Tip: Competence assessment requirements for ambulatory care

Compare and contrast The Joint Commission and Accreditation Association for Ambulatory Health Care stances on competence assessment for initial appointment/initial clinical privileges.

The Joint Commission

There is a defined process for assessing competence of licensed independent practitioners (LIP) granted privileges. Before granting initial privileges to LIPs, the organization collects, verifies, and evaluates information on the following:

• Current licensure
• Relevant training related to privileges requested
• Current competence and ability to perform the privilege requested

In the event an appointed practitioner requests new (additional) or revised privileges, the leaders review and evaluate:

• Data/information from the organization’s performance improvement processes regarding professional performance, judgment, and clinical and technical skills
• Outcomes of peer reviews of the practitioner
• Any clinical performance in the organization that is outside acceptable standards

The Joint Commission ambulatory standards also include some additional requirements for credentialing and privileging practitioners providing care, treatment, or services via a telemedicine link or in an ambulatory surgery center. These additional requirements are all collated and found in the sections on “Telemedicine Services” and “Ambulatory Surgery Centers” in this chapter. (6th edition)

* Verification of competence from primary sources. Peers complete criteria- based questionnaires that provide an assessment or recommendation. The peers (generally three…industry standard) may be identified by the applicant as well as targeted peers through a policy (e.g., previous department chairs, section chiefs, program directors, medical staff officers, medical directors of ambulatory sites, etc.).

Correspondence or documented phone call with primary sources/peers.

Accreditation Association for Ambulatory Health Care

The organization establishes a process to review, assess, and validate an individual’s qualifications, including education, training, experience, certification, and licensure, along with any other competence-enhancing activities.

The applicant provides sufficient evidence of education, training, experience, and current documented competence in performance of the procedures for which privileges are requested.

The experience is reviewed for continuity, relevance, and documentation of any interruptions in that history. 

Current competence is verified and documented through peer evaluation.

* Verification of competence from primary sources. Peers complete criteria- based questionnaires that provide an assessment or recommendation. The peers (generally three…industry standard) may be identified by the applicant as well as targeted peers through a policy (e.g., previous department chairs, section chiefs, program directors, medical staff officers, medical directors of ambulatory sites, etc.).

Correspondence or documented phone call with primary sources and peers.

Documented copy of verification report from an acceptable entity that has done the primary source verification.

Source: Verify and Comply: Credentialing and Medical Staff Standards Crosswalk, Sixth Edition