Departman

Tarih

Staff Qualifications and Education

(SQE)

August, 2014

Main Parts of the Standard

• Planning

• Orientation and Education

• Determining Medical Staff Membership

• The Assignment of Medical Staff Clinical Privileges

• Ongoing Monitoring and Evaluation of Medical Staff

Members

• Medical Staff Reappointment and Renewal of Clinical

Privileges

• Nursing Staff

• Other Health Care Practitioners

Planning

Orientation

Education

Primary Source

Verification

Clinical Privileges

Performance Evaluations

Planning

Standard SQE.1.1: Each staff

member’s responsibilities are

defined in a current job

description.

Standard GLD.1: Governance structure and

authority are described in bylaws, policies and

procedures, or similar documents.

M.E.1. The hospital’s governance structure is

described in a written document(s), and those

responsible for governance of the hospital are

identified by name and governance function.

M.E.1. Personnel files for each staff member are

standardized and current and maintained

according to hospital policy.

M.E.2. Personnel files contain the qualifications

of the staff member.

M.E.3. Personnel files contain the job

description of the staff member when

applicable.

M.E.4. Personnel files contain the work history

of the staff member.

M.E.5. Personnel files contain the results of

evaluations.

M.E.6. Personnel files contain a record of in-

service education attended by the staff member.

Standard SQE.5:

There is documented personnel information

for each staff member

Standard SQE.7: All clinical and nonclinical staff members are

oriented to the hospital, the department or unit to which they

are assigned, and to their specific job responsibilities at

appointment to the staff.

New clinical and nonclinical staff members

Contract workers

Volunteers

Students and trainees

Includes;

• the reporting of medical errors,

• infection prevention and control practices,

• the hospital’s policies on telephone

medication orders,

• and so on

Standard SQE.8.1: Staff members who provide patient care and

other staff identified by the hospital are trained and can

demonstrate appropriate competence in resuscitative

techniques.

"... identified by a recognized training program, or every two years if a recognized training

program is not used."

M.E.2. The appropriate level of training is provided with sufficient frequency to meet

staff needs.

• Basic life support (BLS) • Advanced Life Support (ALS) /

Advanced Cardiac Life Support (ACLS) • Pediatric Advanced Life Support (PALS)

Standard SQE.9: The hospital

has a uniform process for

gathering the credentials of

those medical staff members

permitted to provide patient

care without supervision.

• a diploma from a medical school, • specialty training (residency) completion

letter or certificate, • completion of the requirements of a medical

professional organization, • a license to practice, or recognition of

registration with a medical or dental council

• documenting a telephone conversation with the

issuing source, • by sending an e-mail or

conventional postal letter inquiry with the source.

Credentials

Primary Source

Verification

Appointment

Re-appointment At least every three years,

• continued licensure; • disciplinary actions; • sufficient documentation

for seeking new or expanded privileges or duties in the hospital;

• that the medical staff member is physically and mentally able to provide patient care and treatment without supervision.

Medical Staff includes;

• all physicians,

• dentists,

• professionals licensed to practice independently,

• professionals who provide preventive, curative, restorative, surgical,

rehabilitative, or other medical or dental services to patients;

• professionals who provide interpretative services for patients, such as

pathology, radiology, or laboratory services.

• All types and levels of staff (employed, honorary, contract, visiting, and

private community staff members), are included.

• A hospital must define those other practitioners, such as “house

officers,” “hospitalists,” and “junior doctors,” that are no longer in

training, but may or may not be permitted by the hospital to practice

independently.

• In some cultures traditional medicine practitioners, such as

acupuncturists, chiropractors, and others, may be permitted by law and

the hospital to practice independently.

Primary Source Verification for Physicians who work in Turkey is peovided by the MoH

The Assignment of Medical Staff Clinical Privileges

Standard SQE.10: The hospital has a standardized, objective,

evidence-based procedure to authorize medical staff members to admit

and to treat patients and/or to provide other clinical services consistent

with their qualifications.

a) is standardized, objective, and evidence-based;

b) is documented in hospital policies;

c) is active and ongoing as the credentials of medical staff members change;

d) is followed for all classes of medical staff membership; and

e) can be demonstrated as to how the procedure is used effectively.

• Behaviors

• understands and supports the

hospital’s code of behavior

• unacceptable behaviours

• staff surveys

• Professional growth,

• Patient care,

• Medical/clinical knowledge,

• Practice-based learning and

improvement

• Interpersonal and communication

skills

• Professionalism

• System-based practices

• Stewardship of resources

• Clinical results

Standard SQE.11: The hospital uses an ongoing standardized process

to evaluate the quality and safety of the patient care provided by each

medical staff member.

• standardized by type of medical staff

member

• uses the monitoring data and

information for internal comparisons

• is conducted by the individual’s

department or service head, senior

medical manager, or a medical staff

review body;

• includes the monitoring and evaluation

of senior medical staff and department

heads by an appropriate professional;

and

• provides information that will be

documented in the medical staff

member’s file, including the results of

reviews, actions taken, and the impact

of those actions on privileges (if any).

Nursing Staff

Standard SQE.13: The hospital has a uniform process to gather, to

verify, and to evaluate the nursing staff’s credentials (license,

education, training, and experience).

Understanding the applicable laws and regulations that apply to nurses and nursing

practice; gathering all available credentials on each nurse, including at least

• evidence of education/training;

• evidence of current licensure;

• evidence of current competence through information from other sources in which

the nurse was employed; and

• letters of recommendation and/or other information the organization may require,

such as health history, pictures, among others; and

• verification of the essential information, such as current registry or licensure,

particularly when such documents are periodically renewed, and any certifications

and evidence of completion of specialized or advanced education.

Other Health Care Practitioners

Standard SQE.15: The hospital has a uniform process to gather, to

verify, and to evaluate other health professional staff members’

credentials (license, education, training, and experience).

"These professionals include nurse midwives, surgical assistants,

emergency medical care specialists, pharmacists, and pharmacy

technicians. In some countries or cultures, this group also includes

traditional healers or those who provide alternative services or services that

complement traditional medical practice (for example, acupuncture, herbal

medicine)."

Thank You For Listening!

20.08.2014 17

A. Murat SÜMER

Strategic Planning and Performance Improvement Manager Anadolu Medical Center

E-mail: murat.sumer@anadolusaglik.org

Phone: (+90 262) 678 50 45 Mobile: (+90 533) 270 36 41

Web: http://www.anadolumedicalcenter.com/

Hospital Accreditation Seminar Iran

August 24th – 25th, 2014