Ensuring competence and meeting accreditors’ requirements
Practitioner competency is increasingly in the spotlight for patients, insurers, regulators, and others. Thus, documenting and ensuring competency is an increasing part of your job. CMS’ CoPs state that an organized medical staff must have a process in place for determining the competence of its current and future members. MSPs gather the information needed for physician leaders to determine an applicant’s competence to perform the specific clinical privileges that he or she has requested.
Medical staff members demonstrate (and MSPs verify) competency through such means as peer review, training, continuing education, and board certification/recertification, among other sources. When verifying practitioners’ competency, The Joint Commission suggests using questions related to the six areas of general competencies adopted from the ACGME and the ABMS joint initiative. See “Accreditation Council for Graduate Medical Education”.
HFAP and Joint Commission accredited organizations use focused professional practice evaluation (FPPE) to determine the competency of a provider who has requested privileges and when questions arise concerning the quality and safety of patient care provided by an existing member of the medical staff. Ongoing professional practice evaluation (OPPE) is used to demonstrate continuous competence during a practitioner’s tenure at an HFAP- or Joint Commission-accredited organization.
Facilities accredited by other organizations use elements of FPPE and OPPE to gauge medical staff members’ competence.
Source: Credentialing A to Z