Be site-specific on privilege forms

According to CMS, privileges are not to be granted for tasks/procedures/activities that are not conducted within the hospital—regardless of the practitioner’s ability to perform.  Therefore, when developing your core privileging system, list only those services and procedures that your hospital currently provides; e.g., an activity/task/procedure that the hospital can support and is conducted within the hospital. Do not include services and procedures that your hospital might offer in the future—the forms will not be hospital-specific if they contain services that the hospital does not currently provide. Once your hospital adopts a policy governing the threshold or basic qualifications for eligibility to apply for privileges, it should develop a process for the medical staff to prepare specific criteria for evaluating privilege requests. For example, if your hospital requires formal training for a specialty area, the medical staff should decide which procedures and conditions should be listed within the specialty. The medical staff then should identify what constitutes acceptable training in the specialty. The medical staff also should determine requirements for recent experience, such as documentation of the number and types of cases performed in the past 12 months or the minimum number of patients treated within the past 12 months.