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CMS releases guidance on hospital privileging: Privileges must match individual competencies

Medical Staff Leader Connection, November 18, 2004

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In a much-anticipated, four-page memorandum, the Centers for Medicare & Medicaid Services (CMS) has spelled out what hospitals must do to ensure their medical staff privileging system meets federal requirements.

A hospital's medical staff must individually evaluate each practitioner and determine that he or she has the qualifications and demonstrated competencies to perform all of the specific privileges granted, CMS said in a November 12 letter to its state survey agency directors.

"The hospital's governing body must ensure that all practitioners who provide a medical level of care and/or conduct surgical procedures in the hospital are individually evaluated by its medical staff and that those practitioners possess current qualifications and demonstrated competencies for the privileges granted," CMS said in a summary of its privileging position.

While CMS never refers to the term "core privileging" in its letter, the agency does detail what state surveyors, who perform hospital surveys on behalf of CMS, should look for to determine whether a hospital's privileging process complies with the hospital Conditions of Participation (COP).

Hospitals that have a solid core privileging system in place-one that ensures that the medical staff leadership independently assesses the current competence of each individual practitioner-will comply with CMS regulations, says Carol Cairns, CPMSM, CMSC, a senior consultant with The Greeley Company in Marblehead, MA.

To meet federal regulations, hospitals need to have a well-defined clinical privileging system that is criteria-based and that considers an individual's education, training, experience, and current competence when recommending and granting privileges, Cairns says.

At press time, CMS anticipated posting the memorandum on its Web site at www.cms.hhs.gov/medicaid/survey-cert/letters.asp.

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