Privileging turf battles just won't go away

Dear colleague,

I participated in my first privileging turf battle in 1985 when, just a year into practice as a family physician, I applied for ICU privileges and was told only internists were eligible for those privileges. This was in the days before anybody talked about the “5 Ps”—Our Policy is to follow our Policy. In the absence of a Policy, our Policy is to develop a Policy—so nothing was written down to which I could formally object. I was simply told, “That’s the way it’s done around here.”

Fast forward to today. After more than 25 years since I first encountered this challenge, one would think we in healthcare would have solved the problem. Sadly, we have not. Just last week I found myself responding to a request to work with physicians at a northwest hospital who could not agree on who should be performing endovascular interventional procedures. (I don’t think that surprises anybody!) Even though their respective professional societies had smoked a peace pipe over this issue years ago, these physicians were at it again, including bad mouthing the care provided by physicians in the other specialties. Both the complaining and maligned physicians pointed fingers at the medical staff’s peer review program, claiming either that it failed to find all the problem cases or that it was prejudiced against the physicians whose cases were found.

What is equally sad is that this is not an isolated example. So what should be done? Here is a step-by-step process to eliminate privilege disputes in your medical staff:

• Implement the five Ps. If you don’t already have one, adopt a privilege dispute resolution policy and procedure. It should spell out the steps to be followed each time a privilege dispute arises, regardless of which specialties are involved.
• Critically evaluate your approach to privileging. Has the medical staff adopted core privileging? Have they appropriately developed eligibility criteria for all privileges? Are the criteria appropriate and meaningful? Do they allow for different criteria based on specialty or training while still achieving a single standard of care? Do they use a consistent format for delineation of privileges across all specialties? Implement any needed changes based on evaluating your approach to privileging.
• Critically evaluate your peer review program. Is your process for case finding fair and effective? Do all specialties utilize a standardized approach to case reviews that guides all reviews through the right kind of critical thinking and analysis to achieve unbiased conclusions? Have you implemented meaningful aggregate measures of physician performance beyond just the core measures? Do all physicians receive feedback on their performance that appreciates what they do well and clearly identifies their best opportunities to improve? Do your physicians trust the data they receive? Implement any needed changes based on evaluating your approach to peer review.
• Critically evaluate your approach to training medical staff leaders. Have the board, senior management, and medical staff leaders agreed that training physician leaders in the leadership knowledge and skills they didn’t learn in medical training is an important priority? Has your organization allocated adequate, ongoing resources for physician leadership training? Have you designed a curriculum all medical staff leaders need to complete that includes, but is not limited to, credentialing and privileging, peer review, and conflict resolution? Implement any needed changes based on evaluating your approach to training medical staff leaders.

I said above that following this step-by-step process would eliminate turf battles; I was wrong. The pressures on physician incomes will increase, leading smart physicians to seek additional sources of revenue, some of which will come from competing with other specialties. Technology will continue to progress, making it easier for physicians to train in minimally invasive methods that cross traditional specialty boundaries. And the essential elements of human nature, including avarice and jealousy, are not going away. So privileging turf battles will be with us for a long time to come. Following the steps listed above will help your medical staff reduce privileging turf battles and more effectively address the ones that arise in the future. Minimizing the ones you encounter and managing them more effectively when they arise should be your goals.

All the best,

Rick Sheff, MD
Principal and Chief Medical Officer
The Greeley Company, a division of HCPro, Inc.