The JCAHO, the predominate hospital certification organization in America, has specific mandates and restrictions placed on hospital boards and medical staff regarding privileges. The salient areas of the JCAHO manual are included below. Specifically, the JCAHO standards require 1. clinical departments make recommendations to the medical staff regarding professional qualifications for privileging, 2. the adopted professional qualifications must be applied across the board to all physicians who apply for clinical privileges in a delineated area, 3. the professional criteria will at least pertain to evidence of current licensure, relevant training or experience, current competence, and ability to perform the privileges requested, 4.Departmental or major clinical service recommendations are part of the basis for developing recommendations for continued membership on the medical staff or for delineating individual clinical privileges. 5. Privileges are related to an individual’s documented experience in categories of treatment areas or procedures; the results of treatment: and conclusions drawn from organization performance improvement activities when available. 6. Board certified is an excellent benchmark and is considered when delineating clinical privileges. 7. When privilege delineation is based primarily on experience, the individual’s credentials record reflect the specific experience and successful results that form the basis for the granting of privileges. Clinical privileges are moot if the specific hospital has a clinical service pre-privilege evaluation process. Some hospitals deem a specific procedure or service to be too costly or risky or contrary to the mission of the hospital, therefore the hospital will elect to not offer a particular procedure or service. Hospitals boards may also elect not to grant privileges approved by the credentials committee and med-exec committee of the medical staff. Because of the potential for litigation against hospitals who offer experimental or cutting edge procedures, the priviliging process is used to strike a balance between technological advancement and risk of litigation. To see a document prepared by Algos for malpractice insurers and hospital credentialing committees on the risks and training associated with various pain management procedures, click here.
For pain management, especially for procedures new to the hospital, there are difficulties encountered since the hospital has little experience in the procedure. Some hospital use the "White Papers", a commercial service which hires experts to write recommendation papers about who should be performing certain procedures and give information regarding the procedure.. Small hospitals use the "White Papers" while larger hospitals pay the company which writes these papers to set up credentialing throughout the entire hospital. The White Papers are frequently not current, and do make mention of specific specialty areas which are those predominately performing the specific procedure. Although the company which publishes these papers is vehement that they are not meant to be used to deny privileging, that is precisely what occurs in small hospitals that place excessive weight on these White Papers. JCAHO does not utilize any commercial service as a suggestion on how privileging should be performed, but in small hospitals without experience or guidance resources, sometimes these papers have more influence than their authors intended.
STEPS FOR PRIVILEGING IN PAIN MEDICINE: 1. If the procedure is a standard procedure (eg. radiofrequency neurotomy), give the credentialing office the information they need to make a determination of your capabilities of performing the procedure: experience, training, certification in the procedure, board certification, success/complication rates, number performed, and if possible, sample dictations from the procedures. 2. If the procedure is new to pain management, submit any clinical data to the medical staff office to support the use of the instrument/machine/technique. Include information in section (1), and if there is ANY supporting information available that physicians in YOUR SPECIALTY (yeah, I know it is not supposed to matter what specialty you are in, but to small hospital medical staff offices, it does) are doing the procedure and in which hospital, that information may be invaluable. No hospital wants to create new therapies (in contradistinction to their advertisements about being "cutting edge"), so for hospitals and some ASCs, there is safety in numbers. Certification of training courses are useful, and if the hospital balks at approval, you may wish to offer to bring in a proctor at your expense to demonstrate to the hospital that your skills are sufficient to perform the technique. If you are part of an anesthesiology or PM&R departmen, attempt to have the chairman of the department write a letter of support stating that the procedure is within the scope of practice of advanced pain management physicians. 3. If the procedure is extremely new and is not being taught in any certification courses, performance of the procedure in conjunction with an IRB approved clinical trial is useful. Affiliation with a university pain management physician as a co-author of the study, with University IRB approval is useful. Often the cost of IRBs are waived if it is submitted by a university researcher. CAVEATS: Do not try to perform procedures not yet approved and for which you have applied. Do not try to fudge and perform procedures which may be only vaguely similar to what which are already being performed. Privileges for procedures that utilizespecial equipment such as lasers should always be specifically acquired. Do not become angry if a privilege is delayed or not granted- instead talk to the chairman of the credentials committee to find out what changes need to be made to acquire privileging. Finally, know that not all privileges will be granted in a hospital setting, but may be granted in an ASC. As medicine moves increasingly away from hospitals, the complexities of advanced procedure privileging in hospitals may be avoided through the use of ASCs or the office for performance of procedures.
