Designing systems for delineating clinical privileges

Privileging enables the medical staff to determine what procedures each practitioner may perform and the conditions that they may treat. The privileging process addresses the question: “What can these practitioners do?” The answer, provided via the privileging process, is “only those procedures and treatments that the practitioner can perform competently.” In other words, a privilege is a special right granted to a particular person on an individual basis.

This determination, commonly referred to as delineation of clinical privileges, is one of the most difficult tasks performed by physician leadership—with much assistance from the medical staff services department—because it requires fair, consistent analysis of every applicant’s education, training, experience, and current clinical competence to ensure that they match the procedures the applicant wishes to perform and the conditions they wish to treat.

Most organizations struggle to develop and implement a consistent, effective system for delineating privileges. Not only must the system ensure high-quality patient care, but it also must minimize a hospital’s legal risk and reduce conflicts among medical staff members, some of whom may want the exclusive right to perform particular procedures. Furthermore, as medicine becomes more specialized and reimbursement more highly regulated, the privileging process has become even more complex.

As with credentialing, privileging starts with a request for information, followed by review of the information provided. Before you begin working on a practitioner’s request for privileges, it’s important to have on hand the clinical data for that practitioner and for the specific privilege requested. Many hospitals occasionally request clinical information—such as numbers and types of procedures—for certain practitioners who apply for clinical privileges. Your organization should establish a realistic policy stating that the hospital will consider requests for privileges only when such requests contain the following:

• Current, verifiable clinical data demonstrating the number and type(s) of clinical activities that the practitioner has performed
• The time period(s) in which he or she performed those activities

This process requires comparing all data obtained at initial appointment and reviewing internal information (usually from the quality profile) at the time of reappointment, along with quality (volumes and outcomes) information from other facilities at which the practitioner holds or has held clinical privileges. The policy should indicate that it is the applicant’s responsibility to supply all requested information, and it should specify the time frame for providing that information.

Editor’s note: This article was excerpted from “The Medical Staff Office Manual: Tools and Techniques for Success” by Marna Sorensen, CPMSM. CRC Platinum Plus members can click here for complimentary access to this book.