Partners Consultants | Blog

Medical Staff Privilege – Getting Complicated??

Medical Staff Privilege – Getting Complicated??
By Admin | June 24, 2020 | Comments: 53

Medical staff privileging is a process whereby a specific scope and content of patient care services (that is, clinical privileges) are authorized for a health care practitioner by a health care organization, based on evaluation of the individual’s credentials and performance.(JCI Accreditation standards for Hospitals 7th Ed)

This article is making an attempt to discuss some of the common challenges faced by Medical staff departments while organizations is trying to ensure Privilege delineation process is carried out seamlessly.

Privilege committee members who are involved in granting, denying, or terminating medical staff privileges have an ethical responsibility to be guided by professional practice & regulations of the country which prevails.

Privilege decisions are based on the:

Candidate’s education, experience, demonstrated competence.

Candidates training as needed by profession or law.

Availability of facilities.

Overall medical needs of the community, the hospital, and especially patients.

Defining competence for a procedure is a one of most common debatable issue in medical staff fraternity. It is assumed that candidate’s education, experience and training alone may not give clear, objective evidence of current clinical competence. Joint commission International (JCI) recommends the use of Ongoing professional practice evaluation to validate the areas of presumed competence.

Read as Joint commission International accreditation (JCIA) mandates (SQE 10) The decision as to how clinical privileges are delineated in a specialty area is linked with other processes, including

selection by the department/service leaders of what processes are to be monitored through data collection; (Also see GLD.11.1).

use of those data in the ongoing professional practice evaluation process of the medical staff in the department/service; (Also see SQE.11)

use of the monitoring data in the process of reappointment and the renewal of privileges. (Also see SQE.12).

It is evident that without an integrated software which can fetch OPPE data to privilege platform electronically, it is nearly impossible.

Of the various methods of privileging, Criteria-based privileging incorporates predefined criteria in conjunction with clinically realistic, well-defined core privileges.This is a scientific approach to privileging in which the privileges for each specialty are predefined and divided into two categories, namely Core Privileges and Special Privileges.Practitioners who meet predefined criteria are eligible to apply for core privileges, and those who possess additional training and experience may request special (or noncore) privileges.Criteria Based Core Privileging are more of a scientific approach with clearly defined criteria, consistency, and practicality with ease of standardization.

The real challenge present for a hospital with large number of medical staff with a long list of visiting doctors and community-based doctors is to ensure validity and tracking of each medical staff privilege. Doctors from a same specialty often possess different set of privileges based upon individuals advanced trainings and competence; it is often seen that privilege of consultant surgeon may differ from that of a specialist or resident within the same department.

Critical privileges such as sedation privilege for non-Anesthetists is conditional to them meeting requirements laid out by the organization policy, including training as well as valid ACLS certificates. ACLS has got a validity of 2-3 years varying from country to country. Tracking of number of certificates for each medical staff in a medium to large hospital is a challenge. Many hospitals use HRMS, which tracks certificate expiry, however this information is not linked to individual staff privileges electronically, which is causing disconnect of relaying info between Human resources personnel and medical department, leads to lapse of privileges without being noticed. Usually organizations maintain renewal frequency of two years for medical staff privileges, where a review happens, but an expiry of document within this two year period often goes unnoticed.

I have come across many incidents of legal concerns, when a regulatory investigations is conducted to some patient complaints or surgical mishaps, with a shock the organization realizes that either the doctor was not privileged for that particular procedure or privilege is not valid due to expiry of related documents such as license or ACLS.

In my capacity as OT manager, we struggle every day to spot a particular procedure and its privileges since we use scanned copy of privileges of 100+ surgeons attending Eight OT rooms in our OT complex or Emergency OT in Emergency dept, which is causing a delay in OT booking, this is more miserable when we try to find a list of privileges of visiting surgeon whose visit is less often’’ we always end up with surprises of expired documents, amended privileges and so on, we end up postponing surgeries as a renewal process in the last minutes always delay. I am glad to see that technologies like AccreHealth technologies gives a comfort of getting the info we wanted in a time of click’’ from nursing station of OT or ER. (conversions documented from OT manager of a hospital attended demonstration)

( AccreHealth technologies integrate OPPE data with privilege of individual staff and manage complete privilege to reappointment workflow digitally)

Author is an accreditation consultant with an experience of leading 70+ hospitals across Middle East and Asia for their international accreditation, Mr. Thomas is known as a change agent, who advocates innovation and technology to facelift complex workflows in a Healthcare environment.

Mr. Thomas can be reached at or visit