By Cyndi Newman, MSHL, BSN, RN
“Credentialing and privileging” are often discussed as a pair, but privileging and peer review are seen as distinct. As with credentialing, each informs the other and they should be viewed as integrated activities. Credentialing verifies that a provider’s education, license, and experience matches what that person has presented as fact. Privileging defines the scope of a provider’s service that can be delivered at your organization. Peer review is an informed assessment of competency in performing tasks relevant to privileges.
You may validate a physician’s credentials by confirming their MD/DO degree, their current license, and any board certifications. But that is not sufficient to fill a specific role at your organization. This is where privileging comes in. Unlike credentialing, it depends on policies established by the medical staff and approved by the governing body, including your ASC’s scope of services, eligibility criteria to perform specific procedures and associated tasks, and third-party evaluation of how well those tasks are accomplished.
For example, a CRNA is qualified by training to administer anesthesia. But has your organization identified the types of anesthesia it provides, the procedures to which each level of sedation applies, and those healthcare professionals approved for each level? Does your ASC account for physician supervision of non-physicians administering anesthesia in its list of privileges? Alternatively, has it taken appropriate steps to be exempted from the supervision requirement for CRNAs? If all relevant criteria are met, then the CRNA may be granted those privileges by the governing body based on defined eligibility and professional staff recommendations.
Introducing Peer Review to Privileging
Privileging is a shared responsibility. The practitioner must apply and reapply for specific privileges. The governing body must decide whether to grant, reduce, restrict, or deny the request. The recommendations that inform that decision should be based on peer review.
Cases of gross negligence or provider impairment require immediate action outside of the regular privileging cycle. Organizations must have a process to manage these rare but concerning events. But even within a more typical scenario, individuals can be uncomfortable about peer review as a concept. They view it as looking over the shoulder of a colleague with an expectation of either criticism or a rubber-stamped approval. It can be helpful to reframe peer review from a higher-level perspective; peer review is a collaborative decision about which aspects of care in the organization will be tracked and compared for all practitioners to identify strengths and opportunities.
Let’s assume that your organization is tracking surgical site infections. If the patients of a particular surgeon experience an uptick in infection rates, that would warrant further investigation. Was the change limited to a specific time frame? Was there a change in staffing among the surgical team that evidenced a variation in process? Were patients in that time frame more medically fragile? Was the increase in infections a persistent trend? Collecting and analyzing data can reveal many details that may or may not be related to the surgeon’s competencies. When it is a matter linked to the provider’s professional ability, data-based peer review removes opinion from the decision to restrict or deny privileges, creating opportunities to improve overall quality within your ASC by renewing process training, providing mentoring, or even making tough staffing decisions.
The Basics
Every ASC establishes its own criteria, but the overall privileging process follows these basic steps.
1. Application. Physicians and non-physician practitioner roles including NP, PA, CRNA, anesthesiologist’s assistant, RN first assistant, and others (consistent with state law) must complete an application for privileges at least every three years.
Most organizations have a deleation of privileges (DOP) request form to be used. This form must be specific to the exact surgeries or procedures the provider is seeking privileging to perform. It cannot simply list a general category of practice. For example, a general category is ophthalmology, but specific procedures may be cataract surgery, corneal transplant, cryopexy, goniotomy, etc.
The DOP should never list procedures that cannot be performed in your ASC because the risk involved is too great or your facility lacks the equipment necessary to perform the surgery.
2. Assessment. The medical director and/or medical staff committee reviews the request against currently granted privileges (if any) and the organization’s current scope of services, paying specific attention to anything that may have changed since the last application, including new procedures and new equipment. Privileges requested must match services provided by the organization. Supporting documentation based on regular peer review is part of the application package. A recommendation is forwarded to the governing body.
3. Decision. Granting, reducing, or denying privileges is the responsibility of the governing body. This body reviews the application packet and the recommendations of the medical director, then votes on privileges. This process must be documented and a decision letter delivered to the applicant and maintained in their credentialing file must include an authorized signature.
4. Monitoring and reappointment. When privileges are granted, the staff member’s professional activities are monitored throughout the privilege cycle until reappointment – when the provider begins the process anew and applies for privileges again.
Common Accreditation Deficiencies
When accreditation surveyors cite deficiencies related to privileging, it is often for administrative reasons. For example:
- Medical staff policies address the credentialing and privileging process but fail to include periodic review of the privileges offered.
- The governing body has neglected to approve the list of procedures that may be performed in the ASC.
- The governing body has made a generic approval to “perform orthopedic surgery.”
- The bylaws lack details of the privileging process.
- Credentialing files do not includee evidence that the provider is legally and professionally qualified for the privileges requested and granted.
- The delineation of privileges offered for each category of practitioner is not complete/consistent with the procedures offered.
- The delineation of privileges documentation in the provider’s file is missing:
- specifics regarding procedures or surgeries that can be performed.
- the requesting practitioners’ signature or the date of the request.
- the recommendation from the medical director.
- the formal approval granting privileges signed by an authroized representative of the governing body.
- No renewal request was completed at the time of reappointment.
Reducing Risk, Enhancing Safety
Credentialing, privileging, and peer review serve as risk reduction and patient safety strategies for your organization. Define your scope of service and the qualifications required to perform each procedure. Validate your providers’ education and experience. Approve the procedures they are authorized to perform in your organization. Track your results and use the data.
It’s that simple. And that important.
Cyndi Newman, MSHL, BSN, RN, is a senior clinical review specialist and surveyor for ambulatory surgery and office-based surgery centers at Accreditation Commission for Health Care Inc. (ACHC). Before joining ACHC, she served as a state surveyor of ASCs and hospitals, and as a risk manager for two hospitals. She is passionate about quality patient care and enjoys the collaborative relationship between ACHC and the organizations it serves.
