Criteria-based privileges: What, why, and how

(Editor's note: In this issue, we will deal with determination of the scope of services that an organization decides to provide. Future issues will deal with steps 2-4 of privileging.)

According to Vicki Searcy, vice president, consulting services at Morrisey Associates Inc. in Chicago, most Joint Commission-accredited health care organizations "are aware that the processes related to defining and granting clinical privileges are under intense scrutiny." Why? No. 1, the Centers for Medicare & Medicaid Services (CMS) "is focused on criteria-based privileges and has mandated that clinical privileging systems in hospitals (and other health care organizations required to privilege practitioners) be carefully surveyed to assure that when CMS pays for health care services, those services are provided by qualified and competent individuals," she says.

In discussing privileging systems, Searcy defines four relevant terms:

  1. Clinical privileges: "The specific clinical duties that may be provided by practitioners at a health care organization."
  2. Criteria-based privileges: "A group of privileges (i.e., pain medicine privileges) or single privileges (i.e., the privilege to administer deep sedation), matched with criteria that must be met in order for a practitioner to be eligible to apply for the privilege(s). Criteria may include any/all of the following: education, training, clinical activity, board certification, other certification, contractual relationships, meet qualifications for other related privileges, behavior, etc."
  3. Practitioners:"Health care professionals who are licensed independent practitioners (i.e., they provide care without supervision or direction) and additionally, advanced practice allied health professionals who are required by The Joint Commission to be privileged. Those advanced practice allied health professionals include physician assistants and advanced practice registered nurses."
  4. Competent: "Knowledge, skills, behaviors, etc. that provide a practitioner with the capacity to perform. Having suitable or sufficient skill, knowledge, experience, etc.; properly qualified."

Looking back, Searcy says hospitals have been granting privileges for about 40 to 50 years, "but for most of that time period, privileging systems have not addressed current clinical competency in any meaningful way. The emphasis of CMS on criteria-based privileges, and subsequently, The Joint Commission, has forced hospitals and their medical staff organizations to search for effective ways to design and implement criteria-based privileges.

"In the past, a discussion of clinical privileges would bring to mind a privilege form on which a list of procedures would be arrayed in some fashion (sometimes grouped by body systems, sometimes simply alphabetized) with checkboxes for practitioners to request specific privileges. Some privilege forms have also included cognitive privileges (i.e., perform the history and physical examination, treat and manage diabetic patients), but the emphasis over the years has clearly been on the procedures performed," she says.

"Now, most hospitals and their medical staff organizations have come to realize that the processes associated with clinical privileging are much more complex than creation of a simple form. There are four basic components of clinical privileging:

  1. Determining the scope of services that an organization will provide.
  2. Determine the criteria (training, experience, behavior, skills) necessary in order to provide a specific service (or grouping of services) or procedures. Establish how exceptions will be handled.
  3. Allow applicants to apply for privileges and determine if they meet criteria. Make a decision and communicate it.
  4. Monitor the individuals who are granted privileges to ensure their competence and practice is within the scope of privileges granted."

An organization's specific scope of service is determined by the governing body. "For example, will the organization provide obstetrics services, level IV emergency services, services to patients with burns, neonatal intensive care services, etc.? In addition to these broad decisions, the governing body will also decide whether or not robotic surgery will be provided (which is a large expense due to the costs associated with purchase of the equipment) or whether or not a bariatric surgery program will be established (costs of equipment, training of staff, provision of ongoing services to bariatric surgery patients, etc.)," Searcy says.

"In the past, many organizations have not been thoughtful enough about making these decisions and often reacted to requests from practitioners for equipment and other resources in a somewhat haphazard fashion. Now, however, The Joint Commission requires that organizations clearly establish that new services can be added in a way that provides safe and competent care to patients. Many times, the addition of new services is requested by practitioners." When this happens, she suggests the following steps:

• "If a practitioner requests privileges for a service that is not currently provided by the hospital, that request should first be forwarded to hospital administration to confirm that the hospital is prepared to initiate and support the new service prior to being forwarded to medical staff leadership for development of the associated scope of privileges or privileging criteria. Hospital administration and the governing body will make a determination based on the following factors:

— The community and patient need for the new privilege(s). Will there be enough demand for the technology or service to justify its approval?

— The capacity of the organization to support the new privilege(s) requested, including whether appropriate equipment, space, supplies, trained staff, scheduling and other necessary resources are reasonably available.

— Quality of care issues.

— Whether the new technology or procedure is of proven efficacy and effectiveness and whether it carries a greater risk than existing conventional therapy.

— Patient convenience.

— Reimbursement issues.

— Any other business and patient care objectives of the organization, which the board believes are relevant to consideration of the request."