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Setting-specific privileges a top JCAHO problem standard

Credentialing Resource Center Connection, March 31, 2005

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Medical services professionals (MSPs) should pay close attention to compliance with standard MS.4.20, which requires a process for granting, renewing, or revising setting-specific clinical privileges.

MS.4.20 was the only medical staff standard on the list of the JCAHO's top 10 problem standards, which were most frequently identified as "not compliant" in 2004 hospital surveys. The JCAHO published the list in the April issue of Perspectives. MS.4.20, found in the medical staff chapter of the Comprehensive Accreditation Manual for Hospitals, was tied for number 10 on the list, with 9% of hospitals surveyed not in compliance.

MS.4.20, which was number eight on the 2003 list, requires hospitals to comply with the JCAHO's time frame for granting privileges. Specifically, it mandates that appointments and reappointments to the medical staff for the granting, renewal, or revision of clinical privileges do not exceed two years. The standard also requires setting-specific privileges, an amendment to element of performance number four that the JCAHO added in 2004.

Hospitals can expect further focus on this standard in future surveys, because the JCAHO provided its surveyors with additional insight into MS.4.20 at its January surveyor training session. The expectation is that hospitals will classify privileges that physicians can perform in certain settings, such as intensive care units or catheter labs. Privileges should also be specific to the services provided at the hospital.

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