Privileges Flashcards
The Joint Commission
Privileges
The hospital must have a clearly documented procedure for the processing of requests for initial granting, renewal, or revision of privileges. this process must be approved by the medical staff.
The privilege delineation system is tailored to the hospital (hospital specific) and must take into account the hospital’s technical and staff capability or supporting the procedures.
Standards require all physicians or other licensed practitioner (defined as individuals who are permitted by law and the hospital to provide care, treatment, or services without direction or supervision) to be privileged through the medical staff process.
The organization can only grant privileges when the facility has the necessary resources to support the privilege or will have the resources available in a specified time period.
An objective, evidenced-based process must be used to grant or deny privileges and when renewing existing privileges.
The hospital must establish the criteria used to determine a practitioner’s ability to provide patient care, treatment, and services within the scope of the requested privileges.
These criteria must be based on the medical staff’s recommendations and must be approved by the governing body.
Criteria must include consistent evaluation of -
- PSV for current licensure or certification
- PSV relevant training
- Evidence of physical ability to perform the requested privilege
- if available, data from professional practice review from other organization where the applicant currently has privileges
- Recommendations from peers/faculty
On renewal, review of the applicant’s performance within the hospital is also acquired.
NCQA Health Plan
Privileges
Verification of clinical privileges is not required. On initial credentialing, practitioners attest to loss of limitation of privileges or disciplinary actions since their initial licensure. On recredentialing, practitioners attest to loss of limitation of privileges or disciplinary actions since the last credentialing cycle.
ACHC
Privileges
Standards are a direct quote from 482.12(a), 482.12(a)(1) through 482.12(a)(6) and 482.51(a)(4)
Applicants must provide clinical activity documentation and competency to be used is consideration of privileges requested. This can come from residency, fellowship or from facilities where the applicant has been practicing.
They must also provide procedure logs with outcomes to support privilege requests for procedures not attested to in postgraduate references.
DNV NIAHO for Hospitals
Privileges
MS 11
Interpretive Guidelines state that all patients shall be under the care of a member of the medical staff or under the care of a practitioner who is directly under the supervision of a member of the medical staff.
All patient care is provided by or in accordance with the orders of a practitioner who meets the medical staff criteria and procedures for the privileges granted, who has been granted privileges in accordance with those criteria by the governing body, and who is working within the scope of those granted privileges.
MS 2 SR 1
The medical staff bylaws shall describe the organization of the medical staff and include a statement of the duties and privileges of each category of medical staff to ensure that acceptable standards are met for providing patient care for all diagnostic, medical, surgical, and rehabilitative services.
MS 6 SR 6
The medical staff bylaws shall include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to those individuals that request privileges (initial, renewal, and revision/amendment)
MS 6 SR 6a(1)
In addition to other privileging criteria defined in the medical staff bylaws or policy/procedure/delineation, the hospital shall determine and document any identified needs for further training or proctoring and/or modification/amendment to initial privileges granted.
SR 6b(1) In addition to other privileging criteria established in the medical staff bylaws or policy/procedure/delineation, as part of the process for determining whether existing clinical privileges will be renewed or require modification/amendment, a review of individual performance data (see MS 8) shall be performed and documented in order to identify variation from defined criteria/benchmarks established by the medical staff.
SR 7
All individuals who are permitted by the organization and by law to provider patient care services independently in the organization shall have delineated clinical privileges.
SR 7 There shall be a provision in the medical staff bylaws for a mechanism to ensure that all individuals with clinical privileges provide services only within the scope of privileges granted.
SR 10 appointment or reappointments to the medical staff and the granting, renewal, or revision/amendment of clinical privileges shall be made for a period defined by state law or if permitted by state law, not not exceed three years.
MS 9 SR 1 The organization shall have a process to validate that continuing education and/or training required by the organization is met prior to the granting or renewal of those affected clinical privileges.
