Privileges to Practice: How to Safeguard Healthcare Quality and Safety

Within a healthcare organization, patient safety is everyone’s job, from medical services professionals (MSPs) to the C-suite and the board of directors. Credentialing and privileging are vital to success at that job. Together these two processes ensure that the healthcare providers practicing within an organization have the appropriate education, training, and skills to perform the specific clinical procedures or services they’ve been entrusted to perform.

Effective credentialing and privileging protect the patient, the provider, and the organization. The patient receives the highest quality of care delivery. The provider is equipped with the expertise and competence to succeed. The organization safely fulfills its mission and upholds its standing in the community it serves.

Our eBook “A Beginner’s Guide to Privileging” covers everything from the history and fundamentals of clinical privileging to the regulatory and legal aspects of this work. Whether you are an MSP, a credentialing committee member, or a director on the hospital’s board, this eBook can help increase your understanding of this essential function. In the meantime, this blog post will serve as a high-level introduction.

Please note that privileging requirements vary by healthcare organization, depending on applicable accreditation body standards and state scope of practice laws.

Privileging protects everybody

Much of the responsibility for credentialing and privileging falls on MSPs, who are considered the gatekeepers of patient safety for healthcare organizations. Using these complementary — and complicated — processes, MSPs help healthcare organizations screen providers, verify providers’ ability to practice, and determine which procedures and services providers are competent to deliver.

There is an important difference between credentialing and privileging:

• Credentialing involves evaluating and confirming, via primary sources, various qualifications of licensed or certified healthcare Some of those sources include the successful completion of education and training programs, current and unrestricted medical or professional licensure, and certifications (as applicable), as well as the absence of sanctions, exclusions, and other disciplinary actions.
  
• Privileging grants healthcare providers the authority to perform specific clinical procedures or services within a healthcare organization and within their scope of practice. This is done via a process that evaluates not only the providers’ confirmed credentials but also the providers’ current clinical competency, meaning that the provider meets the established criteria or required qualifications required to perform the privilege. It is a healthcare organization’s most effective tool for ensuring the delivery of safe and high-quality patient care on a continuous basis and it also helps the organization meet regulatory requirements and accreditation standards.

That’s credentialing vs. privileging in a nutshell. This article will focus primarily on privileging.

4 basic steps in privileging

 Taking into consideration the overarching Centers for Medicaid and Medicare Services (CMS) Conditions of Participation (CoPs) related to privileging, applicable accreditation body privileging standards, and state laws regarding scope of practice, healthcare organizations establish rules for their privileging process. On a broad level, this involves four steps:

1. Determining the scope of services and procedures. The organization must decide which kinds of patient care, treatment, and services it will offer and support. Various factors will go into this determination, based on resources such as available space, equipment, staffing, and finances.
   
2. Determining criteria and qualifications. What are the minimum requirements for providing those services and procedures? What must a given provider do to demonstrate the necessary competence to request and be granted clinical privileges in a specified area?
   
3. Evaluating the applicant and making the privileging decision. To what degree does the provider who is applying for privileges meet the specified criteria, qualifications, and other requirements? Have they acquired the appropriate education and training, or experience required to be granted the requested privileges?
   
4. Ensuring current competency. The organization, through their peer review/professional practice evaluation processes, continuously monitors the privileges granted to providers to ensure their ongoing competency to deliver safe and high-quality patient care.

It’s not meant to be easy

Of course, there are very good reasons that not just anyone can become a physician, and that healthcare organizations have rigorous standards for those they allow to practice. People’s lives and health are at stake.

Pre-med, like most undergraduate programs, takes four years. That is typically followed by four years of medical school and then anywhere from three to seven years (or more) of specialized training known as a residency. The time varies depending on the medical specialty the individual chooses to pursue. Options include allopathic doctor (MD), doctor of osteopathic medicine (DO), doctor of dental surgery (DDS), and doctor of podiatric medicine (DPM).

After completing a residency, a physician may decide to acquire additional education through a fellowship that allows them to sharpen their expertise and skills in a particular subspecialty within their chosen field. Once physicians have completed their training, they must obtain a medical license in order to practice.

