Medical Student H&P | Four years on, upstart nears 350 clients. Find out more about our accreditation, certification & training programs. Available at: http://www.jointcommission.org/NR/rdonlyres/2F04C126-906D-4155-B16F-1F1A6570C387/0/jconlineAug1209.pdf. Delia Constanzo . Infection Control & Hospital Epidemiology. Before the audit starts, you provide input on what operational processes are most crucial to your business success. DNV: Det Norske Veritas: DNV: Der Norske Veritas: DNV: District of North Vancouver (British Web DNV GL Healthcare (DNV GL) The Compliance Team (TCT) The Joint Commission (JC) There are currently another seven AOs approved under CLIA, which are: American Association of Blood Banks (AABB) American Association for Laboratory Accreditation (A2LA) American Osteopathic Association (AOA) 1350 0 obj
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Download the Standards created and offered by DNV Healthcare, I've just been hired on at a hospital that is Det Norske Veritas (DNV) accredited as opposed to the Joint Commission. 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. <]>>
Det Norske Veritas (DNV) is a global quality About 200 hospitals have switched to DNV Accreditation over the past two years. Because while undergoing the accreditation process, a hospital makes critical decisions about how it provides services, manages medications and allocates resources. All Rochester Regional Health labor and delivery hospitals. The focus areas should be linked to the management system and reflect the risks or opportunities that are most important to you. The certification process - DNV You must complete the Participant's Agreement in order to access your purchased NAMSS Education. 0
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 Because there would be a time gap between Joint Commission and DNV accreditation, Rosen worked with the state Department of Health and the local CMS Metrics and Performance Accessed August 5, 2009. 131 0 obj
SCRMC serves as the second largest employer in Jones County. 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. ISO is recognized by businesses around the world as the benchmark for continual quality improvement. The report indicates if your organisation is ready to proceed with the certification audit. DNVs accreditation program, called NIAHO (Integrated Accreditation of Healthcare Organizations), involves annual hospital surveys instead of every three years and encourages hospitals to openly share information across departments and to discover improvements in clinical workflows and safety protocols. The certification decision is taken after an independent DNV GL internal review. Digital monitoring of medium-voltage cable networks, Offshore classification fleet in service, Electric grid performance and reliability, Reliability, availability and maintainability (RAM), Ship management, operations and ship design, procedure for suspension and withdrawal of certificates. 2022 NAMSS Comparison of Accreditation Standards endstream
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Centers for Medicare and Medicaid Services. WebAccreditation and certification are important accomplishments and we are here to help your organization throughout the entire process. We use cookies to help provide and enhance our service and tailor content. WebThe more variables and inter-dependencies in you organization, the more relevant ISO becomes. 4NuH.z)z06q?Rt|E"vzQV-\\-U=^4/M6z`| Y, 2mKe59\^9xg6`?,^eaQ)PHwzX=ixf#`x[aA;B|A3 $z(Gc(A%aC@)4"44SY S20L: 2("ukvVhMg9a,"J0$8 1sb s6s[fPE<1I!4XOLv^+d2(i}%C9X WebThe important role of the Joint Commission. Top management should be involved at this stage. The password to view the NAMSS Comparison of Accreditation Standards is: Q7r&Km 0000002012 00000 n
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WebCommission, Healthcare Facilities Accreditation Program (HFAP) and Det Norske Veritas Healthcare, Inc. (DNV) for hospitals; gives deeming authority to NCQA for Medicare Advantage health plans Accrediting Organizations Targets for Accreditation Types of Standards Accreditation Categories NCQA Joint Commission Health plans 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. (Are minimal standards sufficient in todays healthcare climate? ) DNV Healthcares hospital accreditation program is unique in that it integrates the ISO 9001 standards (international quality standards that define Medical Student SOAP Note | DNV To fulfill the accreditation criteria, an accrediting authority assesses the certification body/registrar to verify that the certification body/registrar complies with existing requirements. WebAccreditation is voluntary and seeking deemed status through accreditation is an option, not a requirement. xref
The scope of certification is agreed at an early stage in the certification process. org 22, Questions to Consider Will our reputation in the community suffer if we change? WebAccredited hospitals. Accreditation verifies the certification body/registrars competence. 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. 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. "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
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ISO is the International Organization for Standardization. Lab Specimen Guideline | This product includes updates that will be made by NAMSS over the next 12 months. South Central Regional Medical Center was the first hospital in Mississippi to be accredited by DNV Healthcare. Accreditation endstream
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David Eickemeyer, MBA; Associate Director, Hospital Business Development. The annual survey model keeps hospitals moving forward on the path of continued improvement. We evaluate how well your management system supports your focus areas. Accredited certification of management systems is used to demonstrate compliance to a standard in a trusted way. endstream
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HSMo0+TR E9dR-,Q DNV Healthcare - Accreditation Organization for DNV is kept apprised of the organization's level of compliance with ongoing organizational reporting. Meeting DNV Accreditation Standards | The Latest News and Country-wide, more than 5000 hospitals are permitted to provide Medicarefinanced services solely DEPARTMENT OF HEALTH & HUMAN SERVICES endobj
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Based on a positive outcome, he/she will recommend certification. WebThis electronic reference tool provides plain-language interpretations of the credentialing standards for The Joint Commission, NCQA, Healthcare Facilities Accreditation Why? 8618 0 obj
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The ability to integrate ISO 9001 quality standards with our clinical and financial processes is a major step forward.. View our list of disease-specific and specialty program certifications.
