• E-mail
• Print
• RSS

Joint Commission clarification regarding core privileges

Credentialing Resource Center Connection, April 10, 2008

Want to receive articles like this one in your inbox? Subscribe to Credentialing Resource Center Connection!

Anne Roberts, CPMSM, CPCS, is the director of medical affairs at Children's Medical Center in Dallas, where she oversees the medical administration, graduate medical education, and medical staff services departments.

Dear credentialing colleague:

On April 1, The Joint Commission (formerly JCAHO) published a new FAQ related to core privileges on its Standards Frequently Asked Questions Web page for the Comprehensive Accreditation Manual for Hospitals (CAMH). Another term for core privileges is bundled privileges.

The FAQ states, “Joint Commission’s credentialing and privileging standards in all accreditation manuals do not reference the concept of core privileges nor do they suggest or promote a particular format for granting privileges.”

The Joint Commission clarifies that an organization’s core privileges (if it uses them) must be:

• Clearly and accurately defined to reflect specific activities/procedures/privileges to be included in the core terminology, as well as those activities/procedures/privileges that are outside the core
• Clearly and accurately defined to reflect only activities/procedures/privileges actually performed at the organization
• Clearly defined to reflect activities that the organization believes a majority applicants should be able to perform

For implementation purposes, the organization must evaluate each applicant’s education, training, and current competence to perform each procedure or activity listed in the core privileges, as well as any privileges that are requested/granted outside the core. The Joint Commission also notes that “the expectation for the evaluation of each applicant’s education, training, and current competence to perform each specific activity would be the same if the organization were to use a ‘laundry list’ format for the applicant to select activities.”

An organization also cannot assume that every applicant can perform every procedure or activity it lists in the core. The organization must clearly define the process for an applicant to not request or to request the deletion of specific procedures or activities that an organization may include in the core if the applicant does not wish to apply for those procedures or activities. Additionally, if the organization deems that the applicant is not qualified or competent to perform specific procedures or activities which are included in the core, there must be a mechanism in place to modify the core appropriately.

MS.4.00 requires organizations to ensure that the resources necessary to support requested privileges are currently available, or available within a specified time frame, prior to granting privileges. When developing a privileging system, whether core format or laundry list format, organizations must determine that there is sufficient space, equipment, staffing, and financial resources to support each procedure/privilege at each location where the organization will offer that procedure. Additionally, most organizations are also incorporating their focused professional practice evaluation requirements into their privilege delineations.

Click here to access The Joint Commission’s FAQ page for the CAMH.

Remember, clear, effective communication is the key to success!

That’s all for this week.

All the best,

Anne Roberts, CPMSM, CPCS

Editor’s note: Looking for more information about this topic? Visit the Credentialing and Privileging Advisor archives to read the column “Is core privileging accepted by CMS and The Joint Commission? Yes.” By Sally Pelletier, CPMSM, CPCS. This column appeared in the February 7 issue of the Credentialing and Privileging Advisor. 

Want to receive articles like this one in your inbox? Subscribe to Credentialing Resource Center Connection!

• Comment
• E-mail to a Colleague
• Print
• RSS
• Archive

Comments