Apply privileging criteria consistently to meet accreditation standards

The Joint Commission (TJC) standards call for an objective, evidence-based process when deciding whether to grant or deny a privilege(s) or to renew existing ones. Criteria must be consistently evaluated to determine a practitioner’s ability to provide patient care, treatment, and services within the scope of the privilege(s) requested. This includes the need to meet specific volume requirements for special procedure privileging. However, problems arise when volume requirements are set significantly below established industry standards.

CMS does not provide specific language requiring the same criteria for every specialty for a given privilege. Healthcare organizations that have adopted a flexible approach generally do not run into accreditation problems so long as the criteria is consistently applied. The problem is, not all healthcare organizations consistently apply privileging criteria.

CMS (CoP) §482.12(a)(6) requires that every practitioner is individually evaluated for each of their requested privileges. It cannot be assumed that every practitioner can perform every task, activity, or privilege specific to a specialty, nor can it be assumed that the practitioner should be automatically granted the full range of privileges. CMS also requires that the organization have a process to ensure that practitioners granted privileges are working within the scope of those privileges.

Source: News & Analysis