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What to Expect with The Joint Commission's New Reappointment Process Guidelines

What to Expect with The Joint Commission's New Reappointment Process Guidelines

December 20th, 2023
December 20th, 2023

In November of 2022, The Joint Commission announced a change to the reappointment timeline. As a Medical Service Professional (MSP), you know that reappointment is the process of re-evaluating a practitioner’s qualifications and current competency to provide services for a healthcare organization after they’ve been appointed to the medical staff.

What is the Reappointment Process?

One of the many responsibilities MSPs share is that of reappointment, the process of re-evaluating a provider’s current competency and qualifications to provide care. Reappointment is critical for patient safety as it’s an opportunity to ensure the provider’s performance, medical judgment, clinical skills, and professional behavior continue to meet the organization’s standards.

Why change the Reappointment timeline?

In 2021, the National Association of Medical Staff Services (NAMSS) hosted a roundtable, Focused Revision: Moving to a Three-Year Practitioner Reappointment Cycle and Enhancing Continuous Monitoring, that brought stakeholders together to discuss reappointment and continuous monitoring alignment and duplication. The Roundtable conversation shed light on the inefficiencies and shortfalls that a two-year reappointment cycle, alongside continuous monitoring, had on healthcare organizations.

At the roundtable, NAMSS 2021 President, Aimee Wooley-Randall detailed the amount of time and resources MSPs must dedicate to simultaneously reappoint and continuously monitor practitioner competency, “Both reappointment and continuous monitoring evaluate practitioner competency—and share similar processes and measures. The overlap creates administrative duplication, stretches resources, and prevents MSPs from working at the top of their scopes.” In November of 2022, The Joint Commission extended the practitioner requirement from two years to three years, stating “This change was made to better align with the standard practice of evaluating licensed practitioners every three years.”

What are the new Reappointment Guidelines?

Extending the practitioner reappointment time from two years to three years is effective immediately unless laws and regulations require a shorter period. This change enables MSPs to perform continuous monitoring and quality assessment, as well as help reduce duplicative credentialing/re-credentialing processes. These updated guidelines apply to:

  • Hospitals
  • Critical Access Hospitals
  • Ambulatory Health Care
  • Behavioral Health Care and Human Services
  • Nursing Care Centers
  • Office-Based Surgeries

Under these updated guidelines, due dates and governing body approval dates have also changed. Per The Joint Commission:

Due Dates

Reappointment/re-privileging is due no later than three years from the same date from the previous appointment or reappointment, or for a period required by law or regulation if shorter. For example, if the reappointment period is July 1, 2021, through June 30, 2024, the reappointment date would be July 1, 2024.

Governing Body Approval Dates

The reappointment/re-privileging dates do not need to match the governing body approval dates. The governing body should be approving effective periods in advance of the expiration date. For example, in June, the board would approve all July reappointments/re-privileging effective periods and in July the board would be approving all August reappointments/re-privileging effective periods. It would not be necessary to keep changing the effective period to match the date the board actually met and approved the appointment/reappointment or privileges.

Benefits of the new Reappointment Process Guideline

The biggest benefit of this change is that the new timeframe will better align with the standard practice of evaluating licensed practitioners every three years, but there’s much more. In fact, during the NAMSS roundtable, Focused Revision: Moving to a Three-Year Practitioner Reappointment Cycle and Enhancing Continuous Monitoring, they outlined a variety of reasons an extension would be favorable, including:

  • Extending reappointment to three years would enable MSPs to focus on OPPE between reappointment cycles and more readily take action on performance concerns that OPPE discovers.
  • A three-year reappointment cycle would also reduce the burdens that overlapping evaluations have on:
    • Practitioners
    • The costs health systems incur from practitioner evaluation
    • The amount of time MSPs spend performing redundant administrative tasks - enabling MSPs to focus exclusively on assessing practitioner performance and clinical privileges, competency, and quality—components that are critical to ensuring patient safety.
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