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What’s the best way to rollout new privileges?

Credentialing Resource Center Connection , February 26, 2009

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Dear readers,

A credentialing coordinator recently completed the long and arduous task of getting core privileging forms approved. She wasn’t claiming victory yet, though, because she knew the hospital still faced implementation. Hospitals have used various methods of implementation including:

• On an individual basis, as each practitioner is reappointed
• Specialty by specialty, rolling each specialty into the new core system one at a time
• Organization-wide, implementing core privileges for everyone at the same time

Many factors—regulatory issues, medical-legal risks, staff resources—must be taken into account.

The first option poses potential regulatory problems. If the current privileging system at your hospital is outdated or not criteria-based, your facility risks noncompliance with regulatory standards. Remember that implementing core privileges practitioner by practitioner will take about two years. Thus, some specialists will be practicing under core privileges while others practice under their old set of privileges. The practitioners’ privileges might vary significantly between the two systems, leading The Joint Commission to question whether the hospital provides a single standard of care.

Consider too, the method by which your hospital disseminates privileging data. If you use credentialing software to communicate throughout the organization what privileges have been granted to each practitioner, it is likely that it will not accommodate two styles of privileges. You’ll need to determine how to handle this communication during the two-year rollout period—if implementation during reappointment is selected.

Each method is a valid way to rollout core—if the hospital is aware of the regulatory and medical-legal concerns raised. It is recommended that hospitals reprivilege the entire medical staff at once if your medical staff office can handle the workload. One option is for the board to pass a resolution adopting the new core privileges and criteria and to authorize the MEC to implement them. Once the board adopts such a policy, all practitioners must complete a new core privileging request form. The department chairs would review the forms and determine whether any of the requested privileges were outside of previously granted privileges. For applicants whose requested privileges are not outside of previously granted privileges, their privileges can be granted using the new core privilege form following a positive recommendation from the department chair, credentials committee (if applicable), MEC, and board.

This might sound like a lot of work, and it is. But it results in all practitioners providing the same level of care at the same time. Hospitals and their medical staffs must consider the medical-legal risks associated with continuing the current system. There is legal precedence for findings of negligent credentialing in instances when a privileging system is not criteria-based and is outdated. These findings are based on noncompliance with accreditation standards that require organizations to have a setting-specific, criteria-based privileging system.

All the best,

Maureen Coler
Executive Editor

HCPro offers many resources to assist hospitals with core privileges. Services range from assistance with developing core forms/criteria to a software “add-on” designed to disseminate core privileges throughout your organization. For more information, email Executive Editor Maureen Coler at mcoler@hcpro.com or call 781-639-1872 x3741.

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