Take necessary credentialing steps
When it comes to temporary privileges, required credentialing steps vary based on the accreditor and, in some cases, the purpose for the grant. For example, when the impetus is an important patient care need, The Joint Commission requires verification of only two elements: the applicant’s current licensure and competence. When, on the other hand, the grant is for an applicant who’s awaiting review by the medical executive committee and board approval for longer-term privileges, the accreditor requires evaluation of 10 elements, including challenges to licensure/registration and history of involuntary privilege modification or termination of medical staff membership. (Either finding would bar the practitioner from receiving temporary privileges.)
While a condensed list of credentialing activities allows for speedier turnaround on privileging requests, it can also introduce confusion regarding the scope and rigor of required steps. Consider, for example, The Joint Commission’s scant criteria for patient need–related temporary privileges. While verifying current licensure is a straightforward process, assessing competence is less cut and dry. The medical staff should define and document its chosen approach, which will ideally promote both the capture of meaningful performance data and the expediency allowed for temporary privileging activities. Consider using a peer evaluation from a physician with firsthand knowledge of the applicant’s clinical abilities.
When settling on a viable credentialing pathway, also weigh potential conflicts between accreditation standards and regulations. For example, The Joint Commission doesn’t require hospitals to query the NPDB prior to granting temporary privileges related to a patient care need. However, the NPDB regulations call for such a query before granting any form of privileges, including temporary ones. To resolve the discrepancy, favor the more stringent requirement. Performing an NPDB query is a relatively quick activity that can reveal valuable information about an applicant.
A simple Google search can also turn up helpful findings. “I have discovered malpractice lawsuits and unfavorable patient reviews, which I add to my report for the leadership,” says Diana El Banna, medical staff officer at American University Beirut Medical Center.
Source: News and Analysis
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