Is this privilege/procedure required by enough patients in the community to warrant your facility offering the service
How many local facilities offer the same procedure
How many times has the procedure been required/performed in the last two years
Perform an FPPE for the high risk procedure, include a plan for monitoring, so the Medical Executive Committee (MEC) can confidently approve re-privilege
Consider Peer Referencing from other facilities
Allow Department Chair proctoring for those procedures less likely to be performed often
Keep an open mind in relation to outcomes and observations and collegial interactions. Giving your medical staff flexibility will increase adoption and improve compliance with the program.
Define LV/HR procedures for your institution
Keep an open mind in defining reliable confirmation of competency; don’t just use “the provider must perform ‘X’ number of procedures to maintain this privilege”
Consider peer referencing, proctoring or direct observation to validate competency of known LV/HR procedures
As with any unexpected situation, always keep your standards and regulations handy for reference. Don’t forget to utilize the resources of your surveying authority; there are few questions they haven’t already confronted and conquered so don’t be shy about taking advantage of their knowledge and experience.
Lastly, keep the intent of the standard in mind when answering questions and developing your plan. If you develop your processes from that perspective you will usually find yourself in good standing come survey time.
RESOURCE: The Medical Staff Handbook: A Guide to Joint Commission Standards, Third Edition, Joint Commission Resources, Inc., Oakbrook Terrace, Illinois, 2011.