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Changing privileging criteria during a reappointment cycle

Credentialing Resource Center Connection, January 10, 2008

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Sally J. Pelletier, CPMSM, CPCS, is a consultant with The Greeley Company, a division of HCPro, Inc., specializing in the areas of credentialing and privileging.

Dear credentialing colleague:

A recent question posed by one of our readers asked whether a healthcare organization can change privileging criteria in the middle of a reappointment cycle and if so, what would be the circumstances that allow this?

The simple answer is yes, although it is difficult to answer this question without enough background information upon which to make an informed decision. That being said, you should consider the following circumstances before you proceed:

• Changes in privileging criteria can occur at any time as recommended by the credentials committee (if applicable) and the medical executive committee, pending approval by the governing board. As a result, it would not be unusual for such a change to fall in the middle of a practitioner's reappointment cycle. Organizations should establish a reasonable effective date (usually the date of approval of the criteria by the board). It is important to note that methods for determining reappointment cycles vary from organization to organization and may be categorized in the following ways:

         -   By the birthdates of the practitioners
         -   By the initial appointment dates of the practitioners
         -   All reappointments at the same time (more common in smaller 
             facilities)
         -   Half of the staff one year and half of the staff the next year.

• Will the practitioners who currently hold the privilege be grandfathered in and then held to the new standard at reappointment? If so, and their reappointment is in the imminent future, how will the organization determine what is reasonable in terms of that practitioner meeting the newly established criteria? For example if the organization defines that the procedure has to be performed by the physician at least 24 times in 24 months (a reappointment cycle) but only six months have passed since the criteria was established, will the numbers be prorated so that the practitioner would have to perform at least six procedures in the past six months?
  
• What is driving the need for the change in criteria? 

        -   Is the organization in the middle of a privileging system
            redesign? 
        -   Have industry standards changed? 
        -   Does the organization recognize that they have not defined
            what is required in terms of education, training, and experience
            to be able to request the privilege/procedure and that they need
            to establish eligibility criteria?
        -   Is there a cross specialty dispute that needs to be brought to
            resolution?

The following guidelines for developing criteria for clinical privileges seem particularly relevant to this reader's question:

1. Establish a consistent method for delineating clinical privileges
2. Criteria should be specific to a procedure or a clinical condition, not a department
3. Develop and follow a consistent process to determine cross-specialty criteria

As I stated earlier, there is sure to be additional information behind the scenes, perhaps involving a particular physician or a group of physicians that is relevant to determining the answer to this reader's question. While deliberating an effective solution to this issue it is important to remember that credentialing and privileging decisions are about managing the process and applying the credentialing principles consistently and fairly.

Remember, credentialing has no other master than the patient.

That's all for this week.

All the best,

Sally J. Pelletier, CPMSM, CPCS
http://www.greeley.com/consulting.cfm

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