dnv accreditation vs joint commission

South Central Regional Medical Center has been Joint Commission accredited for years and hospital personnel are very familiar with the accreditation process, but Joint Commission does not require ISO certification. 0000007824 00000 n 0000003418 00000 n AORN Guidance Statement: Perioperative Staffing. DNV is a global independent certification, assurance and risk management provider, operating in more than 100 countries. Accreditation Canada accredited its first organization internationally in 1967 in Bermuda. Have questions Contact us DNV Healthcare endstream endobj 128 0 obj <>/Metadata 20 0 R/PieceInfo<>>>/Pages 19 0 R/PageLayout/OneColumn/StructTreeRoot 22 0 R/Type/Catalog/LastModified(D:20081002145347)/PageLabels 17 0 R>> endobj 129 0 obj <>/ColorSpace<>/Font<>/ProcSet[/PDF/Text/ImageC/ImageI]/ExtGState<>>>/Type/Page>> endobj 130 0 obj <> endobj 131 0 obj <> endobj 132 0 obj <> endobj 133 0 obj [/Indexed 148 0 R 255 149 0 R] endobj 134 0 obj <> endobj 135 0 obj <> endobj 136 0 obj <> endobj 137 0 obj <>stream com Jointcomission. View our list of disease-specific and specialty program certifications. 1350 0 obj <>stream hbbd```b``= "@$nDEH`=d`L""@$?/O@o_@H b4l4k#%4#3` , Using an accredited third party certification body/registrars demonstrates that the auditing company is meets the required quality standard set by the accrediting authority. Our lead auditor evaluates your management system documentation. WebThe JCAHO and its accreditation programs are described, the history of the Medicare-JCAHO relationship is reviewed, and why the federal Medicare program has relied on accreditation as an indicator of the quality of participating hospitals is examined. DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. hYmo6+bwRPI-@fulAMTcg5~w'I :^xXoay-uL3,%a8J#!%@aY%I>)ddJ:ph+*jX 9Q43F:\RzvYV:ibv2gTM]oWjQ)|V?AtYuy[uq]{ AORN statement on nurse-to-patient ratios. Access our full portfolio of public and private courses, including CHOP Certification. 2019 HIMSS Annual Conference: Clinical Optimization: One Approach to Integration, 2019 Breakthroughs Conference: Clinical Optimization: A Panel Discussion. The outcome is still a certificate if the management system is found compliant but with added dimension to your improvement journey. DNVs accreditation program is the only one to integrate the ISO 9001 Quality Management System with the Medicare Conditions of Participation. We have taken an entirely different approach to accreditation, and hospitals are really responding, says DNV Healthcare USA Inc. President Patrick Horine. 0000006234 00000 n Certification by DNV Healthcare is key step toward establishing your hospital's reputation for excellence. %%EOF The documentation review report summarizes any findings from this process. Provides a framework for organizational structure and management Accreditation involves preparing for a survey and maintaining a high level of quality and compliance with the latest standards. Joint Commission accreditation provides guidance to an organizations quality improvement efforts. 0000003466 00000 n 0000003710 00000 n Thats where ISO 9001 comes into play and turns the typical get-your-ticket-punched accreditation exercise into a quality transformation.. x- [ 0}y)7ta>jT7@t`q2&6ZL?_yxg)zLU*uSkSeO4?c. R -25 S>Vd`rn~Y&+`;A4 A9 =-tl`;~p Gp| [`L` "AYA+Cb(R, *T2B- Admin, South Central Family Medicine & Urgent Care, Directions to South Central Regional Medical Center, Where to Get the Best Care and When to Go. DET NORSKE VERITAS (DNV) )CL:E8 $@eB5(ABRg]._e p`'ih]ao]|. 0000020794 00000 n Infection Control & Hospital Epidemiology. 630-792-5509 | rzordan@jointcommission.org. What happens if an organisation fails to maintain their management system and certification? As with all accreditation programs, surveyors from the organization will visit the hospital on regular annual intervals to monitor the organizations progress in implementing the new requirements. After the audit you need to address and respond to non-conformities within an agreed deadline. Hospitals are no longer stuck in a cycle of addressing the same issue every three years. We felt that by moving from Joint Commission accreditation to DNV accreditation we were taking our organization to an all new level, he said. Frustrated with The Joint Commission, Midland Memorial Hospital (TX) made the shift to DNV this year, says accreditation specialist Lisa Williams, PT, MS, HACP.The hospital had already been looking at the Centers for Medicare & Medicaid Services' conditions of participation in After the three years are up, your certification will be extended through a re-certification audit. As an example, a hospital could have its Joint Commission accreditation renewed for three years on July 10, 2010. 