That said, the ability to meet standards and the appropriate format for privileges continues to be an ongoing topic within the Medical Staff Office and Physician Leadership. Though TJC does not offer any specific product endorsement, the TJC website1 provides guidance for the privileging process and the three things your privileging process must contain to comply:
"The core/bundled privilege must clearly and accurately be defined to reflect specific activities/procedures/privileges to be included in the core terminology as well as those activities/procedures/privileges that are outside the core.
The core/bundled privilege must be clearly and accurately defined to reflect only activities/procedures/privileges actually performed at the organization.
The core/bundled privilege must be clearly defined to reflect activities the organization believes a majority of applicants should be able to perform."
Bottom line, be sure your privileging system and process reflects exactly what your provider is doing and how you’re measuring the provider's competency and performance. This includes delineating threshold criteria for special privileges, CPT/ICD-9/ ICD-10 procedure tracking and trending with specific quality indicators.
It’s also important to consider how your organization tracks the privileges providers are granted. Since providers can opt out of specific core privileges, it’s no longer valid to simply look at a provider's specialty when scheduling procedures. Utilizing a technology solution to perform these tasks is key to your organizations ability demonstrate compliance in the following areas:
Ability for a provider to specifically select the procedures they are qualified to perform
Access for staff to quickly validate privileges
Real-time updates to system/staff in cases of privilege suspensions or revocations
Administrative access/ reporting to determine if privileges were not selected by a provider or if not available at the time the provider requested privileges. In some cases, a procedure/privilege may be new to your organization and was not available when the provider was originally granted privileges
Confirming your organization meets privileging standards is a requirement. Arming your organization with automation and tools to be successful with creating, granting, and tracking privileges is a necessity to deliver quality healthcare.