2019 HIMSS Annual Conference: Clinical Optimization: One Approach to Integration, 2019 Breakthroughs Conference: Clinical Optimization: A Panel Discussion. 0000002447 00000 n
Through its broad experience and deep expertise, DNV advances safety and sustainable performance, sets industry benchmarks, drives innovative solutions. AORN Guidance Statement: Perioperative Staffing. Accreditation options: Understanding DNV GL xb```f``ue` ea *(ltSa{+ 9QQ (MHKX*?6Y
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Infection Control & Hospital Epidemiology,40(9), 1066-1069. doi:10.1017/ice.2019.164. Comparisons of the NIAHO and Joint Commission Approaches to %%EOF
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The DNV program is consistent with our long-term commitment to quality and patient safety, says Dr. Teresa Camp-Rogers, Chief Quality Officer at SCRMC. 1327 0 obj
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The trademarks DNV GL, DNV, the Horizon Graphic and Det Norske Veritas are the properties of companies in the Det Norske Veritas group. 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. 8644 0 obj
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hVO0W4u~yHZVm6)am|;#\zn$2N'*P1!$''BoD/We/Tze DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. DNV has accredited about 300 hospitals with another 80 or so awaiting accreditation, according to Horine. This is much more than an accreditation program, its a catalyst for our ongoing commitment to patient safety and clinical quality.. hbbd```b``= "@$nDEH`=d`L""@$?/O@o_@H b4l4k#%4#3` ,
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. The certification audit consists of informal interviews, examinations, observations of the system in operation and review of relevant documentation. 0000038715 00000 n
Antibiotic Susceptibility | The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. The American Nurses Credentialing Center has recognized Clifton Springs Hospital & Clinic, Rochester General, Unity, Newark-Wayne Community hospitals and PCASI with the highest honor available for nursing excellence. WebThis background is fascinating in view of The Joint Commissions (TJC) history. startxref
To check your readiness for the certification audit, i.e. This helps hospitals create a corrective action plan to improve their process and prevent that variance from occurring again. endstream
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Accreditation | A successful management system is one that is improved on a continual basis. In 2020, Rochester Regional Health participated in 123 regulatory surveys in our acute care settings, outpatient settings and specialty programs from compliance agencies like DNV Healthcare, The Joint Commission and the Department of Health. Published by Elsevier Inc. All rights reserved. Midland Memorial happy with DNV shift. 0000012414 00000 n
During surveys, DNV wants to see the improvements that have been made as a result of the annual survey process. Available at: http://cert.branswijck.com/. Making the Switch: Washington Hospital Turns to DNV Reflective of an organizations performance with respect to Joint Commission standards and elements of performance (EPs).Transparent all components of the process are fully disclosed to accredited and certified organizations.Easily understood by all involved parties.More items To update your cookie settings, please visit the. 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. At least one periodic audit per year is required. Our lead auditor will verify that you have properly addressed the nonconformities. V)gB0iW8#8w8_QQj@&A)/g>'K t;\
$FZUn(4T%)0C&Zi8bxEB;PAom?W= v4?fBHQ [C. Although the costs of Joint Commission and DNV are about the same, according to health experts, there are some big differences between the two: The organization surveys the hospitals that use their commissioning services annually, while the Joint Commission extends its survey periods from 18 months to three years. Driven by its purpose, to safeguard life, property, and the environment, DNV helps tackle the challenges and global transformations facing its customers and the world today and is a trusted voice for many of the worlds most successful and forward-thinking companies. 0000001195 00000 n
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In case of expanding the scope the process will restart at section 2 with a documentation review (if needed) and will further follow the normal process from section 4 with a (scope extension) certification audit. <>stream
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Have questions Contact us DNV Healthcare All rights reserved. We focus on achieving this aspect at every survey. ".*RK6"zf9ss~3 AARJA=Z\&6c@+|dk{GKY B_],IEmmq_rS}gX;L9nL%)5Ek&$;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~ Rochester General Hospital Maternity Care,Unity Hospital Maternity Care,United Memorial Medical Center Maternity Care. wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 In addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. This is applicable in situations where an organisation persistently and seriously fails to maintain compliance with the management system standard or due to other situations, as defined in the procedure for suspension and withdrawal of certificates. Organizations seeking CMS approval may choose to be surveyed either by an accrediting body, such as the Joint Commission, DNV, and HFAP, or by state surveyors on behalf of CMS. DNVs accreditation program is the only one to integrate the ISO 9001 Quality Management System with the Medicare Conditions of Participation. Each issued certificate has a three-year life period. Our Risk Based Certification approach tailors the process to evaluate your select business risks in addition to compliance with the standards requirements. 121 0 obj
