Author: Jackie M. Jones, CPMSM, Senior Consultant
Shortly after I joined Verity, A Healthstream Company my boss asked me to write an article for the Consulting Connection. Having been onboard just a few months, I was not quite sure what topic to write about but before recalling a reoccurring theme I found when helping clients revise their delineation of privileges.
Most, if not all, of the facility privileges we reviewed were outdated and either missing privileges the practitioners were doing in their facility or there were privileges still on their delineations which were no longer being offered. SO I wrote an article “When was the last time you REALLY read your privileges?”.
Now in 2019, more than three years later, and the same theme is emerging. I am noticing when sitting down with organizations to review their privilege forms they are often surprised by some of the same issues; privileges not on their delineations, missing procedures or outdated criteria.
This reinforced to me the importance of setting a schedule to review your facility privileges every few years for content/correctness and compare them to what your facility is licensed to perform in your facility. Even if there are no significant changes, you can feel confident that your privileges are up to date with your criteria and privileges.
It is extremely important that your organization’s DOPs be current, match your medical staff bylaws, rules and regulations, credentialing and privileging polices as well as truly reflect what your physicians and advance practice practitioners are able to do within your facility. This must occur in order to meet the requirements set by Centers for Medicare & Medicaid Services (CMS) and more importantly, is critical to assure that practitioners are appropriately privileged by your organization in order to assure patient safety.