Privilege delineation, defined as the practice of listing specific clinical privileges/procedures that a provider is allowed to perform within an organization, is essential in assuring quality care and minimizing the liability exposure of an institution and its staff. In our Privileging 101 Webinar Series, we go into all the details you need to become a privileging expert. In part four of the series, Privileging 101 - Introduction to Privileges: Part 4 - Anatomy of a Privilege Delineation, we discuss the nitty-gritty details of the many components of privilege delineation. This session covers everything from the development of required criteria/qualifications for education/training to additional qualifications for core/primary privileges, and everything in between.
For an overview of the webinar, read on, or click here to watch the full recording of Session 4.
Practitioners are granted privileges based on their education and training. This means a practitioner must meet certain criteria in order to request privileges at any organization. These criteria not only need to be spelled out in the medical staff bylaws, policies, and procedures, but they should also be listed on the delineation of privileges, so the practitioner is aware of the requirements for requesting those privileges. The delineation of clinical privileges designates the specific services and procedures that a physician is deemed qualified to provide or perform.
An organization’s delineation of privileges must always be current. At a minimum, in order to meet the Centers for Medicare and Medicaid Services (CMS) requirements, they should contain requirements for education, training, board certification, continuing medical education, initial competencies for new hires, re-appointment criteria, and any additional training or qualifications.
There are different criteria to meet CMS requirements, and different states may have their own criteria too, so it’s always important to know all needed requirements, which usually include:
Although residency fellowship program director evaluations and recommendations may not be required, it is considered best practice to get both. Some accrediting bodies, like The Joint Commission (TJC), consider it best practice to perform some type of professional practice evaluation to be considered for reappointment of clinical privileges. You may even want to include complaints or incident reports depending on what your accrediting body/bodies.
It is common practice to have core or primary privileges listed in your delineation of privileges. These are privileges that any provider or physician who has completed a residency or fellowship should be able to perform. There are many ways to delineate privileges including: delineation by practitioner specialty; delineation by patient risk categories; delineation using a list of procedures; and approaches combining these three methods. There are also many ways to delineate privileges incorrectly! For example, a large paragraph or list of procedures will not meet CMS requirements as this runs the risk of allowing a physician to request privileges for something they are not qualified to perform.
Proper delineation of privileges must:
Special advanced privileges should be separated out from the core primary privileges because they require either additional fellowship training, a manufacturer's recommendation, or more specific training or experience. It's just as important to make sure that the practitioner doesn't inadvertently request privileges that they're not currently competent in or may not be able to perform because they haven't got the requisite training.
Delineation of privileges will vary by institution, but here are some basics that should come standard for most.
There is a lot more that goes into privilege delineation, like:
To learn all the details, go ahead and watch our webinar covering the entire topic, Privileging 101 - Introduction to Privileges: Part 4 - Anatomy of a Privilege Delineation. Or, for more information on how CredentialStream can help keep you organized and ahead of the game, set up a demo with one of our resident experts. We know that with the right solution, your organization will have all it needs to assure quality care.