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Privileging 101 - Introduction to Privileges - Anatomy of a Privilege Delineation

Privileging 101 - How Organized Privilege Delineation Supports Patient Safety

January 9, 2023
January 9, 2023

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.

Delineation of Privileges (DOPs)
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:

  • Education and training
    • Medical school
    • Residency/Fellowship
    • Hands-on experience
  • Board certification (if required per bylaws)
    • Maintaining Certification (MOC)
    • Certificates of additional qualifications
  • Current competence
    • Case logs
    • Program director recommendation
  • Reappointment
    • OPPE data
    • Peer references
    • Department chair assessment

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.

Core/Primary Privileges
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:

  • Meet ACGME requirements
  • Be separated into systems or subgroups of privileges
  • Provide physicians with the ability to “opt out” of a privilege
  • Not allow the option for “writing in” a privilege not listed
  • List criteria for each specific privilege to ensure they can be met
  • Allow for focused professional practice evaluation (FPPE), especially if the accrediting body requires it

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.

Components of a Privilege Form
Delineation of privileges will vary by institution, but here are some basics that should come standard for most:

  • At the beginning of the privileged delineation, before the actual privileged details, the practitioner should see a section listing the required qualifications. The criteria should address any required education and training and board certifications (if applicable), as well as clinical experience activity and outcomes when appropriate.
  • After the required qualifications, privileges should be listed in detail. Core and primary privileges should be listed and separated into two sections: cognitive and procedural privileges.
    1. Cognitive includes admission to the hospital, performance history, and physicals performed. Evaluation of medical management of this specialty would also be included.
    2. Procedural privileges should be listed so that applicants, as well as the organization, can modify the group of privileges to the specific expertise of that applicant.
  • Special privileges or advanced privileges and procedures should then be noted. These require additional training, either a fellowship or manufacturer's recommendation or experience, or training for the specific advanced procedures during residency.
  • Some organizations may have requirements for their focused professional practice evaluation (FPPE) or Proctoring, as called by some organizations, which must also be listed.
  • There should also be a provider acknowledgment section. This is a statement by the provider who's requesting the privileges, acknowledging they're currently competent based on their education and training, board certification, and competency to perform the privileges requested. Often, this acknowledgment will also have a statement that they agree to abide by the hospital medical staff bylaws, policy procedures, and rules and regulations. It also indicates that any restriction on the clinical privileges granted to the provider is waived in an emergency situation and in such situations, their actions are governed by the applicable section of the healthcare organizations.
  • The final component of the privileged form is reviewers. A department chair or chief who makes recommendations regarding requested privileges. This would include any privileged conditions, modifications, or deletions or maybe an explanation that the practitioner or the department chair wants to make regarding the recommendation of the privileges for the practitioner.

Other Delineation of Privileges (DOPs) Considerations
There is a lot more that goes into privilege delineation, like:

  • NP/PA Requirements
  • Advanced/Supplemental Privileges
  • Manufacturer’s Recommendations
  • Types of Privileges
  • Temporary Privileges
  • Emergency Privileges
  • Emergency Privileges in a Declared Disaster

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.