Delineation of clinical privileges in hospitals

G D Kunders

The medical staff of a hospital can be organised in two ways. Under one system, by and large prevalent in our traditional hospitals, members of the medical staff are full-time, hospital-based, salaried professionals with or without limited consultation practice outside regular working hours. In the other system, as is the common practice in advanced countries like the US and in some of our high-tech corporate hospitals, medical staff are granted privileges to practice in the hospital in their respective specialties. Clinical privileges are therefore carefully delineated.

Delineation is the process by which the hospital determines what specific procedures may be performed by each medical staff applicant and appointee in the hospital by analysing his or her relevant education, training and experience with respect to the particular procedures that he or she seeks to perform. In the US, the criteria for delineation of privileges are stringent. They specify certification or specific training and experience needed to be eligible for specific privileges in any specialty. Delineation of privileges may well be considered the ultimate in establishing and guaranteeing high standards for patient care in hospitals.

In a well-organised system of the second type, the medical staff who are granted privileges from themselves into a self-governing medical staff organisation and are subject to the medical staff bye-laws, rules and regulations adopted thereunder.

The medical staff organisation carries out its duties and functions through various elected and nominated committees such as the executive committee, credentials committee, medical records committee, pharmacy and therapeutic committee, quality assurance committee, tissue committee, utilisation committee, infection control committee, etc aimed at maintaining high standards in patient care. The staff are categorised as active medical staff, honorary medical staff, associate medical staff, consulting medical staff, etc. Attendance at medical staff meetings is mandatory for active staff who are eligible to be elected or nominated to various standing committees. For the purpose of our discussion, we are concerned with the credentials committee.

Delineation of privileges is an integral part of the hospital's credentialling programme. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that "All individuals who are permitted by law and by the hospital to provide patient care services independently in the hospital have delineated clinical privileges, whether or not they are members of the medical staff."

The accreditation manual states that one of the responsibilities of the department's chairpersons or chiefs of division is "recommending to the medical staff the criteria for clinical privileges in the department." These criteria, according to JCAHO, must include at the least, evidence of current licensure, relevant training and/or experience, current competence and health status.

A distinction is made between the criteria for appointment of medical staff in the hospital and the criteria for the delineation of clinical privileges. The criteria for appointment to the medical staff are the general requirements that must be met by all applicants for medical staff appointment and by all medical professionals currently practising in the hospital.

They encompass the current license, DEA number, malpractice insurance, no physical and mental impairments, no past or present history of conviction of crimes involving moral turpitude, and ability to work well with others. A physician must meet the criteria for appointment before any privilege can be delineated. That is a prerequisite.

Criteria for delineation of clinical privileges on the other hand specify the certification or specific training and experience needed to be eligible for specific clinical privileges in any specialty. In other words, the criteria for delineation of clinical privileges must be specialty-specific as opposed to department-specific. For example, the department of surgery includes a variety of what in the US they call sub-specialties (commonly referred to as superspecialties in our country) that require particular credentials in those sub-specialties to perform related procedures. These criteria, recommended by the chairpersons of departments or the chiefs of division, should be approved by the credentials committee, the executive committee of the medical staff and the governing board of the hospital. They focus on specific sub-specialties and specific procedures rather than general criteria applicable to the entire department.

Individuals who do not meet the threshold criteria in a particular specialty may still qualify for certain limited clinical privileges in that particular specialty by providing evidence that they possess training and experience to perform the procedures requested.

A good example is that of a family practitioner who could apply for certain procedures on the core obstetrics and gynaecology list such as caesarian section. But to be granted those privileges, he or she would have to demonstrate to the satisfaction of the credentials committee and the board that he possesses satisfactory credentials to perform the procedures he is seeking.

All requests for clinical privileges must be accompanied by appropriate documentation that the basic criteria have been fulfilled as set forth in the delineation of privileges.

Regardless of his or her departmental or staff status, in case of an emergency, any member of the medical staff attending a patient shall be expected to do everything in his or her power to save the life of the patient, including the call of such medical help as may be available

Regardless of his or her departmental or staff status, in case of an emergency, any member of the medical staff attending a patient shall be expected to do everything in his or her power to save the life of the patient, including the call of such medical help as may be available. For this purpose, an emergency is defined as "a condition in which the life or organ of a patient is in immediate danger and in which any delay in administering treatment would increase the danger." As soon as the emergency is over, any extended privileges are terminated and the practitioner's regular privilege status is re-instituted.

Clinical privileges are monitored and evaluated for reappointment. They can also be reduced (voluntarily or involuntarily) and made conditional under certain circumstances. Privileges are also granted on temporary and locum tenens basis.

The American Academy of Family Physicians lists over 700 privileges for family physician departments in hospitals. "Family practice is a dynamic and comprehensive specialty. Adult medical care, child care, maternity care, surgical care, critical care and psychiatric care are integral components of the specialty." Other professional organisations such as the American Academy of Dermatology, American Academy of General Dentistry, American College of Obstetrics and Gynecology, American Psychiatric Association have listed their privileges in a similar fashion.

By way of illustration, some privileges that family physicians can request and be granted for performing procedures on the core lists of other specialties are listed below.

Granting of clinical privileges after careful scrutiny of the applicant's demonstrated credentials and experience ensures that a member of the medical staff undertakes only the treatment and the procedures for which he is fully qualified. What better way is there to ensure that the lives of patients are not placed in the hands of the uninitiated or half-baked physicians? The Quality Council of India (QCI), which is currently engaged in drafting standards for healthcare institutions in India, could take a leaf out of the book of their American counterparts.

American standards are so high and the rules are so stringent that they may be unattainable in our country for a long time to come. All the same, it is absolutely imperative that we establish mandatory albeit minimum standards in our hospitals with built-in quality assurance and safeguards for patients.

The writer is hospital management consultant and author.

E-mail: gdk@vsnl.net