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Heads up! The Joint Commission licensed practitioner evaluation timeframe has changed. The previous timeframe was every two years. Effective February 19, 2023, it will be every three years.

This change applies to organizations TJC accredits under the Hospital standards as well as those it accredits under the Behavioral Health Care & Human Services standards. So, let’s review the details and some of the implications.


What’s the rationale for this change in timeframe for evaluating licensed practitioners? The primary reason is this new three-year reappointment cycle aligns with the recredentialing schedule of most health plans. Indeed, the National Association of Medical Staff Services endorsed the change.

In addition, the expanded timeframe will ease paperwork and documentation requirements. That’s always welcome!

Joint Commission Licensed Practitioner Evaluation: Hospital Standards

In the Hospital manual, there will be changes to two standards in the Medical Staff chapter.

MS.06.01.07 EP 9 will state: “Privileges are granted for a period not to exceed three years or for the period required by law and regulation if shorter.”

MS.07.01.01 EP 3 will state: “The organized medical staff uses the criteria in appointing members to the medical staff and appointment does not exceed three years or the period required by law and regulation if shorter.”

Some important points to keep in mind: First, TJC is not requiring this change. If you wish to keep your evaluation and privileging cycle as is, you may do so. Second, if any applicable law or regulation has a shorter timeframe, TJC requires you to follow that more stringent requirement.

Last, if you decide to change to the three-year cycle, you’ll need to change your medical staff bylaws and medical staff rules and regulations. You’ll also need to change any related procedures such as the timeframes for Ongoing Focused Professional Practice Evaluation and Focused Professional Practice Evaluation.

On a related note, be aware TJC is eliminating the term “licensed independent practitioner” in the Hospital standards. This will be effective February 2023 and will make the terminology consistent with the CMS Conditions of Participation.

TJC is also updating definitions for other terms related to individuals working in hospitals. These include Staff, Clinical Staff, Physician, and Practitioner (replacing with Licensed Practitioner.) Last, there is one new definition and that’s for Provider.

Joint Commission Licensed Practitioner Evaluation: Behavioral Health Care Standards

In the Behavioral Health Care & Human Services manual, there will be a change to one standard in the Human Resources Management chapter:

HRM.01.02.01 EP 7: “The organization queries the National Practitioner Data Bank (NPDB) for information on physicians and dentists at the time of hire, and at least every three years thereafter or within the period required by law and regulation if shorter.”

It’s important to note that the BH standards differ from the Hospital standards in terms of licensed practitioners and evaluating their performance. There is no Medical Staff chapter in the BH standards.

Several years ago, TJC revised the BH standards to remove the privileging language and requirements. Instead, the BH standards allow for licensed practitioners to function under either a job description or a contract.

You can evaluate them via performance evaluations and the clinical competency assessment process. (For a bit of history on the BH standards vs. Hospital standards as they relate to privileging, see our post from back in 2014: Changes to Behavioral Health Human Resources Chapter)

Again, remember TJC is not requiring you to change your evaluation timeframe for licensed practitioners. You can stick to your current timeframes.

For example, if you currently evaluate all clinical staff annually (including licensed practitioners) you can stick with that.  At the same time, you can take advantage of the new three-year timeframe for querying the National Practitioner Data Bank.

Barrins & Associates Consultation

We’ll be sure to update our clients on this change when we do our 2023 Mock Surveys and Customized Survey Preparation.

As always, we’re prepared to support your ongoing survey readiness and best practices for regulatory compliance.