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Monitor clinical activity to match privileges

Credentialing Resource Center Connection, March 17, 2004

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Dear Credentialing Colleague:

Under most states' regulations--as well as JCAHO and Healthcare Facilities Accreditation Program standards and federal requirements--physicians can treat patients in a hospital only if the facility has granted the practitioner clinical privileges to do so.

Medical staff bylaws and rules also make hospitals responsible for assuring that physicians practice only within the bounds of the privileges they have been granted (except for emergencies). Hospitals and medical staff leaders have known for many years that they have this responsibility. So, how then could any of the following occur?

- A physician without privileges to admit does so anyway and treats the patient through discharge. In this case, a pathologist admitted his neighbor to the hospital for treatment of pneumonia.

- A surgeon who has a long list of surgical privileges (including a number of laparoscopic procedures) schedules and performs a complicated laparoscopic procedure for which she has no privileges.

- A physician admits and cares for a 23-year-old patient in the pediatric unit, although his privileges permit him to only care for patients up to the age of 21.

- An elderly physician on emeritus staff, without any clinical privileges, admits and cares for a long-term patient.

It is likely that each of these situations occurred because hospitals and their medical staffs did not have systems in place to prevent physicians from exceeding the limits of their privileges. This may have been exacerbated by poorly designed privileging systems (such as lists of surgical privileges instead of core privileges), lack of technology to detect such variation in real time (such as electronic linking of privileges with the surgical schedule), poorly trained admission/scheduling staff, a bit of intimidation here or there, or simply the presence of a cavalier attitude toward the issue by both management and medical staff leaders.

Regardless of the reason(s), medical staff leaders and credentials committee members must see to it that situations such as those described above cannot occur in your facility. Changing the method you follow to privilege physicians will alleviate many of these problems. In most cases, however, hospitals will need to put in place systems designed to alert leaders when a physician attempts to schedule a "clinical event" in the absence of clinical privileges. When such an event is detected, keep in mind that physicians do not review their privileges every time they admit or schedule. Physicians simply go about the business of caring for patients and hope others--such as the medical staff leaders and credentialers--are paying attention to needed bureaucracy.

That's it for this week.

All the best,

Hugh Greeley

http://www.greeley.com/seminars/

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