Credentialing and Privileging - Hospital-Based Nursing Care Center

Can Hospital-Based Nursing Care Center surveyed under the Comprehensive Accreditation Manual for Nursing Care Center have a separate medical staff and credentialing and privileging process or must they be integrated with the hospital’s medical staff and credentialing and privileging process?

Any examples are for illustrative purposes only

Organizations are free to decide to have either a separate process or to integrate with the hospital’s medical staff and processes.  Whichever is selected, the approach must meet the requirements of the NCC (Nursing Care Center) manual, including the role of the NCC Medical Director.  See LD. 01.06.01 EPs 1-5 and HR. 02.01.04 EP 10 and 13. For organizations that elect the Post-Acute Care Certification, please also see LD. 01.06.01 EPs 6, 7, and 16.   

When the licensed independent practitioner is receiving privileges/authorization/clinical responsibilities in multiple settings using a single credentialing and privileging process, it must be clear as to what the practitioner can do in the Nursing Care Center.  (HR. 02.01.04 EP 10 and 11).  For example, some hospital based NCCs will have a separate list of privileges for the physicians who practice in the NCC unit. 

If the Licensed Independent Practitioner is new to the organization and not currently privileged at any Joint Commission-Accredited Organization, such as the Dentist, Optometrist, or Podiatrist, the Medical Director must monitor the Licensed Independent Practitioner’s performance in the Nursing Care Center. This monitoring continues until the Medical Director is satisfied the new Licensed Independent Practitioner can provide safe and effective care that he or she is being permitted to provide in the Nursing Care Center.  

Last updated on June 17, 2020
Manual: Nursing Care Center
Chapter: Human Resources HR

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