Medical Staff

Significant DNV standard changes

Medical Staff Leader Insider, March 15, 2012

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When The Greeley Company discusses accreditation, it is usually centered on The Joint Commission, not Healthcare Facilities Accreditation Program or Det Norske Veritas (DNV). As DNV recently made updates to its medical staff standards (effective January 15), here is a highlight of some of the more significant changes, with additions being underlined.

MS.8:  Appointment

SR.1e is a new requirement that mandates additional information be gathered prior to initial appointment to the medical staff.

                “…receipt of database profiles from NPDB, OIG Medicare/Medicaid Exclusions”

MS.12: Clinical Privileges

SR.4a now allows outpatient practitioners to order appropriate outpatient services that previously were not allowed being granted clinical privileges.

There shall be a provision to authorize LIPS to order outpatient services that are within their scope of service to order

MS.13:  Temporary Clinical Privileges

SR.1 now includes the following underlined language, which allows a broader group of individuals—not just the medical executive committee—to recommend to the CEO (or designee), to grant temporary privileges to an applicant.

                “…on the recommendation of a member of the medical executive committee, president of the                medic al staff, or medical director (as defined by the medical staff)”

SR.2 now allows a grant of temporary privileges up to 120 days, instead of the previous 90 days (initial grant of 30 days with two subsequent re-grants of 30 days each).

                “…for a period of time not to exceed one hundred twenty (120) days”

SR.3a and SR.3c now require primary verification of education and state professional licenses where before only verification was required.

                SR.3a : “…primary verification of education (AMA/AOA profile is acceptable)”

                SR.3c:  “…primary verification of State professional licenses”      

There is also an addition regarding emergency and disaster privileges in SR.4. The guidelines are not as prescriptive as The Joint Commission’s, but there must be language in the bylaws that addresses these issues.

The medical staff bylaws shall include a process for approving practitioners for care of patients in the event of an emergency or disaster.”

No matter the accreditation agency, it is best practice to review your bylaws yearly, especially in regard to any new regulatory changes. 

Mary J. Hoppa, MD, MBA, is a senior consultant with The Greeley Company, a division of HCPro Inc. in Danvers, MA.


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