Credentialing & Privileging

Potpourri for 2007

Credentialing Resource Center Connection, November 9, 2006

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There is clarification in MS.4.10 regarding license verification that now includes language in the Element of Performance (EP) for primary source verification at the time of initial granting, renewal, and revision of privileges, and at the time of license expiration.

 

MS.4.10 also addresses verification of the identity of a practitioner requesting approval through one of the following two acceptable methods:  a current picture hospital ID card or a valid picture ID issued by a state or federal agency.  This verification should be performed prior to the practitioner beginning to provide care at your facility, and can be performed by an appropriate hospital designee, i.e. human resources staff, medical staff professional, vice president of medical affairs, credentials committee chair.


MS.4.15 addresses the area of privileging, with significant focus on the need for decisions related to privileging to be evidence-based.  This is where the information gathered from OPPE and FPPE is utilized. The privileging process is the responsibility of the organized medical staff to plan and implement, including the development and approval of a procedure list, application process, and an evaluation of applicant-specific information.  It is up to the hospital to determine whether there is sufficient clinical information upon which to make this decision to grant, limit, or deny the privileges requested.  The requirements for peer review recommendations now include obtaining information related to interpersonal skills, communication skills, and professionalism, in addition to medical and clinical knowledge, technical and clinical skills, and clinical judgment.  MS.4.15 requires a thoughtful review and more space than will be dedicated to it within this brief overview.

 

The language related to the time limits as determined in the medical staff bylaws for temporary privileges that are granted to meet an important patient care need has moved from the rationale statement for MS.4.100 to EP 1.  When defining timeframes within your bylaws, make sure to address whether the privileges can be extended or re-granted for another defined time period based on circumstances in which the important patient care need still exists.


Analysis and use of privileging information received (MS.4.20) includes in EP8 the one statement throughout the medical staff standards that addresses that privileges are granted for a period not to exceed two years. In addition, the analysis and resulting decision must be timely and take into account the use of privileging criteria and that is consistently applied.


These are just some of the other highlights beyond those changes and additions appearing in the 2007 standards. There are many redlined pages and new standards to review and analyze for the 2007. 


All the best,
Sally J. Pelletier, CPMSM, CPCS

 

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.



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