0000007461 00000 n xref Select from the topics below to get started. These surveys, often routine or planned to certify our specialty programs, look at our communication processes, governance, processes, standardization, safety precautions and outcomes. The documentation review can be performed prior to or conducted as part of the initial visit. Risk Based Certification is our exclusive approach to all management system certification. Using an accredited third party certification body/registrars This collaborative approach is crucial in continuing to improve and be a quality improvement hospital. 0000004038 00000 n Lesho, E., Walsh, E., Gutowski, J., Reno, L., Newhart, D, Yu, S., Bress, J., Bronstein, M. A Cluster-Control Approach to a SARS-CoV-2 Outbreak on a Stroke Ward with Infection Control Considerations for Dementia and Vascular Units. Vendor Login | This is much more than an accreditation program, its a catalyst for our ongoing commitment to patient safety and clinical quality.. v4?fBHQ [C. Hospital Mater Dei. DNV Healthcare introduces a hospital accreditation program for stand-alone Psychiatric Hospitals, part of our dedication to helping hospitals improve quality, patient safety and healthcare delivery. The focus areas should be linked to the management system and reflect the risks or opportunities that are most important to you. H\J@{6fgBA[^Hi M}{voI\]fcuvO1}yPYq:\xvwm,.rsi`at3Xvizx)vnn. Whether youre new to the Joint I.3A 8J8rzW&g0( dmOz!%_z+=vkwq/&&p':G~fEG`9.}kh}@%/C7}` 7l Rex Zordan . ISO standards ensure that products and services are safe, reliable and of good quality. Webparticipation was based on Joint Commission accreditation issued prior to that date will continue to participate in Medicare via deemed status until the normal expiration date of its accreditation. The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. 131 0 obj To update your cookie settings, please visit the. David Eickemeyer, MBA; Associate Director, Hospital Business Development. If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. The certification decision is taken after an independent DNV GL internal review. NIAHO is the National Integrated Accreditation for Healthcare Organizations and encourages collaboration between different hospital departments. "F$H:R!zFQd?r9\A&GrQhE]a4zBgE#H *B=0HIpp0MxJ$D1D, VKYdE"EI2EBGt4MzNr!YK ?%_&#(0J:EAiQ(()WT6U@P+!~mDe!hh/']B/?a0nhF!X8kc&5S6lIa2cKMA!E#dV(kel }}Cq9 This commitment to safe, reliable and high-quality care is also demonstrated through our regulatory compliance and accreditations, awards and recognition and participation in national conferences and journals. All Rochester Regional Health labor and delivery hospitals. The Joint Commission on the Accreditation of Healthcare Organizations. org 22, Questions to Consider Will our reputation in the community suffer if we change? 1 27. South Central is a public, not for profit hospital owned by Jones County, MS, who has an economic impact to our local community annually of almost $200 million. Each issued certificate has a three-year life period. To check your readiness for the certification audit, i.e. Available at: http://cert.branswijck.com/. Our surveyors employ a variety of methods for assessment, including staff interviews, medical record review, organizational document review, building and offsite visits, as well as patient interviews and feedback. The initial visit can be combined with the documentation review. This decision is made based on a review of the certification process and associated documentation. 0000000913 00000 n <]>> Blood use Prescribing of medications Surgical Case Review Specific departmental indicators Moderate Sedation Outcomes Anesthesia events Appropriateness of care for noninvasive procedures/interventions Utilization data Significant deviations from established standards of practice Timely and legible completion of patients medical records Variants analyzed for statistical significance 19, Addressed by TJC, Not NIAHO Verification of applicant identity Use of CVO (DNV does allow is addressed under telemedicine) Health status (DNV only under surgical privileges) Applicant required to provide info re: previously successful or currently pending challenges to licensure or voluntary relinquishment, felony convictions Leadership standards place additional responsibilities on MS Residency program requirements 20, Addressed by NIAHO, not TJC Receipt of database profile from OIG Medicare/Medicaid Exclusions initial/reappointment/temporary privileges 21, Resources Standards: NIAHO Standards, Interpretive Guidelines, or Accreditation Process www. I've just been hired on at a hospital that is Det Norske Veritas (DNV) accredited as opposed to the Joint Commission. 