Competency Must Be an Integral Part of the Privileging Process

Hospitals have been granting clinical privileges for approximately 40-50 years, but for much of that time period, privileging systems have not addressed current clinical competency in any meaningful way. The emphasis of the Centers for Medicare & Medicaid Services (CMS) on criteria-based privileges, and subsequently, of The Joint Commission, as well as other accrediting organizations, has forced hospitals and their medical staff organizations to search for effective ways to design and implement criteria-based privileges.

There are a number of terms that are used when discussing clinical privileging systems that should be defined for the purposes of this post. They are:

  • Clinical Privileges: The specific clinical duties which may be provided by practitioners at or on behalf of a healthcare organization. The privileges must be granted by the Board.
  • Criteria-Based Privileges: A group of privileges (for example, pain medicine privileges) or single privileges (for example, the privilege to administer deep sedation), matched with criteria that must be met in order for a practitioner to be eligible to apply for the privilege(s). Criteria may include any/all of the following: education, training, clinical activity, board certification, other certification, contractual relationships, meet qualifications for other related privileges, behavior, etc.
  • PCCB: Morrisey’s privileging website, available via subscription, which enables organizations to design and maintain criteria-based privileges from researched content provided by industry experts.

How does PCCB (Morrisey’s Privilege Content and Criteria Builder) assist in development of criteria-based privileges and meet CMS/Joint Commission requirements?

PCCB assists hospitals and other organizations that privilege practitioners to develop criteria-based privileges and comply with CMS and accreditation requirements as follows:

  1. Content for privileges is posted for all specialties/sub-specialties, and each group of privileges is linked to specific training requirements, clinical activity (as applicable), etc. The format for the PCCB privileges offers organizations the opportunity to use the Morrisey PCCB criteria or to insert their specific criteria for privileges at the level of each group of privileges.
  2. Criteria for privileges is located on the privilege delineation, so that applicants and evaluators are in no doubt as to the requirements related to education/ training, certification, etc. for specific groups of privileges or individual privileges.
  3. Privileges are coded with CPT and ICD-10 codes—which will allow an organization to compare granted privileges with clinical activity reports and identify when privileges are granted but not exercised.
  4. PCCB privileges are designed to be used electronically. There is no possibility for applicants to write in requests for additional privileges. Applicants should be encouraged to petition for additional privileges/procedures to be added to a delineation in a more formal process so that the organization can determine if new privileges should be added to the scope of a particular specialty.
  5. PCCB privileges can be modified by the applicant or by the organization. By that, we mean that an applicant can electronically deselect privileges within a grouping (i.e., core or a cluster) that he/she does not want to request. The organization can also deselect granting of a privilege within a group of privileges.

See Joint Commission requirements related to this practice below (the following was downloaded from the Joint Commission website on December 30, 2016):

“Systems for defining and granting clinical privileges are fundamental to ensuring patient safety and improved outcomes.”

PCCB, provided by Morrisey, A HealthStream Company, is the most comprehensive, updated tool available for organizations that want to implement and maintain a state-of-the-art privileging system. HealthStream is dedicated to improving patient outcomes through the development of healthcare organizations’ greatest asset: their people. Confirming and improving the competency of the physician and other practitioner workforce makes PCCB a natural fit into HealthStream’s provider solutions.

This blog post excerpts an article in the Q1 2017 Provider Advisor. For additional information, complete the form below to download the entire issue.

April 1, 2021