Clinical privileges are specific services and procedures that a healthcare practitioner is authorized to provide or perform within a facility. The delineation of clinical privileges is a process that matches a practitioner’s clinical training and abilities with the services they perform and is one of the most important ways hospitals ensure patient safety and high-quality care.
Understanding privileging
Ensuring accurate provider credentialing and privileging is more critical than ever. Privileging grants healthcare professionals’ specific services or procedures they can perform within a facility based on their experience, credentials, and training.
The purpose of delineating clinical privileges is to manage what services a practitioner is qualified and authorized to deliver to a patient for that specific facility.
The Joint Commission requires privileging delineation to be an objective, evidence-based process. Privileging forms and the respective criteria must meet regulatory requirements and reflect industry best practices and expert research.
Here are five guidelines for developing privileging content for healthcare practitioners:
1. Know your regulations and standards
Understand your accrediting body’s standards as well as CMS and state regulations when developing privileges. For example, The Joint Commission Medical Staff Standards state that the privilege must clearly define the specific activities and procedures to be performed at the organization.
It’s also important to know your bylaws, policies, and procedures as they are the best defense for compliance, quality, and ultimately, patient safety.
Regulatory bodies require that privileges be individualized, meaning that any practitioner can opt in or out of a particular privilege with few exceptions. Additionally, it’s important to ask, “Does my facility have the staff, resources, and equipment to include the privilege?”
Researching industry standards ensures that your privileging content reflects accreditors’ changes and helps you continuously monitor practitioners who have been granted privileges.
2. Research multiple recognized sources
Remember that the privileging content you are researching will ultimately be presented to department heads and others for review. As a result, you’ll want to conduct thorough research. For its customers, symplr uses up to 40 resources when researching content for privileges in a specialty.
Whether or not you use core or cluster privileges, the Accreditation Council for Graduate Medical Education (ACGME) and American Osteopathic Association (AOA) provide the training and education necessary for any specialty that may be considered for the core privilege. When developing the privilege, it may seem like you’re building a laundry list, but documenting each procedure or service will help develop the core/cluster.
Even if you outsource the information-gathering steps when creating or updating privileges, relying on one source is not enough. Use multiple, objective, evidenced-based resources to create a solid defense that you have done everything you can to appropriately set the bar for provider competence.
Conducting thorough research and tapping into multiple trusted, expert resources when data-gathering for core or special privilege reflects an effort to weigh different thresholds for the education, training, and volume criteria decided upon for your facility. It can also help avoid malpractice lawsuits, loss of accreditation, investigations, and negative media attention.
3. Seek in-house clinical input and approval
Accrediting bodies require clinical expert approval. That’s why it’s important to tap in-house expertise for developing specialty privileges, such as the department chair and one or two additional practitioners. By doing so, your practitioners will feel invested in the qualifications and criteria, and your timeline for getting the privilege drafted and approved will remain on track.
Know that privileges can apply to multiple specialties. On occasion, “turf issues” arise where differing specialties disagree on who should provide the care or service reflected in the privilege.
A best practice is to create a multispecialty task force with representation from each specialty. Allow that task force to report back to the Credentials Committee for a final determination.
4. Establish a policy for review of new technologies
In the digital age, surgical procedures, medical devices, and treatments evolve rapidly and reach the market quickly. Often, a new or expanded technology may cost a lot but with it comes higher quality of care and increased revenue streams.
Creating or revising privileges when an organization is presented with a new technology is difficult for medical staff credentialing teams who are under pressure to quickly determine whether to adopt it and decide what the new privilege will look like.
Due diligence at the organizational level must be conducted to determine if the new technology will be offered by the facility.
If new privileges are required, questions must be answered, such as:
- Does the procedure, treatment, or service represent a direct extension of existing clinical skills or judgment?
- Does the procedure carry a risk greater than existing conventional therapy?
- What specialties will be eligible for the privilege?
5. Consistently review privilege forms
Often, high-profile or high-reimbursement specialties have privilege forms regularly reviewed and updated, while other forms go unchecked. Setting a schedule to review privileging forms is critical.
Ideally, set a schedule to review forms every one to two years, working in collaboration with each department to decide if changes need to be made.
Whether you “buy” or “build” your organization’s privileging templates, prepare to conduct the due diligence that sets your organization up for compliant privileging, quality, peer review, and patient safety.
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