SCRMC has three years from the date of its accreditation to achieve compliance with ISO 9001, the worlds most trusted quality management system used by performance-driven organizations around the world to advance their quality and sustainability objectives. endstream
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In recent years, DNV have been challenging TJC in the USA. Lesho, E., Hix, J., Bronstein, M., Shastry, S., Hanna, J., Scroggins, G., & Grieff, M. (2019). endstream
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TCI certification. %%EOF
We are honored to provide behavioral healthcare facilities the same option provided to their hospital partners - a choice in their accreditation.PsychiatricHospital Accreditation Program Components 630-792-5787 | lberkeley@jointcommission.org. 0000001631 00000 n
Det Norske Veritas (DNV) NIAHO Accreditation Requirements Interpretive Guidelines & Surveyor Guidance Revision 7, 2008. 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 $200 million. Accepted manuscript, pp. doi:10.1017/ice.2020.295. Accreditation Guide | The Joint Commission After the audit you need to address and respond to non-conformities within an agreed deadline. Webknown as DNV Accreditation, they came equipped with the experience of TUVs previous effort to become deemed and their National Integrated Accreditation for Healthcare WebWe have a variety of resources to help you explore and master the accreditation process. HtTKo0Wh( This accreditation underscores our commitment to developing and continually improving quality and safety for employees, patients and visitors throughout our system. Certification by DNV Healthcare is key step toward establishing your hospital's reputation for excellence. There is always an opportunity to improve. Hospitals are no longer stuck in a cycle of addressing the same issue every three years. We currently have 26 Beacon Awards across our system. 2010 Mosby, Inc. Comparison of The Joint Commission and DNV GL hbbd``b` @)H0A@"*HpE$> oL,F6~0 d
Meeting DNV Accreditation Standards LAUREL, MS, South Central Regional Medical Center (SCRMC) announces the successful completion of its new accreditation process that has been awarded by DNV. We have to get a clear understanding of your business strategy and conditions that affect your ability to reach said strategy. Rochester Regional Health is a national leader with the most Beacon Awards from the American Association of Critical Care Nurses, recognizing hospital units that have integrated evidence-based practices to improve patient and family outcomes. Det Norske Veritas (DNV) vs JC? - General Nursing Talk Using an accredited third party certification body/registrars We provide services at more than 400 locations across the region. %
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. WebIn addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. Accreditation Canada accredited its first organization internationally in 1967 in Bermuda. Learning happens when staff are comfortable and not intimidated by the process. WebThis approval provides hospitals with another accreditation option in addition to the Joint Commission and the American Osteopathic Association. I.3A
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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. The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. Vendor Login | Felicio Rocho Hospital. DNV is a global independent certification, assurance and risk management provider, operating in more than 100 countries. 2002 Jun;75(6):1179-82. doi: 10.1016/s0001-2092(06)61621-9. Similar review also applies in cases of suspending or restoring certification or withdrawing the certification. Find the residency program, fellowship, or training program that's right for you, or explore our research and clinic trials. endstream
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DOI: https://doi.org/10.1016/j.mnl.2009.10.004, The International Organization for Standardization (ISO), To read this article in full you will need to make a payment. An integrated health services organization serving the people of Western New York. Comparison of The Joint Commission and Det Norske - WAMSS Both your management system and certificate have to be maintained. What happens if an organisation fails to maintain their management system and certification? Following a positive decision you will receive the certificate shortly thereafter. 0000003960 00000 n
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Hospital accreditation 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 The outcome is still a certificate if the management system is found compliant but with added dimension to your improvement journey. HyTSwoc
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WebAssistant Director - Accreditation Services . By 1991, TJC had learned that it was not possible to ensure quality and had moved on to quality improvement and its many iterations, now known as performance improvement. Findings, including non-conformities, and conclusions are presented at the end of the audit in a closing meeting and included in the audit report. 8667 0 obj
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Today, 300 follow DNV Accreditation procedures, and 80 more are in the process DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. It is widely recognized as the gold standard in healthcare accreditation, and its standards are considered rigorous and comprehensive. [fy^Mx_6vbvX,'Mqtr)yzQn.^%~&PdXfbpqxu5Y)Vwuq_DO1ou{)v]tiply/m}+s[(E}Zyc"F%x.%i%NW?VE\gcuJ[Q[Ka/.W. Available at: www.iso.org/iso/home. 630 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.