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Is core privileging accepted by CMS and The Joint Commission? Yes.

Credentialing Resource Center Connection, February 7, 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:

Is core privileging still relevant? You may have heard stories that the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (formerly JCAHO) have concerns about core privileging, including:

• Providers who meet threshold criteria are automatically granted privileges without solving the competency equation
• The core is too broadly defined to correlate with competence in all aspects of the core
• Hospital staff can't answer the question, "Does Dr. X have privileges to do that?"

Whenever there is a question as to whether core privileging meets accreditation and regulatory requirements, it is important for us to first understand exactly what the CMS and The Joint Commission are looking for.

CMS' Conditions of Participation (CoPs), contain the expectation that a healthcare organization's governing body and the medical staff are responsible for creating elements related to competency for those individuals who the organization privileges.

According to CMS's Requirements for Hospital Medical Staff Privileging memo of November 2004: "The process must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners. It cannot be assumed that a practitioner can perform every task/activity/privilege listed/specified for the applicable category of practitioner. The individual practitioner's ability to perform each task/activity/privilege must be assessed and not assumed. If the practitioner is not competent to perform one or more tasks/activities/privileges, the list of privileges is modified for that practitioner. Hospitals must assure that practitioners are competent to perform all granted privileges.

"Any procedure/task/activity/privilege requested by and recommended for a practitioner beyond the specified list of privileges for their particular category of practitioner would require evidence of additional qualifications and competencies, and be an activity/ task/procedure that the hospital can support and is conducted within the hospital. Privileges cannot be granted for tasks/procedures/activities not conducted within the hospital despite the practitioner's ability to perform the requested tasks/ procedures/ activities."

According to The Joint Commission's standard MS.4.15: "The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidence-based process." The EPs for this standard further define The Joint Commission's expectations in this area.

We can conclude that CMS and The Joint Commission both require the governing body and the medical staff to have criteria in place to evaluate both initial and existing medical staff member's requests for privileges based on the individual's character, competence, training, experience, and judgment, as well as a procedure for applying the criteria to individuals who are requesting privileges.

By now, many of you know that core privileging is an approach for creating a criteria-based privileging system-a requirement of both CMS and The Joint Commission. This method describes the care, treatment, and services that a practitioner should be competent to perform coming out of a training program in his or her area of specialty within a "core," and establishes the qualifications an applicant must meet in order to be eligible to request the "core" privileges. The eligibility criteria should address education, training, and experience, and answer the competency equation: That is, have you (the applicant) done "it" (the privilege or procedure) recently, and when you did "it," did you do it well?

It is important to recognize that there are required components of a core privileging system that address the potential concerns stated above. These required components include:

• A well-defined core with an accompanying procedure list that is facility-specific, as applicable, to a particular specialty/subspecialty.
• Special non-core procedures delineated separately from the core based on pertinent factors such as, but not limited to, additional knowledge; education or training; a higher risk; or new technology or equipment.
• Eligibility criteria that answer the "competency equation." In essence, these are the defined qualifications for initial applicants and reapplicants to request and maintain core and special non-core procedures that take into account education, training, experience, and outcomes.
• The ability for the applicant to modify the core and accompanying procedure list as necessary.

In closing, once again quoting CMS: "CMS does not have a preference as to the 'term' used to name the hospital's privileging process. A hospital's privileging process must comply with the CMS hospital CoPs." Similarly, The Joint Commission does not dictate what type of privileging system organizations use, but rather it evaluates whether organizations are compliant with the requirement that they (governing boards and medical staff leaders) evaluate the individual's qualifications and demonstrated current competence when recommending and granting privileges. 

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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