Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 03: MEDICAL STAFF 03.01.15 Application and reapplication requirements Frequency of the citation: 26%
Overview of the requirement: Professionals seeking medical staff appointment must complete an application that is reviewed, evaluated, and summarized by credentialing professionals in preparation for Medical Executive Committee discussion and a subsequent recommendation to the hospital’s governing body regarding an appointment decision. Comment on deficiencies: Compliance is assessed through review of credentialing files, governing body meeting minutes, and appointment letters. Surveyors noted that individual files reviewed lacked one or more of the required elements. Examples of ACHC Surveyor findings: ■ The hospital has a core privileges form that is used universally. This results in inappropriate approval of telemedicine physicians for paracentesis, thoracentesis, lumbar puncture, insertion of central venous catheters and arterial lines, intubation, etc. ■ Files for initial applicants lacked work affiliation history. ■ Files lacked evidence of clinical activity associated with privilege requests for a physician assistant, anesthesiologist, emergency physician, internal medicine physician, and CRNA. ■ Files did not include the number of peer references required by the medical staff bylaws. ■ Files lacked evidence of a criminal background check.
ACUTE CARE HOSPITAL ACCREDITATION
FREQUENT DEFICIENCIES IN CLINICAL AND ADMINISTRATIVE STANDARDS IN ACUTE CARE HOSPITALS 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 03.01.15 03.15.01 07.02.01 07.04.03 08.00.03 10.01.16 12.00.01 15.01.02 15.02.07 15.02.14 15.02.15 15.02.17 15.03.01 15.03.02 16.00.10 16.01.02 16.02.02 24.01.03 24.01.08 25.01.03 30.00.11
Patient Rights and Safety
Nursing Services
Surgical Services
Nutritional Services
Medical Staff
Infection Prevention & Control
Medical Records
Quality Assessment & Performance Improvement
Pharmacy Services/ Medication Use
Materials Management
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