847-324-7487 | msweeney@aaahc.org . %%EOF PMID: 12085409 Joint Commission on Accreditation of Healthcare Organizations* / history The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. 0 0 Our lead auditor will verify that you have properly addressed the nonconformities. SCRMC serves as the second largest employer in Jones County. WebAccredited hospitals. 1327 0 obj <> endobj Innovative hospitals have started embracing ISO as a way to identify and focus on the most successful approaches to patient care, billing and other critical aspects of running a modern hospital system. South Central Regional Medical Center operates as a 285-bed hospital, an alcohol and drug inpatient detox facility, a wound care center with hyperbaric oxygen chambers, a cancer center, 22 medical clinics, two large nursing homes, a wellness and rehabilitation center, a home care and hospice division, a full service ambulance service, an emergency department which has 42,000 patient visits annually, and numerous other programs and services. Our leading medical education and research are at the forefront of healthcare innovation. DOI:https://doi.org/10.1017/ice.2020.1437. ".*RK6"zf9ss~3 AARJA=Z\&6c@+|dk{GKY B_],IEmmq_rS}gX;L9nL%)5Ek&$;mcUeEP*wb\yaA.eW:OS3hoRqgi^Ygv`l!7/vou$VZ(T&d$iq-kUh_4<7\R+vi)e35elpG[piiqN#@t9Z]Y?})#=[8GOCb+1QKU,HY WWcVr y"=uOsb%V xOy^N?+OHG'9%[qdF]guPa("2Hbs=Kt0 :J~O|JGn n~ Centers for Medicare and Medicaid Services. hTkSI?ssMl Fundao So Francisco Xavier / Hospital Mrcio Cunha. Contact South Central Regional Medical Center, Hospital Affiliation Request | 0000002012 00000 n doi:10.1017/ice.2020.295. endstream endobj startxref WebAccredited certification of management systems is used to demonstrate compliance to a standard in a trusted way. %PDF-1.6 Accreditation verifies the certification body/registrars competence. nQt}MA0alSx k&^>0|>_',G! Learning happens when staff are comfortable and not intimidated by the process. Lesho, E., Hix, J., Bronstein, M., Shastry, S., Hanna, J., Scroggins, G., & Grieff, M. (2019). The scope of certification may however need to be expanded or reduced due to factors such as acquisitions, downsizing, adding new divisions etc. During surveys, DNV wants to see the improvements that have been made as a result of the annual survey process. DNV conducts a survey every year instead of every three years. DNV Accreditation is based on the companys innovative NIAHO standards. HlSn0}W*vHUYii& 3kj`{YiDsqHI)P(J|\*|H X(PnFc'G]=/L$)$M[x6i; `9aDv}~2$eY@5 f'N^O_SFda55,EgsHwJWP'* xi.qDU_4%4reA)4zq0l>vf_R3;hxxlqn=hK`I8BL!eAS$O=pJI`2xKtQ_hv6 bG2u.S?)UIraqn/S#5gCi3+D WmBK%# Before the actual certification audit, we will normally make a preliminary visit to your organisation. endstream endobj 1331 0 obj <>stream The important role of the Joint Commission AORN J. Accessed April 23, 2010. Agreeing on focus areas is a collaborative effort, and our auditors can help suggest focus areas if necessary. We use cookies to help provide and enhance our service and tailor content. Medical Student H&P | Unlike previous approaches to accreditation, DNV focuses on what works best for each hospital and therefore opens the door to innovation. endstream endobj 1328 0 obj <>/Metadata 142 0 R/OCProperties<>/OCGs[1339 0 R 1340 0 R 1341 0 R]>>/Outlines 204 0 R/Pages 1318 0 R/StructTreeRoot 287 0 R/Type/Catalog>> endobj 1329 0 obj <>/ExtGState<>/Font<>/Properties<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1330 0 obj <>stream 0000004698 00000 n The International Standards Organization (ISO) Web site. Although the costs of Joint Commission and DNV are about the same, according to health experts, there are some big differences between the two: The organization surveys the hospitals that use their commissioning services annually, while the Joint Commission extends its survey periods from 18 months to three years. 8644 0 obj <>/Filter/FlateDecode/ID[<80A28E873128684998433581F605455E>]/Index[8618 50]/Info 8617 0 R/Length 123/Prev 1023342/Root 8619 0 R/Size 8668/Type/XRef/W[1 3 1]>>stream The annual survey model keeps hospitals moving forward on the path of continued improvement. 0000012414 00000 n n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. The ability to integrate ISO 9001 quality standards with our clinical and financial processes is a major step forward.. 127 30 2002 Jun;75(6):1179-82. doi: 10.1016/s0001-2092(06)61621-9. 