Review of Privileging Best Practices

Review of Privileging Best Practices

Jan 22, 2020

Author: Vicki Searcy; Vice President, Consulting Services; VerityStream


This is a good time to do a review of privileging best practices. These relate to defining and formatting clinical privileges. Take a look and see if you identify any gaps in how your organization handles privileging. If you identify gaps, put a plan in place to address them!


Privileges should be organized by specialty – not by medical staff organization departments.


If privileges are organized by departments, it is likely it will lead to confusion about criteria, qualifications to apply for privileges, etc. An example is a privilege form that lists the specialties within a department of medicine. The form could include internal medicine and its subspecialties, but might also include dermatology, PM&R, and psychiatry. The last three mentioned specialties might be included in the medicine department, but the training required for each of these specialties is different from internal medicine and its subspecialties. Additionally, organizing privilege forms by departments often leads to voluminous forms, and providers who request privileges outside of their specialty.


Privilege criteria should be objective so that it can be consistently and uniformly applied.


Example: Applicant must have performed 6 "        " procedures during the past 12 months. NOT: Applicant must have performed "        " procedures during the recent past that is acceptable to the Credentials Committee.


Criteria should address required education/training as well as clinical activity and outcomes when appropriate.


To determine competency, the first question is: Did you do it? The second question is: How well did you do it?


Privileges within a grouping should have the same criteria and require similar education/training, knowledge, skills and/or technique. A grouping should represent what the majority of the specialty in your organization actually does.


Don’t include “breast procedures” in the general surgery core/primary privileges if, in your organization, there are general surgeons who ONLY perform breast procedures OR there are a number of general surgeons WHO DO NOT perform any breast procedures. Another example would be including spine surgery within the general orthopedic core privileges if there are orthopedic surgeons with advanced spine surgery training and they are the only ones who provide spine surgery services.


Procedures that are included in a group should be listed like a laundry list, rather than in a large paragraph so that applicants as well as the organization can modify the group of privileges to the specific expertise of the applicant.


CMS (Center for Medicare and Medicaid Services) – as well as The Joint Commission requires that core privileges are able to be modified. Traditionally, providers have been instructed to “cross out” privileges they don’t wish to request from a paragraph. That process does not work electronically.


The organization should have well-defined policies and procedures in place that allows providers to request that new procedures/privileges/technology be added to privilege delineations.


The old way was to allow a provider to write in a request for something new on his/her privilege form. Privileges should not be allowed to be requested until the organization determines that the privilege in question should be added to the scope of services for the organization and have developed criteria for what providers will be eligible to apply for the new privilege.


Privileges should be defined in sufficient detail to allow monitoring of the exercise of privileges to assure that providers do not exceed the scope of privileges granted.


Again, monitoring to assure that providers stay within the scope of what they have been granted is a CMS and accreditation requirement. Don’t list: Stomach procedures (not enough details).


A plan for confirmation of competency of the full scope of privileges granted (i.e., FPPE – focused professional practice evaluation) should be implemented as soon as new privileges are granted to a provider.


This means that the plan should be formulated as part of the granting of privileges. It also means that the organization can’t determine that “the first six cases” will be proctored – as the first six cases probably will not cover the full scope of privileges granted.


Multi-facility or enterprise privilege delineations should be used when there are several hospitals in an immediate geographic area that report to the same board.


This will reduce duplication of effort for physicians and assure that the same criteria are used for privileges. This should eliminate the possibility that a provider could be granted a privilege by one hospital and denied the same privilege by another hospital, both hospitals reporting to the same board.


Have a plan for regular review and update of all privilege delineations in order to keep privilege forms current and relevant.


Some privileges will require annual review – others that do not change much might be on a two-year schedule.


Whenever possible, incorporate provision of telehealth services on the applicable specialty privilege forms instead of creating separate privilege forms for telehealth services.


This will eliminate the proliferation of privilege forms for telehealth services and will make more sense to your providers.


Thanks for reading! I hope that 2020 is off to a great start for you and your organization.

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