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Putting privileging information in the right hands

Credentialing Resource Center Connection, March 15, 2007

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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.

Dear credentialing colleague:

The method for disseminating privileges to the places that "need to know" throughout healthcare organizations seems to be one of those areas where many have not kept up with the times when it comes to technology. 

Today, numerous hospitals and medical staff offices are still utilizing a manual, hardcopy, paper process for the sharing of critical information related to privileging. Notebooks containing copies of privilege forms are stored in designated clinical areas with the medical services professional (MSP) responsible for keeping them current. There are multiple areas within a facility where this information may need to be distributed, including the operating room, emergency department, ICU, endoscopy suite, and more.

All too often, due to a lack of time and resources, the information provided within those notebooks becomes outdated, perpetuating a lack of trust in the process itself. So the notebooks get moved, step by step, from a prominent place on the counter, to behind other documentation, and eventually wind up on the high shelf in the cupboard that no one can reach.

For those organizations that have not yet computerized their privileging process, the benefits and rewards for doing so are more and more prevalent-accuracy, more efficient use of time and resources, better use of environmental resources, and access to real time information are just a few. Conversely the excuses for maintaining the traditional manual system-especially if it doesn't provide current, accurate information related to what procedures or privileges a practitioner may perform-just don't hold up. 

The Joint Commission Medical Staff Standards (MS.2.10, EP 2) state that a practitioner must practice only within the scope of their privileges as determined through mechanisms defined by the organized medical staff. When a surveyor poses the question to staff how she or he knows whether a particular practitioner can perform a specific procedure, the staff person needs to be knowledgeable about where to find current and accurate information. Having a system that allows an MSP to electronically enter and maintain this information and enables the staff to view the information from their clinical units is well worth the time and effort it takes to implement.

Don't forget, the dissemination process for privileging decisions (granting, modifications, or restrictions) needs to be approved by the Medical Executive Committee via a policy.

Remember, credentialing has no other master than the patient.

That's all for this week.

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

http://www.greeley.com/consulting.cfm

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