;bjbjqPqP ::1nDDDDDDDDlll0m$Tm3oooooo"p p$#hؤDpooppؤDDooqqqpXDoDoqpqqޖDDoo P Xlrpd" 03mp mDmDppqpppppؤؤqppp3ppppD4929DDDDDD  Date Facility Name Facility Address Regarding applicant: John Doe, M.D. Specialty: General Surgery Dear Medical Services Professional: We have received a request from the above-named provider to provide services in the area of radiological interpretations. According to information provided, the applicant currently holds privileges at your hospital. Pursuant to our contract with your facility, we require the following in order to document compliance with the accreditation requirements of The Joint Commission: Completion of the attached chart documenting your facilitys compliance with the requirements specified in MS.06.01.03 through MS.06.01.07 (Alternate text for ambulatory care facility: Standard HR.02.01.03) and copies of all bylaws/policies/procedures in which these processes are documented; A copy of the providers privilege form from your facility; and Current documentation of your organizations internal review of this practitioners performance including all adverse outcomes related to sentinel events that result from the telemedicine services and complaints from patients, licensed independent practitioners, or staff. In addition, please forward for completion the attached evaluation form to the medical service chief responsible for oversight of the care, treatment and services provided by this applicant. Sincerely, Medical Staff Coordinator TJC RequirementPlace Where DocumentedCommentsMS.06.01.03 The organization collects information regarding each practitioners current license status, training, experience, competence, and ability to perform the requested privilege.The hospital credentials applicants using a clearly defined processThe credentialing process is approved by the governing bodyThe credentialing process is outlined in the medical staff bylawsThe hospital verifies that the practitioner requesting approval is the same practitioner identified in the credentialing documents by viewing one of the following: Current picture hospital ID card. Valid picture ID issued by a state or federal agency (e.g., drivers license or passportThe credentialing process requires that the hospital verifies in writing and from the primary source whenever feasible, or from CVO, the following information: current licensure at time of initial granting, renewal, and revision of privileges, and expiration. relevant training current competenceMS.06.01.05 - The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidenced-based processAll LIPs that provide care possess a current license, certification, or registration, as required by law and regulationThe hospital, based on recommendations by the organized medical staff and approval by the governing body, establishes criteria that determine a practitioners ability to provide patient care, treatment, and services within the scope of the privilege(s) requested. Evaluation of all of the following are included in the criteria: Current licensure and/or certification, as appropriate, verified with the primary source. The applicants specific relevant training, verified with the primary source. Evidence of physical ability to perform the requested privilege. Data from professional practice review by an organization(s) that currently privileges the applicant (if available). Peer and/or faculty recommendation. When renewing privileges, review of the practitioners performance within the hospital.All of the criteria used are consistently evaluated for all practitioners holding that privilegeThe hospital has a clearly defined procedure for processing applications for the granting, renewal, or revision of clinical privilegesThe procedure for processing applications for the granting, renewal, or revision of clinical privileges is approved by the organized medical staffAn applicant submits a statement that no health problems exist that could affect his or her ability to perform the privileges requested. The applicant's ability to perform privileges requested must be evaluated. This evaluation is documented in the individual's credentials file.The hospital queries the National Practitioner Data Bank (NPDB) when clinical privileges are initially granted, at the time of renewal of privileges, and when a new privilege(s) is requested.Peer recommendation includes written information regarding the practitioners current: Medical/Clinical knowledge. Technical and clinical skills. Clinical judgment. Interpersonal skills. Communication skills. - Professionalism.Before recommending privileges, the organized medical staff also evaluates the following: Challenges to any licensure or registration. Voluntary and involuntary relinquishment of any license or registration. Voluntary and involuntary termination of medical staff membership. Voluntary and involuntary limitation, reduction, or loss of clinical privileges. Any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant. Documentation as to the applicants health status. Relevant practitioner-specific data as compared to aggregate data, when available. Morbidity and mortality data, when available.The hospital has a process to determine whether there is sufficient clinical performance information to make a decision to grant, limit, or deny the requested privilege.Completed applications for privileges are acted on within the time period specified in the medical staff bylawsInformation regarding each practitioners scope of privileges is updated as changes in clinical privileges for each practitioner are madeMS.06.01.07 - The organized medical staff reviews and analyzes all relevant information regarding each requesting practitioners current licensure status, training, experience, current competence, and ability to perform the requested privilegeThe information review and analysis process is clearly definedThe hospital, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a requested privilegeThe hospital completes the credentialing and privileging decision process in a timely mannerThe hospitals privilege granting /denial criteria are consistently applied for each requesting practitionerDecisions on membership and granting