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Proposed standards focus on evidence-based privileging

Medical Staff Leader Connection, December 21, 2005

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Evidence-based medicine has become the norm in healthcare. Now, in its proposed 2007 standards for credentialing and privileging, the JCAHO aims to bring the evidence-based approach to the process of vetting providers.

The JCAHO solicited comments on its proposed credentialing and privileging standards until December 5, with the final standards taking effect in January 2007. The proposed standards regarding privileging and ongoing performance monitoring state the following:

If an applicant does not have a current performance record at the organization, data should be collected during a performance-monitoring period. Performance monitoring may include:

• chart review
• monitoring clinical practice patterns
• simulation
• proctoring
• external peer review
• discussion with other individuals involved in the care of patients (consulting physicians, nursing personnel, assistants at surgery)

Performance monitoring may also be used to evaluate currently privileged practitioners when issues are raised about performance. The organization may also identify privileges that require consistent performance monitoring. Go to www.jcaho.org for more information.

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