According to DNV, what is required to ensure that clinical privileges are strictly followed?

The requirement for ensuring that clinical privileges are strictly followed, as indicated by DNV accreditation standards, revolves around having a provision in the medical staff bylaws. This is significant because the medical staff bylaws serve as the governing document that outlines the rules, responsibilities, and procedures related to the granting and monitoring of clinical privileges. By embedding the expectations for adherence to clinical privileges within the bylaws, organizations establish a formal framework that supports accountability and compliance among healthcare providers.

This provision not only emphasizes the importance of following established protocols related to clinical privileges but also enforces consistency across the organization. Additionally, having such provisions helps to facilitate clear communication among staff members about their rights and responsibilities, thereby enhancing patient safety and quality of care.

While regular audits, emergency protocols, and random checks may contribute to oversight and monitoring efforts, they do not provide the foundational governance that the medical staff bylaws ensure in the context of accreditation standards. Having a robust bylaws framework is essential for proper credentialing processes and sets the stage for effective management of clinical privileges.