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MS.4.00: Determination of Resource Availability

Credentialing Resource Center Connection, May 15, 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:

Remember when there was a great deal of focus by The Joint Commission (formerly JCAHO) on the individual practitioner’s ability to perform privileges granted in a specific site or setting?  In 2007, The Joint Commission moved the focus away from granting setting-specific privileges and shifted the spotlight to competency-based privileging with the introduction of the three concepts of:

• Ongoing professional practice evaluation
• Focused professional practice evaluation
• The six areas of general competency 

As a matter of fact, if you search for the terminology “setting specific” in the 2007 and 2008 Joint Commission standards, you will not find it.

However, the introduction of standard MS.4.00, Determination of Resource Availability, in 2007 does necessitate that organizations define, in a policy, the care, treatment, and services exercised at specific settings. This is determined by the availability of appropriate equipment, license, beds, staff, and other requirements that support the particular procedure or privilege.

Standard MS.4.00 states that, “Prior to granting of a privilege, the resources necessary to support the requested privilege are determined to be currently available, or available within a specified time frame.” EP 1 requires a process to determine whether sufficient space, equipment, staffing, and financial resources are in place or available within a specified time frame to support each requested privilege. EP2 requires that the organization consistently determines the resources needed for each requested privilege.

In essence, consideration must be given to whether there are available resources (finances, space, equipment, types of personnel, sufficient staffing, etc.) so that specific privileges are supported when performed a particular setting. The Joint Commission is not prescriptive as to how you define your settings—that decision is left up to each organization. Your organization may identify the setting and define the scope of care in that setting based on a broad perspective (i.e., different buildings located on your hospital campus due to type or age of construction or the availability of equipment in a particular building), or define the settings more specifically, such as ICU, endoscopy labs, etc.

As mentioned previously, The Joint Commission used to link an individual practitioner and the privileges granted in a particular setting, but that is no longer the case. Now a practitioner who holds ventilator management privileges can perform those privileges in any setting the organization deems appropriate. Thus the ability of the practitioner to perform a particular procedure or privilege is competency-based, not setting driven.

At The Greeley Company, the following statement has been added to our template core privilege forms to accommodate this change in the standards: “Note that privileges granted may only be exercised at the site(s) and/or setting(s) that have the appropriate equipment, license, beds, staff, and other support required to provide the services defined in this document. Site-specific services may be defined in hospital and/or department policy.”

The following are steps your own organization should take to comply with MS.4.00:

• Identify settings and create a listing of the scope of care, treatment, or services that is provided in each setting based on available resources
• Have a policy/procedure in place for the introduction of new privileges and services and use of technology
• Educate department heads, nursing personnel, and other individuals regarding the above mentioned policy, and the need for a continuous evaluation of the resources necessary to support defined services

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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