Mitigating turf battles when granting privileges across specialties
It is a situation that has replayed in hospitals for many years: a physician from one specialty wants to perform a procedure or apply for privileges that traditionally fall under the domain of another specialty. The physician applying for privileges might have the training and the qualifications to perform the procedure safely, but it is the political ramifications that the credentials committee must manage. Crossover privileges, or privileges that are shared across several specialties, can cause disputes among physicians as to who should (and should not) perform certain procedures.
These turf battles often arise when physicians feel that practitioners from other specialties do not have the proper qualifications to perform a procedure. Physicians could also lose money if practitioners in another specialty are allowed to perform the same procedure. The credentials committee must navigate these political issues and handle requests for privileges with an unbiased and well-informed approach.
Common areas of crossover include labor and delivery privileges (see sample form on p. 3), peripheral vascular interventional procedures, esophagogastroduodenoscopy and colonoscopy, cosmetic surgery, and spine surgery, says Sally Pelletier, CPMSM, CPCS, senior consultant and director of credentialing services at The Greeley Company, a division of HCPro, Inc., in Danvers, Mass.
Each of these areas involves physicians from two or more specialties. For example, interventional radiologists, vascular surgeons, and interventional cardiologists can all perform peripheral vascular interventional procedures, but they might not all agree that the others should hold the same privileges.
Initiating the decision-making process
Pelletier notes that credentials committees should establish and follow a thoughtful process for determining which specialists should perform crossover privileges.
"Unless there is an exclusive contract involved that makes it clear cut as to which specialty provides the service, credentials committees are wise to base their decisions on researched information and make judgments based on quality of care and concern for the patient," Pelletier says. She adds that the decision-making process should stand up to legal scrutiny by avoiding restraint of trade or antitrust statutes.
Medical staffs should consider creating a multidisciplinary task force to deal with each specific instance of crossover privileges. The team should include specialists from each of the involved specialties, as well as any other people in the organization pertinent to the discussion, such as OR supervisors, nurse directors, or hospital administrators, says Terry Wilson, BS, CPMSM, CPCS, director of the medical staff services department at Flagler Hospital in St. Augustine, Fla. She recommends that the team addresses the following concerns:
- Which specialty should perform a procedure
- Whether the procedure should cross specialties
- Why it should cross specialties
- What competency levels are required for individual specialists to perform the procedure
- The financial feasibility of the procedure for the hospital
- Special equipment or training required to perform the procedure
- Where the procedure will be performed
After thoroughly researching and discussing the issue, the task force should make recommendations to the credentials committee, which considers it and in turn makes recommendations to the medical executive committee (MEC). The MEC also weighs in on the recommendations before the issue moves on to the board, where the final decision is made, according to Wilson.
"The best advice is to get all the right people involved up front to discuss it," says Wilson. "That way, you hide nothing, it's an open and frank discussion, it's fact-based, and you deal with it at that level first."
Researching issues and determining criteria
After bringing together everyone who should be involved in the discussion, the group must look into the necessary training and requirements for the requested privileges. The physician requesting the privileges should provide some of the information about general requirements, such as education, training, board certification, and experience, Pelletier says. However, she notes that regardless of the information provided by the requesting physician, the credentials committee or task force should conduct its own research to reach its own conclusions. This will mitigate any potential bias within the information provided by the physician requesting privileges.
Society and board websites, including societies that join forces to publish consensus statements for areas of crossover privileges, are great places to begin research. Pelletier also recommends using other hospitals as a resource for obtaining previously developed policies and criteria related to crossover privileges.
Wilson, like Pelletier, recommends collaborating with local hospitals to determine how others are handling crossover privileges. Flagler uses HCPro resources, such as the Credentialing Resource Center's Clinical Privilege White Papers and the "Medical Staff Talk" e-mail listserv, to connect with other professionals and gather information.
"You do your research and you avail yourself to the information that's out there as best you can, and that's the information you put in front of your committee for them to make a recommendation," says Wilson.
She estimates that the entire process, from establishing the task force to making a final decision, takes an average of six months, during which time the physician requesting privileges should not perform the procedure.
Once the credentials committee or task force has gathered a sufficient amount of information, the committee must come to an agreement about the amount and type of residency, fellowship, or postgraduate continuing medical education necessary to acquire the appropriate knowledge and skills for the privilege or procedure, says Pelletier.
When creating criteria, credentials committees should focus on education, training, and current experience, says Pelletier. The committee should focus on addressing those three major categories in any privileging criteria. When it comes time to vote on criteria, Pelletier suggests that members of the credentials committee who practice in any of the specialties involved in the crossover privilege debate excuse themselves from the vote.
Liability concerns and other considerations
Liability exists whenever a physician is granted privileges that extend beyond the core privileges covered during training, regardless of whether the privilege crosses specialties. In the case of crossover privileges, Wilson recommends starting at the basic level of evaluating whether practitioners in a specialty are trained for the privilege, but then focusing on the competency of the practitioner requesting the privilege.
"If the organization sets criteria that it believes will prove competency, then the individual practitioner must provide proof that he or she meets that competency," says Wilson. "Liability rests in granting the privilege to the right person up front, rather than trying to figure out how to reverse the decision later on after realizing a practitioner wasn't competent to perform a procedure."
The research performed by the credentials committee, as well as the established eligibility criteria, should provide the hospital with clear policies by which to evaluate the competency of each individual practitioner requesting crossover privileges, according to Pelletier.
Ultimately, a hospital must also make the best decision for its patients. "The needs of the patient and the community, as well as the interest of the hospital and physicians must be the basis for the decision as to who is granted what type of privilege," says Pelletier.
Crossover privileges will inevitably arise, and it is up to the credentials committee to scrutinize each privileging dispute, assess the available information, and establish policies and procedures based on thorough research to determine the appropriate course of action.