Current Competence

Question 1

The Joint Commission TJC
Current Competence

Answer 1

1. The medical staff is responsible for the ongoing evaluation of the competency of privileged practitioners.
2. The hospital verifies in writing and from the primary source, whenever feasible, or from a CVO, information concerning the current competence.
3. The practitioner’s ability to perform privileges requested must be evaluated and documented.
4. The organization must review data from professional practice review by other organizations where the applicant currently has privileges, if such data is available.
5. Information from ongoing professional practice evaluation (OPPE) information is used in the decision to maintain, revise, or revoke existing privilege(s) prior to or at the time of renewal.
6. The organized medical staff defines the frequency of OPPE data collection. However, the timeframe for review of the data cannot exceed every 12 months.
7. A period of focused professional practice evaluation (FPPE) is implemented for all initially requested privileges. Medical staff defines circumstances requiring monitoring and evaluation of a practitioner’s professional performance.

Question 2

NCAQ
Current Competence

Answer 2

CR 1 Factors 3 & $
NCQA requires the organization to assess the practitioner’s ability to deliver care based on the credentialing information collected and verified prior to making a credentialing decision.
CR 8
The organization develops and implements policies and procedures for ongoing monitoring of practitioner sanctions, complaints and quality issues between recredentialing cycles and takes appropriate action against practitioners when it identifies occurrences of poor quality.

Question 3

ACHC
Current Competence

Answer 3

1. Criteria for membership and privileges must include current competence. Evaluation and granting of clinical privileges must be commensurate with the individual’s documented training, experience, and current competence.
2. Applicants must provide clinical activity documentation and competency to be used in consideration of privileges requested. This can come from residency, fellowship or from facilities where the applicant has been practicing. They must also provide procedure logs with outcomes to support privilege requests for procedures not attested to in postgraduate references.
3. Reapplicants provide departmental recommendations. Low volume may require review of procedure logs and competency from other facilities including recent experience and recommendations from QA committee and/or other committees based upon peer review findings.
4. Ongoing professional practice evaluation (OPPE) information is factored into the decision to maintain existing privilege(s), and/or to revoke an existing privilege prior to or at the time of renewal. Data is collected on an ongoing basis and summarized at least three (3) times during each two-year appointment cycle.
5. The organized medical staff defines the circumstances requiring additional, focused monitoring and evaluation of a practitioner’s professional performance.

Question 4

DNV
Current Competence

Answer 4

MS.6 SR.4a MS
1. bylaws describe the qualifications to be met by a candidate in order for the medical staff to recommend that the governing body appoint the candidate
2. Those qualifications shall include verification of current competence on initial appointment and reappointment.
MS 7 SR3(b)
Proof of current competence required prior to granting temporary privileges
SS.3
Surgical privileges correspond with the established competencies of each practitioner.
MS.8
Practitioner specific performance data is evaluated, analyzed and appropriate action taken as necessary when variation is present and/or standard of care has not been met as determined by the medical staff.
SR 1
Performance data collected periodically within the reappointment period or as required as a part of the peer review process. This may included comparative and/or national data if available.

Question 5

URAC
Current Competence

Answer 5

Not specifically addressed.
The credentialing program defines the organization’s criteria for qualifications as a participating provider.
The credentialing program includes a statement that credentialing decisions will be based on multiple criteria related to professional competency, quality of care, and the appropriateness by which health services are provided

Question 6

AAAHC
Current Competence

Answer 6

On formal application for initial medical or dental staff privileges, the applicant (including AHPs) must provide documentation of current competency in performing the requested procedures Documentation of current competence is obtained from peers.

Question 7

Medicare Hospital COPS
Current Competence

Answer 7

482.12(a)(6) and 482.22(c)(4)
The governing body must ensure that the criteria for selection of medical staff are individual character, competence, training, experience and judgement