SS 3 SR 1 The organization shall have delineated surgical privileges established by the organization’s department of surgery and medical staff and approved by the governing for each practitioner that performs surgical tasks (see MS 6). This includes practitioners such as MD/DO, dentists, oral surgeons, podiatrist, RN first assistants, nurse practitioners, surgical physicians assistants, surgical technicians, etc.
URAC Health Plan
Privileges
Credentialing application must include information on the practitioner’s hospital affiliations or privileges, if applicable. Verification is not required.
AAAHC for Ambulatory Health Care
Privileges
Privileging is a three phase process that includes -
1. determination of the clinical procedures and treatments to be offered to patients,
2. determination of qualifications (training and experience) required to obtain each privilege
3. establishment of a process for evaluating the applicants qualifications using appropriate criteria, and approving or modifying privileges in a non-arbitrary manner.
Privileges are granted based upon a written request by the applicant, the qualifications for the services provided by the organization and peer recommendations.
Privileges are granted to the applicant for a specified period of time. The health care professional must be legally and professionally qualified for the privileges granted.
The organization has its own independent process of credentialing and privileging that includes review and approval by the governing body.
Appointment or privileges may not be approved solely on the basis that another organization, such as a hospital, took such action, although this information can be used in consideration of the application.
In a solo medical or dental practice, the provider’s credentials file and granting of privileges must be reviewed by an outside physician or dentist (as applicable) at least every three years (or as required by state law organization) with documentation provided to the organization.
Medicare Hosp COPS and Interp Guidelines
Privileges
Interpretive Guidelines 482.22(c)(4)
The medical staff bylaws must describe the qualifications to be met by a candidate for medical staff membership/privileges in order for the medical staff to recommend the candidate be approved by the governing body.
the process articulated i the medical staff bylaws must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners that considers:
- individual character
- individual competence
- individual training
- individual experience
and
- individual judgement
482.22(c)(6)
The bylaws must include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying criteria to individuals requesting privileges. for distant site physicians and practitioners requesting privileges to furnish telemedicine services under an agreement with the hospital, the criteria for determining privileges and the procedure for applying the criteria are also subject to the requirements in 482.12(a)(8) and (a)(9) and 482.22(a)(3) and (a)(4).
All patient care is provided by or in accordance with the orders of a practitioner who meets the medical staff criteria and procedures for the privileges granted, who has been granted privileges in accordance with those criteria by the governing body, and who is working within the scope of those granted privileges.
Privileges are granted by the hospital’s governing body to individual practitioners based on the medical staff’s review of that individual practitioner’s qualifications and the medical staff’s recommendations for that individual practitioner to the governing body.
However, in the case of telemedicine physicians and practitioners providing telemedicine services under an agreement, the governing body has the option of having the medical staff rely upon the credentialing and privileging decisions of the distant-site hospital or telemedicine entity with which the hospital has entered into an agreement. When the governing body has exercised this option, the medical staff’s bylaws must include a provision allowing the medical staff to rely upon the credentialing and privileging decisions of a distant-site hospital to employ a credentialing and privileging process that conforms to the provisions of 482.12(a)(8) and (a)(9) and 482.22(a)(3) and (a)(4).
482.12(a)(2)
Only the hospital’s governing body has the authority to grant a practitioner privileges to provide care in the hospital.
Interpretive Guidelines 482.12(a)(5)
all hospital patients must be under the care of a practitioner who meets the criteria of 42 CFR 482.12(c)(1) (see below) and who has been granted medical staff privileges, or under the care of a practitioner who is directly under the supervision of a member of the medical staff. All patient care is provided by or in accordance with the orders of a practitioner who has been granted privileges in accordance with the criteria established by the governing body, and who is working within the scope of those granted privileges.
482.22(c)(2)
The bylaws must include a statement of the duties and privileges of each category of medical staff (e.g., active, courtesy, etc.) The medical staff must state the duties and scope of the medical staff privileges each category of practitioner may be granted.
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 perform competently and that the hospital can support.
The individual practitioner’s ability to perform each task/activity/privilege must be individually assessed.
See also “practitioners credentialed and privileged section above.
