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Learn MoreHealthStream regularly publishes guest blog posts like the one below from Angela Beardsley, CMPSM, CPCS, Consultant and Jackie Jones, CPMSM, Senior Consultant; VerityStream
Based on the CMS and other Accrediting body requirements, it is a best practice to organize privilege forms by specialty, not by medical staff organization departments. If privileges are organized by medical staff organization departments, it may lead to confusion about the criteria/qualifications required to apply for the privileges. Additionally, organizing privilege forms by medical staff organization departments may lead to very lengthy forms, and providers may inadvertently request privileges outside of their specialty or scope of practice. Once privilege forms are organized by specialty, there are certain components that typically should make up each specialty’s privilege form.
Required Qualifications:
At the beginning of a privilege form, before the actual privilege detail, it is best practice to have a section for Required Qualifications.
Privilege Detail
After the Required Qualifications, next is the actual Privilege Detail. Privilege detail should be written so that privileges with similar criteria and transferable skills are grouped together. Under Privilege detail the privileges are typically categorized as follows:
Primary/Core Privileges
Since the CMS requires that Core Privileges must be able to be modified, when formatting Core Privilege detail, it is imperative to ensure that the providers requesting privileges as well as the clinical reviewers making recommendations, are able to modify the Core Privileges. On an electronic privilege form, the privileges within the Core Privilege group would need to be listed out individually, so that each privilege detail can be “checked” or “unchecked” as opposed to on a paper privilege form where Core Privileges within a group/paragraph could be crossed out.
Cognitive Privileges
This is where the admitting, history and physical exam, and the evaluate, diagnose, manage and treat type privileges would be listed.
Procedural Privileges
Procedural privileges should be written/defined in such a way, that enables the medical staff organization to easily monitor the performance of the privileges/procedures granted to providers, to ensure providers are not exceeding the scope of the privileges granted to them. This is a CMS requirement, as well as a requirement by other Accreditation Organizations.
Advanced Privilege Clusters
Advanced Privileges/Procedures that required Additional Training, such as a Fellowship, or maybe training for a specific advanced procedure during their Residency (for example, formal training during a residency is required for advanced laparoscopic procedures); another example might be required manufacturer recommended training (as is the case with Transcatheter Aortic Heart Valve Replacement (TAVR) ).
Conditions - Focused Professional Practice Evaluation (FPPE)/Proctoring
After Privilege detail, some organization’s privileges forms may have the actual requirements FPPE (Focused Professional Practice Evaluation) or Proctoring (as called by some organizations). FPPE/Proctoring is a requirement by some Accreditation Organizations (like TJC, DNV, and HFAP). This is the process for confirmation of competency of the full scope of privileges granted and should be implemented as soon as new privileges are granted to a provider.
Provider Acknowledgement
Next, there should be a Provider Acknowledgement section on the privilege delineation. This is the attestation that the provider is only requesting those privileges they are currently competent for based on their education/training and current experience. It should also indicate that any restriction on the clinical privileges granted to the provider are waived in an emergency situation, and in such situation their actions are governed by the applicable section of the health care organizations Medical Staff Bylaws or other related documents.
Clinical Reviewer(s) Recommendation
The final component of the privilege form for discussion is the section for the Clinical Reviewer (for example, Specialty Chiefs, Dept. Chairs, Chief of Staffs, CMOs) to make their recommendation regarding the privileges requested by the Provider. This would include any Privilege Conditions, Modifications, Deletions or explanations, and it also may include comments related to the FPPE/Proctoring recommendation (if applicable).
Once privilege forms have been developed, medical staff organizations should have a plan for regular review and updating of all privilege forms in order to keep privilege forms relevant and in alignment with current requirements. Some privilege forms will require annual review while others might be reviewed every other year.
Additionally, in between formal review periods, medical staff organizations should have policies and procedures in place for when new procedures/privileges/technology need to be added to their privilege delineations. The medical staff organization must determine that the privilege/procedure in question should be added to the scope of services for the medical staff organization and must develop criteria for what providers will be eligible to apply for the new privilege/procedure.
