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When physicians disregard their privileges

Credentialing Resource Center Connection, May 26, 2005

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Dear credentialing colleague:

This question was recently submitted by a medical staff professional in New England:

"Physicians on our medical staff are beginning to disregard their assigned clinical privileges. They are performing procedures not included within their core, and a few family physicians are admitting patients to critical care-a privilege they do not currently enjoy. What should we do about this? Our chief of staff seems to think that it is of little consequence and will not even address it at our executive committee."

Fortunately, the answers are simple and direct. Conveying these answers to the medical staff and to the individual physicians involved, however, may prove more difficult.

A hospital is under an obligation to see to it that practitioners practice only within the scope of their delineated clinical privileges.

For example, if admission to the critical care unit is a separately delineated clinical privilege, only physicians possessing this privilege may admit patients to that unit. The hospital must inform other physicians attempting to place their patients within that unit that they must cease doing so. You must likewise inform surgeons performing procedures beyond the scope of their clinical privileges that this is not permitted.

You need to remind all members of the medical staff that clinical privileges serve as an authorization to perform specific procedures or provide medical treatment to specific kinds of patients. They should be encouraged to apply for additional clinical privileges if they believe that their education, training, experience, and competence meet the criteria previously determined by the executive committee and board. As indicated in earlier letters, there must be a mechanism allowing authorized individuals within the hospital to confirm that a physician possesses the privilege necessary to perform a specific procedure or provide care for a specific type of medical patient. You should make such systems available to hospital management in a timely manner, regularly update, and then enforce them.

The answer to the question posed above is simple. The hospital is currently in violation of the Centers for Medicare & Medicaid Services' (CMS) requirements, JCAHO standards, and probably state law and regulations. Certain physicians are out of control and the medical staff leadership needs significant education concerning their roles and responsibilities. The board is not providing effective oversight, and your institution may be jeopardizing patient care quality.

That's it for this week.

All the best,
Hugh Greeley
http://www.greeley.com/seminars/

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