Treatment Protocols & Interventions Flashcards

Under Joint Commission standards, disaster privileges may be granted when:

Answer: The Emergency Operations Plan is activated and the hospital cannot meet immediate patient needs

Disaster privileges are allowed only when the EOP is activated and the organization cannot meet patient needs.

After granting disaster privileges, primary source verification of licensure should generally be completed within:

Answer: 72 hours

TJC expects licensure primary source verification within 72 hours of the volunteer starting work, barring extraordinary circumstances.

Temporary privileges to meet an important patient care need for a pending applicant may last no longer than:

Answer: 120 days

TJC limits temporary privileges for applicants pending approval to 120 days.

A physician requests cardiac catheterization privileges, but the hospital has no cath lab. How should the request be handled?

Answer: Decline it as unavailable at the facility, which is not an adverse action

Privileges can't be granted for services the organization doesn't provide, and declining for that reason isn't based on competence.

A restriction of clinical privileges based on professional competence must be reported to the NPDB when it lasts longer than:

Answer: 30 days

Competence-related actions restricting privileges for more than 30 days are reportable to the NPDB.

A surgeon voluntarily surrenders privileges while under investigation for poor outcomes. This is:

Answer: Reportable to the NPDB

Surrendering privileges while under investigation, or to avoid one, must be reported to the NPDB.

What is the primary role of a proctor during FPPE?

Answer: To observe, evaluate, and report on the practitioner's competence

A proctor evaluates and documents competence for the department, usually without taking responsibility for patient care.