Ongoing professional practice evaluation information is factored into the decision to maintai...

TJC MS.18.02.03

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TJC MS.18.02.03

Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.

(1)

The medical staff's ongoing professional practice evaluation includes a clearly defined process that facilitates the periodic evaluation of each physician's or other licensed practitioner’s professional practice. Note: Privileges are granted for a period not to exceed three years or for the period required by law and regulation if shorter.

(2)

The process for the ongoing professional practice evaluation includes the type of data to be collected, which is determined by individual departments and approved by the organized medical staff.

(3)

The process for the ongoing professional practice evaluation includes the use of information resulting from the ongoing professional practice evaluation to determine whether to continue, limit, or revoke any existing privilege(s).

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