When Was the Last Time You Really Reviewed Your Hospital Privileges?

When Was the Last Time You Really Reviewed Your Hospital Privileges?

Jan 7, 2016
  • Author:
    Jackie Jones, CPMSM
    Senior Consultant
    Jackie works with VerityStream clients on development/conversion of facilities' privileges and has over 25 years of experience as a Medical Staff Services Professional. Prior to joining VerityStream in August 2015, Jackie was the Director of Medical Staff Services at Kaiser Foundation Hospital in San Diego for nearly 18 years.

Since joining VerityStream as a consultant six months ago I have had the opportunity to review a large number of delineation of privileges (DOPs) for hospitals and other organizations and have found everything from a two page Urology delineation (which didn’t include some privileges that are fundamental to the practice of Urology) to a forty-nine page Radiology privilege delineation. As I work with Medical Staff Services Directors and begin reviewing their organization’s privileges, many are surprised (and sometimes embarrassed) when they read them to find criteria for initial or reappointment they were unaware of, criteria that is no longer required, extensive Focused Professional Practice Evaluation (FPPE) or reappointment requirements (which is almost impossible to administer), or services not even offered at their facility.

Newly hired Medical Staff Services Professionals (MSPs) are often so overwhelmed by getting to know the medical staff and learning the ropes at their new facility that reviewing the DOPs, although very important, is understandably pushed aside for more pressing priorities. So when a privileging issue arises or they are called by the hospital attorney to produce a DOP for a possible deposition they are stunned to find out that the physician may not have been properly privileged.

When reviewing your DOPs are they organized in such a way to be easily understood or are they disjointed with criteria/qualifications in multiple places?

Are the qualifications still relevant? Are there specific criteria required by your state licensing and/or scope of practice laws to perform a certain number of procedures? One hospital DOPs had stipulations for initial applicants for physicians and providers who were trained prior to 1990. If that’s still applicable, what are you also requiring to demonstrate current clinical competence?

Do your DOPs contain extra lengthy documentation?

Would this documentation be better suited in a policy or separate document, such as a Procedural (Moderate/Deep) Sedation organization policy/procedure or an Allied Health Scope of Practice from the state licensing regulations? Many facilities have added this type of extraneous information to their DOPs because they believe they needed to be included at time of reappointment. These documents could still be sent to the physician/provider as a separate document as applicable.

Do you have specific reappointment criteria?

Is there a general overarching requirement for a specific number of cases representative of the entire scope and complexity of the physician/provider’s privileges or are they required to perform a specific number of cases for each procedure requested? This can be difficult for the physician/provider to meet for procedures rarely performed and unmanageable for the Medical Staff Office to track. That’s why it is important to group or cluster procedures that require similar education/knowledge and skills.  Some of them will be performed regularly and others not often at all.  Of course, if a procedure does require unique knowledge and skills, it should be a separately delineated privilege with its own criteria.

Is your FPPE program “overkill”?

…do your DOPs require the newly hired physician to perform as many procedures as they would during Fellowship training or just enough to prove they have the necessary skills, can function independently, are oriented to your facility and productively working with your nursing staff to exercise the clinical privileges they have been granted?

Do your primary privileges include every possible procedure/privilege taught in a Residency or Fellowship program?

Can the privileges be grouped under systems or types of procedures? Can the physician/provider opt out of any core or primary privileges? Do you still allow physicians and providers to write in privileges that are not on the delineation? Is the ability to admit to the hospital and perform a history and physical only in your bylaws or is it also included on your DOPs? There are a number of facilities that still have a paragraph of core privileges, unable to be modified by the physician/provider. This is particularly troublesome if your organization is moving to electronic processing – because when that occurs, the provider can’t “cross out” a privilege on a form that he/she doesn’t want to request.

Are the criteria denoted and listed separately for special or advanced privileges, which require additional training and/or specific procedural requirements?

Are the criteria current and up to date with the technology? Is there reappointment criteria listed but not being implemented? Much of the time when hospitals take a “hit” during a survey it’s for not following their own bylaws, policies or procedures and privileging standards.

The following is an excerpt from a letter from the Center for Medicare and Medicaid Services (CMS) dated November 2004:

“Specific privileges for each category must clearly and completely list the specific privileges or limitations for that category of provider. The specific privileges must reflect activities that the majority of providers in that category can do and that the hospital can support. It cannot be assumed that a provider can perform every task/activity/privilege listed/specified for the applicable category of provider. The individual provider’s ability to perform each task/activity/privilege must be assessed and not assumed. If the provider is not competent to perform one or more tasks/activities/privileges, the list of privileges is modified for that provider. Hospitals must assure that providers are competent to perform all granted privileges.”

In today’s litigious society and with the number of negligent credentialing lawsuits on the rise, it is extremely important that your organization’s DOPs be current, match your medical staff bylaws, rules and regulations, credentialing and privileging polices as well as truly reflect what your physicians and providers are able to do within your facility. This must occur in order to meet the requirements set by Centers for Medicare & Medicaid Services (CMS) and more importantly, is critical to assure that providers are appropriately privileged by your organization in order to assure patient safety.