Introducing new procedures and technologies

The following message appeared recently on Medical Staff Talk, the message board for subscribers to Medical Staff Briefing and the Credentialing Resource Center. (Note: the message has been edited to preserve the confidentiality of the sender.)

Does anyone have criteria for _____ privileges? Our hospital has bought the equipment but forgot about the credentialing process. Credentials Committee meets Wednesday morning and they've asked that I bring information. Can anyone help quickly? Thanks so much.

Unfortunately, this request is not a rare phenomenon. In recent months, I have worked with several organizations that have had similar scenarios. These privileging issues occur because:

1. There is no defined process to determine if new privileges/technology should be introduced in an organization.

OR

2. There is a defined process, but it is not followed (sometimes no one remembers that the defined process exists!).

As many of you are well aware, the evaluation of how organizations introduce new privileges or technology is something that smart surveyors (JCAHO, state surveyors, etc.) focus on to determine how the healthcare organization assures competency of those with clinical privileges. A few seemingly simple questions related to whether or not an organization uses a particular type of equipment, such as for laparoscopic bariatric surgery, and the surveyor is well on his or her way to making a determination about the effectiveness of the privileging process.

If that weren't enough, think of the potential liability when new technology or procedures are not thoughtfully and carefully introduced and there is an adverse outcome.

Organizations that are determined to dot the Is and cross the Ts when it comes to adding new privileges/technology should follow several steps before addressing criteria for competency. The organization should first make a determination of whether (or not) to add the new privileges or use of technology to the scope of services of the organization. There are many issues involved in this analysis, including

• determination of community need
• purchase costs of the new technology
• additional costs, such as staff training, additional equipment needs, etc.

I have never heard organization leaders lament taking the time necessary to make an informed, careful decision. But I certainly have heard enough disaster stories (clinical as well as financial) about what can occur when there is a lack of careful decision-making.

Once an organization has determined to add new procedure(s)/technology to the scope of services, the organization must formulate criteria for applying to exercise the new procedure(s) or use the new technology. Only after approval of the new criteria (by the Board) should practitioners who meet the eligibility threshold criteria be allowed to apply. For example, the use of some new technology may require significant training and ability to demonstrate a specific amount of clinical activity. Proctoring may be required, and the organization may determine that it is best to bring in proctors from outside the organization when no one on the medical staff is currently qualified to act as a proctor.

Remember that when introducing new privileges and/or technology in your organization, the competency equation needs to be answered for the safety of our patients, to manage risk, and to meet accreditation and regulatory requirements:

Competency = Have you done it?
When you did it, did you do it well?

For a sample request form for the introduction of new technology or procedures, click this link.

Until next week,

Vicki L. Searcy, CPMSM
Practice Director, Credentialing & Privileging
The Greeley Company