630 Read Part 3: Accreditation Options: Understanding the Joint Commission DNV Healthcare originated in Norway in 1864 as a risk management company. All rights reserved. WebAddressed by TJC, Not NIAHO Verification of applicant identity Use of CVO (DNV does allow is addressed under telemedicine) Health status (DNV only under surgical Lesho, E., Clifford, R., Vore, K., Zenits, B., Alcantara, J., Gargano, B., Phillips, M., Boyd, S., Eckert-Davis, L., Sosa, C, Vargas, R. Riedy, D., Stamps, D., Bhavsar, H., Fede J., Laguio-vila, M., Bronstein, M. Sustainably reducing device utilization and device-related infections with DeCATHlongs, device alternatives, and decision support. `0 d``_}C!\ |S0\`0[znV$5*c"00z`PwzS\u@_w{wSZ3@`|4iE"'-*5wIsr]gI qyO'WAm)U1Ys96S=ffXTjMJ5P)TTOVyN9xddiV,ey-E% 0000001372 00000 n hVO0W4u~yHZVm6)am|;#\zn$2N'*P1!$''BoD/We/Tze Accreditation can directly affect the quality of hospital care. Learn About Accreditation Survey WebWe have a variety of resources to help you explore and master the accreditation process. Top management should be involved at this stage. The trademarks DNV GL, DNV, the Horizon Graphic and Det Norske Veritas are the properties of companies in the Det Norske Veritas group. In the few years since DNV Healthcare became the first new <>stream Our Privacy Policy | This 2.5-day course is a basic course designed to train healthcare professionals in the principles and requirements of DNV's approach to hospital accreditation. 0 We have to get a clear understanding of your business strategy and conditions that affect your ability to reach said strategy. DNVs philosophy is to assist Psychiatric Hospitals through compliance with the NIAHO Hospital Accreditation Program and Appendix B standards, encouraging a safe and therapeutic milieu which allows patients to be treated safely and effectively. More than 2,100 individuals are employed throughout health system and approximately 125 providers representing 28 medical specialties provide care to patients. [lW7wI/_./-";)n*R+lx-I$,4|t*0#__ l) wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 By earning accreditation, SCRMC has demonstrated it meets or exceeds patient safety standards (Conditions of Participation) set forth by the U.S. Centers for Medicare and Medicaid Services. <>/Pages 117 0 R /StructTreeRoot 177 0 R /ViewerPreferences<>/PageLayout/OneColumn/Type/Catalog/MarkInfo<>/Lang( E N - U S)/Metadata 262 0 R >> At this stage you have completed the initial certification and can move on to maintenance of your certification. %PDF-1.6 % Please enter a term before submitting your search. Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-02.pdf. WebDNV Healthcare introduces a hospital accreditation program for stand-alone Psychiatric Hospitals, part of our dedication to helping hospitals improve quality, patient safety and healthcare delivery. endstream endobj 1332 0 obj <>stream hbbd``b` @)H0A@"*HpE$> oL,F6~0 d Senior Account Executive . 0000002975 00000 n 121 0 obj CMS-2895-FN, September, 26, 2008. Both your management system and certificate have to be maintained. In case of expanding the scope the process will restart at section 2 with a documentation review (if needed) and will further follow the normal process from section 4 with a (scope extension) certification audit. See upcoming training courses. DNV Healthcares hospital accreditation program is unique in that it integrates the ISO 9001 standards (international quality standards that define Project Director, CHC Accreditation . Academic & Personal: 24 hour online access, Corporate R&D Professionals: 24 hour online access, https://doi.org/10.1016/j.mnl.2009.10.004, Comparisons of the NIAHO and Joint Commission Approaches to Accreditation, Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-02.pdf, Available at: http://www.dnv.com/binaries/NIAHO%20Accreditation%20Requirements-Rev%20307-8%200(2)_tcm4-347543.pdf, Available at: http://www.jointcommission.org/NR/rdonlyres/2F04C126-906D-4155-B16F-1F1A6570C387/0/jconlineAug1209.pdf, For academic or personal research use, select 'Academic and Personal', For corporate R&D use, select 'Corporate R&D Professionals', Association for periOperative Registered Nurses. 