Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
Compliance tips for:
03.15.01 Ongoing professional practice evaluation Frequency of the citation: 26%
Specific areas must be reviewed prior to action on an application/reapplication for medical staff appointment and privileges. These include: ■ Confirmation of licensure, medical education and postgraduate training, and specialty board status based on primary source verification (PSV). A credentials verification organization (CVO) can be used. ■ Criminal history background check. ■ Evidence of malpractice insurance and history. ■ Employment history. ■ Identification of sanctions or disciplinary actions taken. ■ Professional references. ■ Evidence of clinical activity (e.g., procedure logs) ■ Evidence of attendance at required meetings (for reappointment consideration). ■ Regularly review a sample of credentialing files for inclusion of all required documentation. ■ Review “core privileges” documents to ensure that they are relevant to the department/specialty for which they are being used. ■ Train credentialing staff to immediately return applications that are missing peer references, clinical procedure logs, evidence of current malpractice insurance, etc. Applications should not be advanced to the MEC or the governing body without all required elements.
Nerd Newbies (understand the requirement)
Overview of the requirement: Each practitioner participates in ongoing practice evaluation as defined by the medical staff. The results of this evaluation are factored into the decision to continue, revise, or revoke an existing privilege. Comment on deficiencies: Compliance is assessed through review of the medical staff bylaws and credentialing files. Surveyor findings identified specific files that were missing OPPE data.
Examples of ACHC Surveyor findings:
■ Clinical indicators were missing from some files. ■ OPPE data was not sent to the Credentialing Committee to provide evidence that OPPE factored into privileging decisions. ■ OPPE indicators were not specific to provider specialties. Compliance tips for:
Nerd Apprentices (audit for excellence)
OPPE is the process by which the medical staff monitors the competency of its members. In aggregate, data are used for trending. Individually, data are used to inform privileging decisions for practitioners seeking renewal of their medical staff membership. ■ Audit renewal applications for inclusion of OPPE data. ■ Audit performance measures approved by the medical staff to ensure that they include aspects of practice specific to evaluation of each specialty. ■ Review the OPPE plan to ensure it addresses 12 required elements and identifies roles that can access and review the data. ■ Confirm security of individual practice evaluation data.
Nerd Newbies (understand the requirement)
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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