Main Parts of the Standard
• Planning
• Orientation and Education
• Determining Medical Staff Membership
• The Assignment of Medical Staff Clinical Privileges
• Ongoing Monitoring and Evaluation of Medical Staff
Members
• Medical Staff Reappointment and Renewal of Clinical
Privileges
• Nursing Staff
• Other Health Care Practitioners
Planning
Orientation
Education
Primary Source
Verification
Clinical Privileges
Performance Evaluations
Planning
Standard SQE.1.1: Each staff
member’s responsibilities are
defined in a current job
description.
Standard GLD.1: Governance structure and
authority are described in bylaws, policies and
procedures, or similar documents.
M.E.1. The hospital’s governance structure is
described in a written document(s), and those
responsible for governance of the hospital are
identified by name and governance function.
M.E.1. Personnel files for each staff member are
standardized and current and maintained
according to hospital policy.
M.E.2. Personnel files contain the qualifications
of the staff member.
M.E.3. Personnel files contain the job
description of the staff member when
applicable.
M.E.4. Personnel files contain the work history
of the staff member.
M.E.5. Personnel files contain the results of
evaluations.
M.E.6. Personnel files contain a record of in-
service education attended by the staff member.
Standard SQE.5:
There is documented personnel information
for each staff member
Standard SQE.7: All clinical and nonclinical staff members are
oriented to the hospital, the department or unit to which they
are assigned, and to their specific job responsibilities at
appointment to the staff.
New clinical and nonclinical staff members
Contract workers
Volunteers
Students and trainees
Includes;
• the reporting of medical errors,
• infection prevention and control practices,
• the hospital’s policies on telephone
medication orders,
• and so on
Standard SQE.8.1: Staff members who provide patient care and
other staff identified by the hospital are trained and can
demonstrate appropriate competence in resuscitative
techniques.
"... identified by a recognized training program, or every two years if a recognized training
program is not used."
M.E.2. The appropriate level of training is provided with sufficient frequency to meet
staff needs.
• Basic life support (BLS) • Advanced Life Support (ALS) /
Advanced Cardiac Life Support (ACLS) • Pediatric Advanced Life Support (PALS)
Standard SQE.9: The hospital
has a uniform process for
gathering the credentials of
those medical staff members
permitted to provide patient
care without supervision.
• a diploma from a medical school, • specialty training (residency) completion
letter or certificate, • completion of the requirements of a medical
professional organization, • a license to practice, or recognition of
registration with a medical or dental council
• documenting a telephone conversation with the
issuing source, • by sending an e-mail or
conventional postal letter inquiry with the source.
Credentials
Primary Source
Verification
Appointment
Re-appointment At least every three years,
• continued licensure; • disciplinary actions; • sufficient documentation
for seeking new or expanded privileges or duties in the hospital;
• that the medical staff member is physically and mentally able to provide patient care and treatment without supervision.
Medical Staff includes;
• all physicians,
• dentists,
• professionals licensed to practice independently,
• professionals who provide preventive, curative, restorative, surgical,
rehabilitative, or other medical or dental services to patients;
• professionals who provide interpretative services for patients, such as
pathology, radiology, or laboratory services.
• All types and levels of staff (employed, honorary, contract, visiting, and
private community staff members), are included.
• A hospital must define those other practitioners, such as “house
officers,” “hospitalists,” and “junior doctors,” that are no longer in
training, but may or may not be permitted by the hospital to practice
independently.
• In some cultures traditional medicine practitioners, such as
acupuncturists, chiropractors, and others, may be permitted by law and
the hospital to practice independently.
The Assignment of Medical Staff Clinical Privileges
Standard SQE.10: The hospital has a standardized, objective,
evidence-based procedure to authorize medical staff members to admit
and to treat patients and/or to provide other clinical services consistent
with their qualifications.
a) is standardized, objective, and evidence-based;
b) is documented in hospital policies;
c) is active and ongoing as the credentials of medical staff members change;
d) is followed for all classes of medical staff membership; and
e) can be demonstrated as to how the procedure is used effectively.
• Behaviors
• understands and supports the
hospital’s code of behavior
• unacceptable behaviours
• staff surveys
• Professional growth,
• Patient care,
• Medical/clinical knowledge,
• Practice-based learning and
improvement
• Interpersonal and communication
skills
• Professionalism
• System-based practices
• Stewardship of resources
• Clinical results
Standard SQE.11: The hospital uses an ongoing standardized process
to evaluate the quality and safety of the patient care provided by each
medical staff member.
• standardized by type of medical staff
member
• uses the monitoring data and
information for internal comparisons
• is conducted by the individual’s
department or service head, senior
medical manager, or a medical staff
review body;
• includes the monitoring and evaluation
of senior medical staff and department
heads by an appropriate professional;
and
• provides information that will be
documented in the medical staff
member’s file, including the results of
reviews, actions taken, and the impact
of those actions on privileges (if any).
Nursing Staff
Standard SQE.13: The hospital has a uniform process to gather, to
verify, and to evaluate the nursing staff’s credentials (license,
education, training, and experience).
Understanding the applicable laws and regulations that apply to nurses and nursing
practice; gathering all available credentials on each nurse, including at least
• evidence of education/training;
• evidence of current licensure;
• evidence of current competence through information from other sources in which
the nurse was employed; and
• letters of recommendation and/or other information the organization may require,
such as health history, pictures, among others; and
• verification of the essential information, such as current registry or licensure,
particularly when such documents are periodically renewed, and any certifications
and evidence of completion of specialized or advanced education.
Other Health Care Practitioners
Standard SQE.15: The hospital has a uniform process to gather, to
verify, and to evaluate other health professional staff members’
credentials (license, education, training, and experience).
"These professionals include nurse midwives, surgical assistants,
emergency medical care specialists, pharmacists, and pharmacy
technicians. In some countries or cultures, this group also includes
traditional healers or those who provide alternative services or services that
complement traditional medical practice (for example, acupuncture, herbal
medicine)."
Thank You For Listening!
20.08.2014 17
A. Murat SÜMER
Strategic Planning and Performance Improvement Manager Anadolu Medical Center
E-mail: [email protected]
Phone: (+90 262) 678 50 45 Mobile: (+90 533) 270 36 41
Web: http://www.anadolumedicalcenter.com/
Hospital Accreditation Seminar Iran
August 24th – 25th, 2014