2010 Mosby, Inc. % This accreditation underscores our commitment to developing and continually improving quality and safety for employees, patients and visitors throughout our system. Our Risk Based Certification approach tailors the process to evaluate your select business risks in addition to compliance with the standards requirements. Accreditation | 120 0 obj Comparison of The Joint Commission and DNV- GL HCs National Integrated Accreditation for Healthcare Organizations (NIAHO) MS Standards Kathy Matzka, CPMSM, CPCS 1, History TJC 1952 began Unique statutory hospital deeming authority 1965 Medicare statute July 15, 2008, the Medicare Improvements for Patients and Providers Act of 2008 became law 11/09 CMS approval 4, 546 Hospital and CAH in 2011 4, 429 Hospital and CAH in 2013 (90% of accredited hospitals) 4, 032 Hospital and CAH in 2016 (88% of accredited hospitals) NIAHO 12/19/07 Application to CMS 09/08 CMS approval 94 Hospital and CAH on 7/14/10 393 Hospital and CAH on 4/17/2016 2, Process TJC NIAHO Three year survey Annual Survey Standards directly Most MS standards related to the CMS as directly related to the well as self-defined CMS ISO 9001 quality management 3, Scoring Process TJC NIAHO Three-point scale: 0 = insufficient compliance 1 = partial compliance 2 = satisfactory compliance Icons Documentation required Situational decision rules apply Direct impact requirements apply Category A requirement Category C requirement (based on # of times does not meet standard) Measurement of Success needed Standards Scored as Meets requirements Nonconformity Category I Conditional level Egregious non-compliance Nonconformity Category I Noncompliant Nonconformity Category II Occasional or isolated lapse in compliance Immediate Jeopardy Immediate threat to patient safety No aggregate scoring 4, Appointment Timeframe TJC Two years NIAHO Three years if state law does not address 5, Continuing Medical Education TJC NIAHO LIPs and other practitioners All with privileges participate in privileged through the medical CE that is at least in part staff process must participate related to their clinical in CE privileges Participation must be CME considered in decisions documented and considered in about reappointment or decisions about reappointment, renewal or revision of clinical renewal, or revision of privileges individual clinical privileges Action on an individuals application for appointment /reappointment or initial or subsequent clinical privileges is withheld until the information is available and verified 6, Current Competence TJC The hospital verifies in writing and from the primary source, whenever feasible, or from a CVO, information concerning the current competence Evaluate data from other organizations where the applicant currently has privileges, if available NIAHO Initial - MS qualifications include verification of current competence Reap - Review of individual performance data for variation from benchmark Variations to peer review for determination of validity, written explanation of findings and, if appropriate, an action plan to include improvement strategies 7, Malpractice History TJC NIAHO MS evaluates Review of involvement in a any professional liability action at initial and action, including final reappointment judgments and settlements involving a practitioner Must evaluate any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant 8, Peer Recommendations TJC NIAHO Required at initial, reap, consideration of termination, or revision/revocation of clinical privileges Address the relevant training and experience, current competence, and any effects of health status on privileges being requested Include evaluation of the applicants medical knowledge, technical and clinical skills, clinical judgment, communication skills, interpersonal skills, and professionalism Obtained from a practitioner in the same professional discipline as the applicant with personal knowledge of the applicants ability to practice List of appropriate sources Two peer recommendations required at initial appointment 9, Clinical Privileges TJC NIAHO PSV for current licensure or All permitted by the certification organization and by law to PSV of relevant training provide patient care services Evidence of physical ability to independently have delineated perform the requested privilege clinical privileges If available, data from If available and/or required by professional practice review the MS, a review of individual from other organization where performance data variation the applicant currently has from criteria determined by the privileges medical staff to identify need Recommendations from for training or proctoring that peers/faculty may be required On renewal, review of the applicants performance within the hospital 10, Telemedicine TJC NIAHO 3 choices The originating site can fully privilege and credential the practitioner according to MS standards or Use credentialing information from the distant site if the distant site is a Joint Commission-accredited organization or Use