Ready to be a privileging superstar? See how VerityStream's Privilege solution can help you fortify patient care, satisfy providers, and comply with industry regulations. To learn more, download our article about the “Top Reasons to Automate and Standardize Privileging with Veritystream's Privilege Solution.”
The healthcare system is going through a volume-to-value transformation with the goal of controlling costs and improving patient outcomes. Rigorously assessing the clinical competency of your caregivers is more important than ever before. Privilege by VerityStream automates the clinical competency lifecycle including the standardization of the delineation, request, recommendation, granting, monitoring and evaluation of clinical privileges. With a library of continuously updated forms (best-practice, evidence-based, specialty-specific forms) and FPPE Insights, Privilege eliminates the need to conduct time-consuming research on new procedures and update privilege
HealthStream’s learning management system and comprehensive suite of competency management tools empower your healthcare workforce to deliver the best patient care.
View All Learning & PerformanceHealthStream offers performance learning management solutions to help develop your healthcare staff into leaders and reduce turnover.
View All ProductsHealthStream works with healthcare organizations to create engaging and high-quality training videos for your staff and management.
View All ProductsImprove care quality and save money by making informed decisions about your healthcare facility and staff with HealthStream's reporting analytics solution.
View All ProductsHealthStream's proven methods for the improvement and overall engagement of your healthcare staff foster a positive workplace and increase retention rates.
View All ProductsThe leadership development program from HealthStream helps mold your high-potential healthcare employees into proven leaders.
View All ProductsWhen you enact HealthStream's quality compliance solutions, you can do so with the confidence your healthcare organization will meet all standards of care.
View All Quality & ComplianceFulfill compliance requirements with a variety of programs and courseware designed to address critical regulatory requirements as well as educate staff to recognize and mitigate risks.
View All ProductsBy increasing your healthcare staff's focus on quality and safety with HealthStream, they can help to reduce medical errors and readmission rates.
View All ProductsLearn about what HealthStream's healthcare policy management software and how it can help aid your organization efforts.
View All ProductsHealthStream's education helps address diversity, equity, and inclusion within your organization, as well as promoting health equity in the communities you serve.
View All ProductsHealthStream offers professional training and education on how to best optimize your reimbursement process within your healthcare organization.
View All ReimbursementTeach your healthcare staff about the revenue cycle and claim management through targeted training and video tools from HealthStream.
View All ProductsImprove the preparedness of your staff, increase survival rates, and cut costs with the advanced resuscitation training services from HealthStream.
View All ResuscitationNurture the skills of your nurses and medical staff to help mold them into effective leaders with development training from HealthStream.
View All ProductsIn all areas of resuscitation, from neonatal to elderly care, clinical deterioration is a risk that can be avoided with the help of HealthStream's training programs.
View All ProductsHealthStream's EMS Program offers a comprehensive, CAPCE accredited EMS course library that meets National Registry annual recertification.
View All ProductsExpand the decision-making skills and effectiveness of your healthcare workforce with HealthStream's clinical development programs and services.
View All Clinical DevelopmentMake sure your clinicians have the support they need to provide competent care with clinical competency training and development from HealthStream.
View All ProductsThe suite of healthcare onboarding solutions available from HealthStream aids in nurse retention and improved patient outcomes.
View All ProductsGive your healthcare staff the decision support and skills training they need with the online products available from HealthStream.
View All ProductsHealthStream's solutions allow your healthcare workforce to be confident and competent with the knowledge they are upholding the highest of standards.
View All ProductsHealthStream’s learning management system and comprehensive suite of competency management tools empower your healthcare workforce to deliver the best patient care.
View All ProductsDelivers everything you need to request, gather, and validate information about a provider to create a single source of truth for downstream processes.
View All CredentialingMake sure your healthcare staff can schedule out appointments and work schedules with ease using HealthStream's line of software solutions.
View All Scheduling & Capacity ManagementHealthcare scheduling software designed to optimize staffing requirements & elevate patient care
View All ProductsPrecisely align staffing and needed resources to enable efficient patient flow and high-quality, cost-effective patient care.
View All ProductsHealthStream’s free nurse schedule app, NurseGrid™, is built to help you care for your staff and engage with their specific needs.
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