JCAHO MANUAL: SECTION ON PRIVILEGING MS 5.4 Appointment or reappointment and initial granting and renewal or revision of clinical privileges are MS.5.4 The mechanisms provide for professional criteria that are specified in the medical staff bylaws and unifromly applied to all applicants for medical staff membership, medical staff members, or applicants for delineated clinical privileges. These criteria constitute the basis for granting initial or continuing medical staff membership and for granting initial, renewed, or revised clinical privileges. MS.5.4.1 Each clinical department makes recommendations to the medical staff regarding professional criteria for clinical privileges. MS.5.4.2 The professional criteria are designed to assure the medical staff and governing body that patients will receive quality care MS.5.4.3 The professional criteria at least pertain to evidence of current licensure, relevant training or experience, current competence, and ability to perform the privileges requested. MS.5.4.3.1 For an applicant for an initial appointment to the medical staff and for initial granting of clinical privileges, the hospital verifies information about the applicant’s licensure, specific training, experience, and current competence provided by the applicant with information from the primary source(s) whenever feasible. MS.5.4.3.2 The hospital is also encouraged to consider additional information concerning the applicant from other sources, including the Federation of State Medical Boards Physician Disciplinary Data Bank. These databases and other sources may provide the hospital with information that is new or that may flag an inconsistency when compared with the individual’s application. MS.5.4.4 Decisions on reappointments or on revocation, revision, or renewal of clinical privileges must consider criteria that are directly related to the quality of care. MS.5.4.4.1 Such decisions are subject to a fair hearing and appeal process. MS.5.4.5 Decisions on appointments or on granting of clinical privileges must consider criteria that are directly related to the quality of care. MS.5.5 The medical staff bylaws, rules and regulations, or policies define the information to be provided by each applicant for appointment or reappointment to the medical staff and initial, renewed, or revised clinical privileges, including at least MS.5.5.1 Previously successful or currently pending challenges to any licensure or registration (state or district, Drug Enforcement Administration) or the voluntary relinquishment of such licensure or registration; MS.5.5.2 Voluntary or involuntary termination of medical staff membership or voluntary or involuntary limitation, reduction, or loss of clinical privileges at another hospital; and MS.5.5.3 Involvement in a professional liability action under circumstances specified in the medical staff bylaws, rules and regulations, and policies. MS.5.5.3.1 At a minimum, final judgements or settlements involving the individual are reported. MS.5.6 Appointment or reappointment to the medical staff and the initial granting and renewal or revision of clinical privileges are also bases on information regarding the applicants competence. MS.5.7 Deliberations by the medical staff in developing recommendations for appointment to or termination from the medical staff and for the initial granting, revision, or revocation of clinical privileges include information provided by a peer(s) of the applicant. MS.5.8 A structured procedure, as defined by medical staff bylaws, rules and regulations, and medical staff policies, is used for the expeditious processing of complete applications for appointment, reappointment, and initial renewal or revised clinical privileges. MS.5.8.1 A separate record is maintained for each individual requesting medical staff membership or clinical privileges. MS.5.8.2 Complete applications are acted on within a reasonable period of time, as specified in the medical staff bylaws. MS.5.9 Gender, race, creed, or national origin are not used in making decisions regarding the granting or denying of medical staff membership or clinical privileges. MS.5.10 Each applicant MS.5.10.1 Consents to the inspection of records and documents pertinent to his or her licensure, specific training, experience, current competence, and ability to perform the privileges requested and it requested,, appears for an inter view; MS.5.10.1.1 The bylaws, rules and regulations, and policies of the medical staff indicate that the applicant for reappointment or renewal of clinical privileges is required to submit any reasonable evidence of current ability to perform privileges that may be requested. MS.5.10.2 (Each applicant) pledges to provide for continuous care for his or her patients; and MS.5.10.3 (Each applicant) acknowledges any provisions in the medical staff bylaws for release and immunity from civil liability. MS.5.11 Appointment or reappointment to the medical staff and the granting, renewal, or revision of clinical privileges are made for a period of no more that two years. MS.5.12 Appraisal for reappointment to the medical staff or renewal or revision of clinical privileges is based on ongoing monitoring of information concerning the individual’s MS.5.12.1 Profession performance MS.5.12.2 Judgement; and MS.5.12.3 Clinical or technical skills. MS.5.12.13 Departmental or major clinical service recommendations are part of the basis for developing recommendations for continued membership on the medical staff or for delineating individual clinical privileges. MS. 5.14 All individuals who are permitted by law and by the hospital to provide patient care services independently in the hospital have delineated clinical privileges, whether or not they ar medical staff members. MS.5.14.2 The delineation of an individual’s clinical privileges includes the limitations. If any on an individual’s privileges to admit and treat patients or direct the course of treatment for the conditions for which the patients were admitted. MS.5.14.2 There is a mechanism designed to ensure that all individuals with clinical privileges only provide services within the scope of privileges granted. MS.5.14.3 When physicians or other individuals eligible for delineated clinical privileges are engaged by the hospital to provide patient care services pursuant to a contract, their clinical privileges to admit or treat patients are defined through medical staff mechanisms. MS.5 14.4 When appropriate, the chief executive officer or his or her designee may grant temporary clinical privileges for a limited period of time on the recommendation of the director of the applicalble clinical department, when available, or the president of the medical staff in all other circumstances. MS.5.15 Whatever mechanism for granting and renewal or revision of clinical privilges is used, evidence indicates that the clinical privileges are hospital specific and based on the individual’s demonstrated current competence. MS.5.15.1 Privileges are related to M.S.5.15.1.1 An individual’s documented experience in categories of treatment areas or procedures; MS.5.15.1.2 The results of treatment: and MS.5.15.1.3 The conclusions drawn from organization performance improvement activities when available. MS.5.15.2 Board certified is an excellent benchmark and is considered when delineating clinical privileges. MS.5.15.3 When privilege delineation is based primarily on experience, the individual’s credentials record reflect the specific experience and successful results that form the basis for the granting of privileges. MS.5.15.4 When the medical staff uses a system involving classification or categorization of privileges, the scope of each level of privileges is well defined, and the standards to be met by the applicant are stated clearly for each category. MS.5.15.5 When Medical staff clinical departments exist, all licensed independent practitioners are assigned to ar least one clinical department and are granted clinical privileges that are relevant to the care provided in that department. MS.5.15.5.1 There is a satisfactory method to coordinate appraisal for granting or renewal or revosion of clinical privilges when an individual currently holding clinical privileges or applying for clinical privileges requests privileges that are relevant to the care provided in more than one department or clinical specialty area. MS.5.15.6 The exercise of clinical privileges within any department is subject to the rules and regulations of that department and to the authority of the department’s director. MS.5.15.7 When there are no nedical staff clinical departments, all individuals with clinical privileges have their privilges recommended and the quality of their care reviewed through designated medical staff mechanisms, described in the medical staff or governing body bylaws and rules and regulations.