of privileges include criteria that are directly related to the quality of health care, treatment, and services.If privileging criteria are used that are unrelated to quality of care, treatment, and services or professional competence, evidence exists that the impact of resulting decisions on the quality of care, treatment, and services is evaluated.The governing body or delegated governing body committee has final authority for granting, renewing, or denying privilegesPrivileges are granted for a period not to exceed two years TJC RequirementStandard MetCommentsYesNoMS.06.01.03 The organization collects information regarding each practitioners current license status, training, experience, competence, and ability to perform the requested privilege.The hospital credentials applicants using a clearly defined processThe credentialing process is approved by the governing bodyThe credentialing process is outlined in the medical staff bylawsThe hospital verifies that the practitioner requesting approval is the same practitioner identified in the credentialing documents by viewing one of the following: Current picture hospital ID card. Valid picture ID issued by a state or federal agency (e.g., drivers license or passportThe credentialing process requires that the hospital verifies in writing and from the primary source whenever feasible, or from CVO, the following information: current licensure at time of initial granting, renewal, and revision of privileges, and expiration relevant training current competenceMS.06.01.05 - The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidenced-based processAll LIPs that provide care possess a current license, certification, or registration, as required by law and regulationThe hospital, based on recommendations by the organized medical staff and approval by the governing body, establishes criteria that determine a practitioners ability to provide patient care, treatment, and services within the scope of the privilege(s) requested. Evaluation of all of the following are included in the criteria: Current licensure and/or certification, as appropriate, verified with the primary source. The applicants specific relevant training, verified with the primary source. Evidence of physical ability to perform the requested privilege. Data from professional practice review by an organization(s) that currently privileges the applicant (if available). Peer and/or faculty recommendation. When renewing privileges, review of the practitioners performance within the hospital.All of the criteria used are consistently evaluated for all practitioners holding that privilegeThe hospital has a clearly defined procedure for processing applications for the granting, renewal, or revision of clinical privilegesThe procedure for processing applications for the granting, renewal, or revision of clinical privileges is approved by the organized medical staffAn applicant submits a statement that no health problems exist that could affect his or her ability to perform the privileges requested. The applicant's ability to perform privileges requested must be evaluated. This evaluation is documented in the individual's credentials file.The hospital queries the National Practitioner Data Bank (NPDB) when clinical privileges are initially granted, at the time of renewal of privileges, and when a new privilege(s) is requested.Peer recommendation includes written information regarding the practitioners current: Medical/Clinical knowledge. Technical and clinical skills. Clinical judgment. Interpersonal skills. Communication skills. Professionalism.Before recommending privileges, the organized medical staff also evaluates the following: Challenges to any licensure or registration. Voluntary and involuntary relinquishment of any license or registration. Voluntary and involuntary termination of medical staff membership. Voluntary and involuntary limitation, reduction, or loss of clinical privileges. Any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant. Documentation as to the applicants health status. Relevant practitioner-specific data as compared to aggregate data, when available. Morbidity and mortality data, when available.The hospital has a process to determine whether there is sufficient clinical performance information to make a decision to grant, limit, or deny the requested privilege.Completed applications for privileges are acted on within the time period specified in the medical staff bylawsInformation regarding each practitioners scope of privileges is updated as changes in clinical privileges for each practitioner are madeMS.06.01.07 - The organized medical staff reviews and analyzes all relevant information regarding each requesting practitioners current licensure status, training, experience, current competence, and ability to perform the requested privilegeThe information review and analysis process is clearly definedThe hospital, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a requested privilegeThe hospital completes the credentialing and privileging decision process in a timely mannerThe hospitals privilege granting /denial criteria are consistently applied for each requesting practitionerDecisions on membership and granting of privileges include criteria that are directly related to the quality of health care, treatment, and services.If privileging criteria are used that are unrelated to quality of care, treatment, and services or professional competence, evidence exists that the impact of resulting decisions on the quality of care, treatment, and services is evaluated.The governing body or delegated governing body committee has final authority for granting, renewing, or denying privilegesPrivileges are granted for a period not to exceed two years     Sample Letter Re: Documentation of TJC Requirements for Services Provided Through Contractual Agreement Chart for Contracted Agency to Document Compliance with TJC Requirements for MS.06.01.03 through MS.06.01.07 Chart for Audit of Documentation of TJC Requirements for MS.06.01.03 through MS.06.01.07 Items in bold represent auditable elements &'Jel  7 A I d h . i n _ ~  ? 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