credentialing and privileging decision from the Joint Commission-accredited distant site Medical staff at both sites make recommendation for services to be provided via telemedicine For non-deeming, can be via contract only if TJC accredited entity 2 choices The originating site can fully privilege and credential the practitioner according to MS standards or Use credentialing and privileging decision from telemedicine entity or distant site Medicare participating hospital When services provided by a contracted entity, GB must identify criteria for selection and procurement of services and how to evaluate the entity 11, Temporary Privileges TJC NIAHO 120 days for new applicant with complete file awaiting MEC approval Time as specified in bylaws for patient care need On recommendation of MS President or designee No successful challenges to licensure or registration; involuntary termination of MS appointment; involuntary limitation, reduction, denial, or loss of clinical privileges Not exceed 120 days Locum tenens not to exceed 6 months On recommendation of a MEC member, MS president or medical director (as defined by MS Urgent patient care need Complete application w/o negative or adverse information before action by the medical staff or governing body 12, Temporary Privileges TJC NIAHO Patient care need verify Current licensure Current competence New Applicant verify Current licensure Relevant training or experience Current competence Ability to perform the privileges requested Other criteria required by medical staff bylaws NPDB In all cases verify education (AMA/AOA Profile OK current competence primary verification of State professional licenses professional references (including current competence) Database profiles from AMA, AOA, NPDB, and OIG Medicare/Medicaid Exclusions 13, Allied Health Professionals TJC NIAHO LIPs through MS process Non-LIP APRNs and PAs HR or MS if not providing a medical level of care If State law allows, MS may include DPM, OD, DC, PA, CRNA, NM, APRN, DMD, PHD or other designated professionals approved by MS and Board and eligible for appointment 14, Executive Committee TJC NIAHO 10 EPs outlining responsibilities, structure, function If MS has an executive committee, a majority of the members of the committee shall be doctors of medicine or osteopathy CEO and the nurse executive of the organization or designee shall attend each meeting on an ex-officio basis, with or without vote 15, TJC Notifications NIAHO The decision to grant, A current roster listing deny, revise, or each practitioners revoke privilege(s) is specific surgical disseminated and privileges must be made available to all available in the appropriate internal surgical suite and external persons scheduling area or entities, as defined Include surgeons with by the hospital and suspended surgical applicable law privileges or whose surgical privileges have been restricted 16, Surgical Privileges TJC NIAHO Included in general category for privileges All practitioners performing surgery have surgical privileges established by the department of surgery and medical staff and approved by the governing body Privileges for general surgery and surgical subspecialties defined with established criteria approved by MS Privileges correspond with established competencies of each practitioner 17, Automatic Suspension TJC NIAHO The medical staff bylaws include description of indications for automatic suspension or summary suspension of a practitioners medical staff membership or clinical privileges description of when automatic suspension or summary suspension procedures are implemented The medical staff will define the criteria and have a mechanism for consideration of automatic suspension of clinical privileges of a practitioner at a minimum when: revocation/restriction of professional license DEA certificate has been revoked, suspended or on probation Failure to maintain the minimum specified amount of professional liability insurance non-compliance with written medical record delinquency or deficiency requirements Mechanism for immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioners Medicare or Medicaid status 18, QA/PI Data TJC FPPE OPPE Medical Assessment Blood Medication Operative and other procedure(s) Appropriateness of clinical practice patterns Significant departures from established patterns of clinical practice Use of criteria for autopsies Sentinel event data Patient safety data NIAHO Practitioner specific performance data is required and must be ratebased with comparative peer or national data available for comparison.

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