How to Stay In Compliance With Centralized Privilege Documentation

Healthcare organizations that are host to various physician specialties and advanced practice professionals (APPs) require a multi-faceted plan for privilege documentation upkeep. After all, delineating clinical privileges to individual practitioners is only a part of the process. Privilege maintenance that uses a centralized process aids in compliance for the broader privilege-related responsibilities of the organized medical staff and governing body. 

We know that privileges must be hospital- or site-specific, according to the CMS, The Joint Commission, and other regulatory and accreditation bodies. MSPs ask the following of individual providers: “Request only those privileges for which by education, training, current experience, and demonstrated performance you are qualified to perform and want to exercise at [name of specific facility]. 

But a true test for ensuring compliance in privileging occurs at the organizational level. In other words, the accreditors and regulators ask hospitals and healthcare systems, “Can you demonstrate that every core or special privilege listed on a privilege delineation form for a given facility is supported by adequate levels of resources, staff, and equipment, in order to ensure safety and quality?” 

Key benefits of centralizing privilege documentation

Centralizing privileging documentation fosters the ability to share data across participating hospitals, outpatient, or other type facilities under the umbrella of the larger organization. Even when the Medicare Provider Numbers (aka CMS Certification Number or CCN) differ among the sites, organizations that centralize privilege information benefit through cost and resource savings, and ultimately better remain in compliance due to elimination of aberrations. 

Centralized privileging done well does not render a less-secure environment for data or add burden to data analysis. Rather, it enables sharing of common research and analysis reporting across selected or all facilities. While providing centralization, each entity maintains a clear view of their own medical staff’s privileging data.

Organizational privilege management pitfalls 

Several areas of privileging compliance at the organizational level commonly stretch the resources of the CVO or medical staff services function, and thus can jeopardize compliance and healthcare quality and safety. Here’s a look at how centralization—but not necessarily standardization in privileging—can aid in documentation upkeep and compliance. A centralized privilege management software, and the automation it provides, can help compensate when other resources are lacking.

Rapid organizational expansion

The last decade has seen large healthcare systems take steps to employ more practitioners to achieve better alignment of administrations and medical staffs, reduce costly care variations, and remain financially viable in a competitive landscape. MSPs have felt the surge, but not only during initial appointment. A multi-facility’s or multi-system’s organizational structure is also put to the test during the reappointment process, when MSPs handle hundreds or thousands of applications.

A centralized credentialing and privileging framework connects hospitals and clinics within the same system and checks the box on the ultimate, specific function any governing board delegates to the organized medical staff: Responsibility for monitoring and improving the quality of care that depends primarily on the performance of individuals granted privileges.

Centralized, or corporate privileging, allows MSPs and medical staffs to specify all or a subset of privileges to apply across the entire organization or by facility or entity. In addition, enterprise-scale privilege publishing enables rapid rollout and updates to privileges across enterprises. This feature allows organizations to draft and review privileges before publishing to the organization.

The advent of new technology

It requires continuous research to stay current with industry developments and technological advancements across specialties and practitioner types (i.e., MD/DO, APP, DMD, etc.). Cutting-edge procedures and services propel healthcare into exciting, new, life-saving areas. However, MSPs understand the disruption of a practitioner who has attended a device manufacturer’s course and comes back to the hospital immediately requesting the privilege. Sound privileging policy in a multi-entity system should be about the “whole” and not the individual. 

A centralized system can quickly identify whether privilege criteria has already been developed and/or is in use elsewhere in the system. This not only saves time and resources, but potentially saves lives. In any centralized privileging resource, look for a comprehensive privilege library with criteria for cores and special procedures within templates that can be easily customized across hundreds of specialties. 

Cross-specialty privileges

So-called “turf battles” occur when a procedure or service considered to be less invasive than a traditional surgery or other medical treatment opens doors for new specialties to offer it. The advent of many endovascular procedures was just one example, and today we’re seeing a prevalence of states granting APPs expanded authority to treat. From a privileging compliance perspective, any practitioner type conducting the same procedure or service must be evaluated in a like manner.   

In addition, hospital systems increasingly own outpatient and other walk-in clinics. And the trend is expected to continue as outpatient revenue has reached about 95% of inpatient revenue for some systems. Multi-entity or multisystem healthcare organizations that do not employ a centralized privileging system risk maintaining control over what privileges are offered to which practitioners at the various facilities managed or owned by the healthcare organization.

Enterprise-wide data accuracy is essential when managing privilege documentation across a system. Avoid unnecessary risks such as negligent credentialing and non-compliance by centralizing both organizational and individual practitioner privilege data.

Learn how to benefit from centralization today by visiting symplr today for a demonstration.