In case you missed it, the August 18, 2010 Joint Commission Online published a summary of the most challenging accreditation requirements for the first half of 2010.  By “most challenging requirements,” TJC means that the surveyed organizations failed to comply with the standard or requirement, which in more colloquial (and non-TJC approved terminology) means the organizations were “dinged” for those standards or requirements.  The requirements include TJC’s accreditation standards, National Patient Safety Goals, the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery and Accreditation and Certification Participation Requirements. 

I was shocked to read the non-compliance rate of surveyed organizations with respect to credentialing and privileging standards.  For example, the non-compliance rate for HR.02.01.03 in Ambulatory Care was 48%.  That means almost half of the organizations surveyed failed to document compliance with the standard addressing how the organization “grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.”  Office-based surgery practices had even a harder time with the similar standard for credentialing and privileging – the non-compliance rate was 63%, meaning that 6 out of 10 practices surveyed failed to comply with this standard.   Behavioral Health Care came in at a 23% non-compliance rate, Home Care had a 20% non-compliance rate with a similar standard (HR.01.02.05) and Medicare/Medicaid Certification-Based Long Term Care had a 38% non-compliance rate.

For hospital folks, credentialing and privileging may now seem elementary, but organizations newer to the credentialing and privileging world appear to need help.

The Joint Commission did not provide any additional detail on why organizations failed to comply with the credentialing and privileging standards, so it is not judicious for me to speculate on what caused the high failure rates.  As we should all know, there may be a difference whether (1) there is a written process, (2) the process is followed and (3) the process is documented, so it could well be that the organizations were compliant but failed to adequately show (document) they were compliant.

This is a cautionary tale for newer organizations like office-based surgery practice seeking TJC accreditation – make sure your credentialing and privileging program is well-documented and in line with the standards before undergoing a survey.  And, if you need help with the credentials verification piece, consider contacting an experienced and reputable credentials verification service like TPQVO to outsource that piece of your credentialing program.