Write-In Privileges:  Why Not?

Write-In Privileges: Why Not?

Mar 20, 2018
  • 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.

Scenario: You’re sitting at your desk and your phone rings. When you answer it, it’s one of your physicians who just finished a week-long training course for a new procedure or technology and he or she wants to add it to their privileges next week. Sound familiar?

When working with hospitals across the nation, I’m continually asked why the Morrisey Privileging Solution (MPS) does not allow for “write-in” privileges. For those of you who need some clarification, “write-in” privileges is a form where there are one or more blank lines where a provider is invited to write-in anything that he or she wants to request that is not currently on the form. Whether you use MPS or have developed your own privileges, write-in privileges are discouraged.

There are multiple reasons for why there are no write-in privileges within MPS. First - and foremost, the Centers for Medicare & Medicaid Services (CMS) Requirements for Hospital Medical Staff Privileging in a letter dated November 12, 2004, states:

“Any procedure/task/activity/privilege requested by and recommended for a practitioner beyond the specified list of privileges for their particular category of practitioner would require evidence of additional qualifications and competencies, and be an activity/task/ procedure that the hospital can support and is conducted within the hospital. Privileges cannot be granted for tasks/ procedures/ activities not conducted within the hospital despite the practitioner’s ability to perform the requested tasks/ procedures/ activities. The hospital’s Governing Body and Medical Staff must assure that every individual practitioner who provides a medical level of care and/or who conducts surgical procedures in the hospital is competent to perform all granted privileges.”

If write-in privileges are permitted, that is a direct “flag” to surveyors of regulatory/accreditation organizations of the potential that privileges were granted outside of the scope of the specialty – and the core privileges for that specialty – without evidence of additional qualifications and competency.

Joint Commission Resources published a book, Assessing Hospital Staff Competence, 2nd Edition (2007) that explains requirements related to the privileging process:

Privileging is the process by which a health care organization, after reviewing an individual practitioner’s credentials and performance, authorizes the practitioner to perform a specific scope of patient care services within the organization. Privileging involves the following four distinct activities:

  • Determining which clinical procedures or treatments the organization will offer and support;
  • Determining what training, skills, behaviors, and experience are required for authorization to perform each clinical procedure or treatment;
  • Determining whether applicants for privileges meet these requirements and officially granting or denying the requested privileges;
  • Monitoring the individuals who are granted privileges to ensure their continued competence and practice within the scope of privileges granted.

The Joint Commission Accreditation requirements within the Medical Staff Chapter state:

MS 06.01.01 Prior to granting a privilege, the resources necessary to support the requested privilege are determined to be currently available, or available within a specified time frame.

In addition, there are two Elements of Performance (EPs) which further explain the requirement for this standard:

  1. 1. There is a process to determine whether sufficient space, equipment, staffing, and financial resources are in place or available within a specified time frame to support each requested privilege.
  2. 2. The hospital consistently determines the resources needed for each requested privilege.

Essential information needs to be gathered, such as hospital resources; medical equipment, i.e. robotic equipment; and types of support staff for follow-on care, which are necessary to support the requested privilege, prior to granting, renewing, or revising clinical privileges. Is the facility licensed to perform the additional procedure? Has the facility established privileging criteria for the new technology? Has the biomedical equipment manager reviewed approved any required medical equipment? Has the governing body approved the additional privileges? Who will complete the required Focused Professional Practice Evaluation (FPPE) once granted? How will the facility monitor competency for the new privileges?

It’s not only imperative the physician requesting the additional privilege be primary source verified to determine if he or she has the requisite license, education/training, experience, and current competency to perform the privilege but that there is evidence to support that the hospital is able to support the requested privilege, and that there are processes in place to monitor competency after the privilege is granted.

Every facility should have a policy in place to address requests for adding new procedures/technology at their organization.