CMS SOM App. A, Tag A-0340

Interpretive Guidelines §482.22(a)(1)

The medical staff must at regular intervals appraise the qualifications of all practitioners

appointed to the medical staff/granted medical staff privileges. In the absence of a State law that

establishes a timeframe for periodic reappraisal, a hospital’s medical staff must conduct a

periodic appraisal of each practitioner. CMS recommends that an appraisal be conducted at least

every 24 months for each practitioner.

The purpose of the appraisal is for the medical staff to determine the suitability of continuing the

medical staff membership or privileges of each individual practitioner, to determine if that

individual practitioner’s membership or privileges should be continued, discontinued, revised, or

otherwise changed.

The medical staff appraisal procedures must evaluate each individual practitioner’s qualifications

and demonstrated competencies to perform each task or activity within the applicable scope of

practice or privileges for that type of practitioner for which he/she has been granted privileges.

Components of practitioner qualifications and demonstrated competencies would include at least:

current work practice, special training, quality of specific work, patient outcomes, education,

maintenance of continuing education, adherence to medical staff rules, certifications, appropriate

licensure, and currency of compliance with licensure requirements.

In addition to the periodic appraisal of members, any procedure/task/activity/privilege requested

by a practitioner that goes beyond the specified list of privileges for that particular category of

practitioner requires an appraisal by the medical staff and approval by the governing body. The

appraisal must consider evidence of qualifications and competencies specific to the nature of the

request. It must also consider whether the activity/task/procedure is one that the hospital can

support when it is conducted within the hospital. Privileges cannot be granted for

tasks/procedures/activities that are not conducted within the hospital, regardless of the individual

practitioner’s ability to perform them.

After the medical staff conducts its reappraisal of individual members, the medical staff makes

recommendations to the governing body to continue, revise, discontinue, limit, or revoke some

or all of the practitioner’s privileges, and the governing body takes final appropriate action.

A separate credentials file must be maintained for each medical staff member. The hospital must

ensure that the practitioner and appropriate hospital patient care areas/departments are informed

of the privileges granted to the practitioner, as well as of any revisions or revocations of the

practitioner’s privileges. Furthermore, whenever a practitioner’s privileges are limited, revoked,

or in any way constrained, the hospital must, in accordance with State and/or Federal laws or

regulations, report those constraints to the appropriate State and Federal authorities, registries,

and/or data bases, such as the National Practitioner Data Bank.

Survey Procedures §482.22(a)(1)

• Determine whether the medical staff has a system in place that is used to reappraise each

of its current members and their qualifications at regular intervals, or, if applicable, as

prescribed by State law.

• Determine whether the medical staff by-laws identify the process and criteria to be used

for the periodic appraisal.

• Determine whether the criteria used for reevaluation comply with the requirements of this

section, State law and hospital bylaws, rules, and regulations.

• Determine whether the medical staff has a system to ensure that practitioners seek

approval to expand their privileges for tasks/activities/procedures that go beyond the

specified list of privileges for their category of practitioner.

Determine how the medical staff conducts the periodic appraisals of any current member of the

medical staff who has not provided patient care at the hospital or who has not provided care for

which he/she is privileged to patients at the hospital during the appropriate evaluation time

frames. Is this method in accordance with State law and the hospital’s written criteria for

medical staff membership and for granting privileges?