• E-mail
• Print
• RSS

Should you credential and privilege organ procurement teams?

Credentialing Resource Center Connection, April 24, 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:

A common question medical staff offices (MSOs) face is “Should the MSO credential and/or privilege physicians who participate on an organ procurement (OP) team?” In March 2007, The Joint Commission (formerly known as JCAHO) updated its FAQ related to privileging OP teams, stating that OP teams “often consist of individuals who are on rotational assignments and may only infrequently visit the healthcare organization.” The FAQ further stated that the work of OP team members often  is “too limited to undergo effective performance improvement activity review at each site that is meaningful for renewal of clinical privileges.”

Healthcare organizations that use OP teams should ensure that an agreement regarding their services on the team use is in place—whether it is a formal contract, memorandum of understanding, or regional governmental authority document. Although organizations are not required to credential and privilege OP team members for that additional function at the facility, according to The Joint Commission, it is the healthcare organization's responsibility to ensure that the agreement provides for qualified individuals who are properly authorized by their organizations.

The Joint Commission outlines requirements related to contractual services in the leadership chapter of the Comprehensive Accreditation Manual for Hospitals (CAMH). LD.3.50 indicates that services provided by consultation, contractual arrangements, or other agreements are provided safely and effectively. These standards require that medical staff advise hospital leaders on the sources of clinical services that they will provide through consultation, contractual arrangements, or other agreements. The standards also state that the nature and scope of services provided must be defined in writing. Hospitals are responsible for evaluating the contracted care, treatment, or services to determine whether they are provided according to the contract and meet the hospital’s safety and quality expectations. The hospital retains overall responsibility and authority for services furnished under a contract.

The Joint Commission, under LD.3.110, further outlines the hospital’s requirements for implementation of policies and procedures, developed with the medical staff’s participation, for procuring and donating organs and other tissues.

Although most MSPs are not directly involved in developing policy related to procuring and donating organs or in establishing contracts with OP organizations, it is important for them to become familiar with the requirements surrounding these services.

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

That's all for this week.

All the best,

Anne Roberts, CPMSM, CPCS

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