Top Ten Privileging Mistakes

Top Ten Privileging Mistakes

Sep 11, 2019

Author: Jackie Jones, CPMSM; Senior Consultant; VerityStream


Having been born and raised in Indiana myself I was a huge fan of David Letterman, a comedian from Indianapolis, who started out on late night television on “The Johnny Carson Show”, eventually ending up with his own show on late night television which ran for over 20 years!! My favorite segment of course was always his “Top Ten” list which ran the gamut from “Homer Simpson for President” to “Top Ten Rejected Disney Movies” presented by the likes of Tim Conway to President Obama. Sometimes mundane, sometimes taken directly from the day’s headlines, they ranged from the satirical to the ridiculous but always, always funny!!


SO, when I was asked to write an article about the Top Ten items I find when consulting with clients building their privileges, I immediately thought back to David Letterman’s Top Ten lists. Here are the top ten mistakes that I see repeatedly when working with clients on building privilege delineations.


#10 Superfluous Information


Too many facilities want to add large amounts of what I call superfluous information in their delineations of privileges (DOPs), whole sections repeated either from the hospital Medical Staff Bylaws and/or Rules and Regulations. This is information better suited in a hospital or departmental policy which can be referred to or linked. Physicians are often pressed for administrative time do not want to be required to (nor will they) read voluminous privilege forms. I recommend keeping the required qualifications listed in a bulleted format which is clear, concise language, leaving little room for interpretation – and much more likely to be reviewed by the applicant.


#9 Dept of Medicine / Surgery Privileges


Instead of separating out subspecialty privileges for medicine or surgical specialties, organization persist in listing all of their Internal Medicine or Surgery subspecialties on one lengthy delineation, requiring the applicant (as well as reviewers) to scan many pages to find the appropriate privileges. This often leads to applicants requesting privileges they are not qualified to request, as they don’t meet the requisite criteria. I recommend separating the subspecialty privileges onto their own delineations with additional special privilege clusters for those privileges requiring additional fellowship or manufacturer’s recommend training.


#8 Combined Advanced Practice Registered Nurse / Physician Assistant privileges


Along the same lines as number 9, instead of putting the Advanced Practice Registered Nurse and Physician Assistant privileges together on the same delineation recommend keep them separate on their own delineations. Although similar in scope of services, they have different education/training and certification requirements and may have different supervising/collaborating physician agreements.


#7 “Write-In” Privileges


Despite numerous regulatory reasons not to allow “write-in” or “add on” privileges, clients tell me they must be able to add blank lines so providers can add privileges to their privilege requests. There are multiple reasons for why there is no option for write-in privileges in VerityStream’s Privileging Solution. An entire Consulting Connection blog post was dedicated to this topic but for brevity sake it’s sufficient to say 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.”


#6 Different Criteria for the Same Privileges


Many times, when working with clients it is noted the criteria for a privilege or procedure that may be performed by multiple specialties, such as Robotic surgery, have different initial or reappointment requirements that need to be met for competency. VerityStream’s privileges are separated into Primary or Core Privileges then additional special privilege clusters can be added which may require a fellowship or manufacturer’s recommendation for training, i.e. for Robotic Surgery or Transcatheter aortic valve replacement (TAVR). It is recommended that any special privileges or procedures which may be applicable to multiple specialties, such as moderate sedation or robotic surgery, be built in a “Special Privileges” template so it may be imported to any specialty delineation of privileges ensuring the criteria for the privileges remain the same regardless of the specialty.


#5 Using “Levels” to Define Privileges


Some organizations define levels of privileges and the scope of privileges with a specialty – but do not define what privileges/procedures are in which level of privileges. For example – here are definitions used by a health system:


  • Level 1 Privileges: This class includes privileges for uncomplicated, basic procedures and clinical application of cognitive skills. Providers applying for privileges in this class will be graduates of approved medical/osteopathic/podiatric medicine schools. Providers will be properly licensed, and have demonstrated skills in appropriate general medicine practice.
  • Level 2 Privileges: Privileges in this class include Level One privileges, as well as privileges for those procedures and cognitive skills involving more serious medical problems and which normally are taught in residency programs. This may include procedures and clinical application of cognitive skills appropriate to the care in perinatal, and behavioral health services or advanced pediatric, cardiology, gynecological or adult medicine. Providers requesting privileges in this class will have met the criteria in Level One, and will also have either completed training in a residency program and/or will be Board Certified, or will have documented experience, demonstrated abilities and current competence for the requested specific privileges.

If your organization wants to use levels, you definitely must determine which privileges/procedures are assigned to each level – and the criteria to be met for the specific level of privileges.


We believe that it is much easier to just define the scope of privileges in a specialty and determine the criteria – adding a classification of levels makes the privileging process more complicated.


#4 Paragraph Core Privileges Not Allowing Providers to “Opt Out” of Privileges


Nearly 15 years since the CMS released its letter for “Requirements for Hospital Medical Staff Privileging” on November 12, 2004 numerous hospitals still list their core privileges in a paragraph format which does not allow a provider to be able to “opt out” of privileges they may not require or be currently competent to perform. The CMS letter states:


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


#3 Privileges That Are Outdated


The privilege portion of the credentialing and privileging process is vitally important not only from a regulatory standpoint but also to ensure the organization has the most qualified providers to provide safe quality care to their patients. But often, when there are multiple high priority tasks, review of their delineation of privileges falls to the lower echelon of those tasks resulting in outdated privileges, many with privileges no longer performed at the organization. It is recommended that a schedule be set up to review the organization’s DOPs every couple of years to update procedures/technologies and for the scope of services provided by the facility.


#2 No Reappointment Criteria for Requesting Privileges


Almost all organizations now have set criteria for initial provider applicants to request privileges; i.e. education/training; state licensure; certification; peer references, etc. but many organizations do not set requirements for requesting privileges at time of reappointment. Again, referring back to the CMS letter which states:


“The Medical Staff must actually examine each individual practitioner’s qualifications and demonstrated competencies to perform each task/activity/privilege he/she has requested from the applicable scope of privileges for their category of practitioner. 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.”


#1 “Perform History and Physical Examination” Privileges


The number one issue found when building privilege is when an organization decides to omit privileges to “Perform History and Physical Examinations” on their provider delineations. Many argue that it’s not required as it is defined in their organization Medical Staff Bylaws (for example: “members of the active medical staff may admit patients and perform the history and physical”). But the Medical Staff Bylaws do not grant privileges to a provider. In the CMS letter: Hospitals – Revised Interpretive Guidelines for Hospital Conditions of Participation: Requirements for History and Physical Examinations, dated February 8, 2008, it states:


“The Medical Staff bylaws must include a requirement that when a medical history and physical examination has been completed within 30 days before admission or registration, an updated medical record entry must be completed and documented in the patient's medical record within 24 hours after admission or registration. The examination must be conducted by a licensed practitioner who is credentialed and privileged by the hospital’s medical staff to perform an H&P.”

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