Medical licenses are specific to the state or territory where the physician will practice. Each state has specific requirements for when a resident physician may begin the license application process. All physicians must have:

1. Graduated from an approved medical school
2. Completed an approved residency
3. Passed a licensing examination

Those are the basic requirements of the Federation of State Medical Boards, which supports the nation’s state medical boards in licensing, disciplining, and regulating physicians and other healthcare providers.

Board certification shows expertise, experience

Board certification, while not mandatory, can be a key component in determining a physician’s expertise and experience in a field. It indicates advanced knowledge, training, and skills, helping patients identify qualified specialists.

Three basic levels of board certification are available for a physician: primary certification, subspecialty certification, and focused practice designation.

• Primary certification is for physicians who successfully complete and maintain requirements for their primary specialty.
  
• Subspecialty certification is for physicians who, in addition to receiving their primary certification, complete additional Accreditation Council for Graduate Medical Education (ACGME)-accredited fellowship training for at least a year.
  
• Focused practice designation is for physicians who demonstrate additional expertise and continued focus in a particular area of specialty or subspecialty.

It is important to note, however, that privileging recommendations cannot be made solely based on the presence or absence of board certification, per CMS CoPs.

A physician must clear at least five hurdles to obtain board certification:

1. Complete four years of medical education at a college or university.
2. Earn a medical degree from a qualified school.
3. Complete 3-7 years of full-time residency training, depending on the specialty.
4. Provide a letter of attestation from a program director.
5. Obtain an unrestricted medical license to practice within the United States or Canada.

Specialty board-specific requirements may vary. For more in-depth information, see the individual board’s website. These sites also provide recertification guidelines, which a healthcare organization can use in developing its own privilege-granting criteria and qualifications.

These organizations are authorities for physician board certification in North America:

1. American Board of Medical Specialties (ABMS): This organization, which has been around for more than 90 years, has 24 member boards with 38 specialty areas and 89 subspecialty areas.
2. American Board of Physician Specialties (ABPS): This certifying body has 12 governing boards overseeing physician board certification for 20 specialties and subspecialties.
   
3. American Osteopathic Association (AOA): This organization, founded in 1897, represents 16 specialty boards with 27 primary board certifications and 48 subspecialty certifications.
   

Core competencies needed to provide quality care  

Competency represents a provider’s ability to do a particular activity to a prescribed standard or with a desired outcome based on knowledge, education, training, traits, skills, and abilities. It is a principle of professional practice, identifying the ability of a provider to administer safe and reliable patient care on a consistent basis.

The independent, not-for-profit ACGME sets and monitors voluntary professional educational and clinical experience standards essential in preparing physicians to deliver high-quality and safe patient care. It oversees the accreditation of residency and fellowship programs for physicians in the United States for the purpose of evaluating residents to ensure they have the appropriate skills and experience before they are granted progressive levels of authority, conditional independence, and, ultimately, privileging.

The ACGME-accredited training programs are not directly involved in the privileging process. However, the six core competencies that the ACGME established for the purpose of evaluation of physicians in training programs, have been widely adopted by healthcare organizations in the evaluation of ongoing competency for clinical privileges.

• Patient care
• Medical knowledge
• Professionalism
• Interpersonal and communication skills
• Practice-based learning and improvement
• Systems-based practice

Each competency has specific assessment methods. Most of these are included in the privileging process, whether through peer review, simulation labs, case logs, observation, or physician feedback.

Resources that provide education and support

With so much involved, and so much at stake, healthcare organizations can benefit from resources designed to help them in their mission of providing safe, high-quality patient care. Here are a couple:

• Specialty societies promote, advance, and educate their members through the development and publication of evidence-based clinical practice guidelines, position papers, medical consensus documents, journals, or publications, as well as conferences or seminars. They support physicians with continuous quality improvement efforts through education and outreach efforts, allowing them to create common standards.
  
• CredentialStream by HealthStream

To learn more, download the eBook (it’s free)

If you found this blog post helpful, download our eBook “A Beginner’s Guide to Privileging” to learn more — and please contact us if you have any questions.