Question of the Week


The Joint Commission’s November 4 FAQ, which stated that the time frame for reappointment/re-privileging would be expanded from two years to three years, noted that additional information would be published at a later date.  Is there any update?  Did TJC make this official?

Yes, TJC made it official.  TJC issued Prepublication Standards for the Hospital Accreditation Program, among others.  The Prepublication Standards revised the Elements of Performance as follows:

MS.06.01.07, Element of Performance 9:  “9.  Privileges are granted for a period not to exceed two years three years or for the period required by law and regulation if shorter.”

MS.07.01.01, Element of Performance 3:  “3.  The organized medical staff uses the criteria in appointing members to the medical staff and appointment does not exceed a period of two years three years or the period required by law and regulation if shorter.”

TJC stated that these Prepublication Standards are “Effective Immediately; February 19, 2023 Release.”

As noted in the November 17 Question of the Week, which commented on the November 4 FAQ, “you should confirm that your state hospital licensing regulations permit a three-year term.  For example, both Idaho and North Carolina regulations require two-year appointment terms.  As the quoted language from the [November 4 FAQ] states, the appointment term may be shorter than three years ‘if required by law or regulation.’  In other words, state hospital law or regulation will control so you want to be sure to check that first.”

Also, stay tuned – Horty, Springer & Mattern plans to do a podcast on the issue and provide additional information.