Hospitals have a responsibility to ensure that physicians

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1 College of American Pathologists Considerations for the Delineation of Pathology Clinical Privileges Edward W. Catalano Jr, MD; Stephen Gerard Ruby, MD, MBA; Michael L. Talbert, MD; Douglas G. Knapman, MBA; for the Members of the Practice Management Committee, College of American Pathologists Context. The Joint Commission (JC) established new medical staff privileging requirements effective January The new requirements include the development of ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE) processes and incorporate the general competencies of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice jointly developed by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS). The College of American Pathologists makes resources available to assist members and their facilities in implementing the new requirements and improving patient care. Objectives. To review the general requirements for privileging and identify how they may apply to pathologists, to identify currently available activities and metrics that may be useful in addressing these requirements, and to present identified concepts, activities, and metrics for consideration by pathologists and hospitals for their adaptation into the policies and procedures that address the new JC physician privileging requirements. Design. Review available pathology privileging documentation that addressed the previous JC requirements, review the new requirements, and search for and review available and applicable resources, activities, and metrics. Results. Common pathology activities and metrics can be incorporated into the privileging processes. Current and new activities and metrics can be incorporated or developed to address the 6 ACGME/ABMS General Competencies. Conclusion. Each hospital has unique privileging and physician evaluation requirements. Providing concepts, activities, and metrics for pathologists and hospitals to consider in pathology privileging will help implement the OPPE and FPPE processes and meet medical staff privileging requirements. (Arch Pathol Lab Med. 2009;133: ) Hospitals have a responsibility to ensure that physicians on their medical staff who are practicing their profession have the appropriate training, skills, and competency to treat patients. Hospitals seek to place the patients interests first and to limit physicians professional treatment to their areas of competency. Hospitals do this through the concept of clinical privileges, which carefully delineate the scope of practice of each physician in the hospital. Such delineation of privileges is required by the Joint Commission (JC) and is overseen by the medical staff of each hospital. As of January 1, 2008, facilities accredited by the JC are required to meet new standards for privileging physicians at their facilities. The new standards require the use of more formal, detailed, evidence-based Accepted for publication December 4, From the Department of Pathology, Palmetto Richland Memorial Hospital, Columbia, South Carolina (Dr Catalano); the Department of Pathology, Palos Community Hospital, Palos Heights, Illinois (Dr Ruby); the Department of Pathology, University of Oklahoma, Oklahoma City (Dr Talbert); and Membership and Professional Development Division, College of American Pathologists, Northfield, Illinois (Mr Knapman). The authors have no relevant financial interest in the products or companies described in this article. Reprints: Douglas G. Knapman, MBA, Membership and Professional Development Division, College of American Pathologists, 325 Waukegan Rd, Northfield, IL ( practicemanagement@ cap.org). processes to evaluate physicians. To meet these standards, the JC now requires the development of both ongoing professional practice evaluation (OPPE) processes to evaluate physicians on an ongoing basis and focused professional practice evaluation (FPPE) processes for granting a physician initial privileges, granting of new privileges, and addressing concerns regarding existing privileges. After addressing general considerations and qualifications in the privileging of pathologists, we will describe these processes in more detail. The evaluation processes and delineation of pathology privileges are developed by the medical staff and are the responsibility of the hospital. The information contained herein is for background purposes only. The College of American Pathologists (CAP) does not make any specific recommendations, and each hospital, with assistance from its medical staff and pathology department, should make its own determination as to what is most appropriate for its specific circumstances. GENERAL CONSIDERATIONS The degree of complexity and specificity required for delineation of professional privileges is influenced by the size of the hospital and by the services and skills available. Although most physicians requesting privileges in anatomic or clinical pathology will be diplomates of the Arch Pathol Lab Med Vol 133, April 2009 Delineation of Pathology Clinical Privileges Catalano et al 613

2 American Board of Pathology, the granting of privileges should be based not solely on board certification but also on evidence of current licensure, education, experience, competence, and due consideration of any prior adverse licensing or credentialing decisions. Fellowship in the College of American Pathologists, membership in other scientific organizations, or the physician s rank or tenure are relevant only to the extent that they are indicative of education, experience, or competence. In most instances, the granting of privileges to hospital staff members in pathology will combine a specialty (pathology) and intraspecialty designation (anatomic pathology, clinical pathology, etc), coupled with specific authorization for the performance of any invasive patient procedure. Typically, hospital-based pathologists practice both anatomic and clinical pathology and are usually certified by or are qualified for examination by the American Board of Pathology (ABP). Pathologists certified by the ABP in clinical pathology or with equivalent qualifications are generally granted privileges in clinical pathology and all its subdisciplines, including immunohematology, blood banking, hematology, hematopathology, and clinical microbiology. Pathologists certified by the ABP in anatomic pathology or with equivalent qualifications are generally granted privileges in surgical pathology, autopsy pathology, cytopathology, molecular pathology, and associated ancillary studies. Pathologists qualified to perform invasive biopsy techniques (needle or surgical), chemotherapy, in vivo nuclear medicine, or other special diagnostic or therapeutic procedures should obtain approval from the medical staff on a procedure-specific basis. There are a number of methods used by facilities for delineation of specific medical staff privileges. This does not release each department within the hospital or the hospital staff from establishing its own specific regulations according to local need and professional resources available. In addition to the pathology-specific privileges, each pathologist should also have typical medical staff privileges necessary to carry out patient-care responsibilities such as those that allow consultation, the entry of data in patient charts, and the ordering of diagnostic studies. QUALIFICATIONS A hospital may establish a list of qualifications, based on recommendations of its medical staff and approval by its governing body, which pathologists must have to be eligible for pathology privileges at its facility. 1 Shown below is a sample set of qualifications: Minimum Formal Training. The pathologist graduated from a medical school in the United States or Canada accredited by the Liaison Committee on Medical Education, graduated from an osteopathic college of medicine accredited by the Bureau of Professional Education of the American Osteopathic Association, or graduated from a medical school outside the United States or Canada that is acceptable to the ABP. The pathologist is able to demonstrate successful completion of an anatomic and/or clinical pathology residency training program that is acceptable to the ABP. 2 Current Competency. The pathologist is able to demonstrate that within a time frame that supports current competence, he or she has maintained competency by being actively involved in the clinical practice of pathology, by participating in an accredited pathology residency or fellowship program, by peer review, or by other means deemed appropriate for the individual. The hospital may request documentation that the pathologist has recently competently performed the activities associated with the privileges he or she has requested. A pathologist who cannot meet this criterion should be considered for limited/ probationary privileges under supervision by a staff pathologist (ie, proctoring) until competence has been adequately demonstrated. Special Requests. Successful, documented completion of approved, recognized course(s), when such exists, or acceptable supervised training in residency, fellowship, or other acceptable experience CHANGES IN PRIVILEGING: OPPE AND FPPE As of January 1, 2008, the JC requires 2 new privileging processes. 1. The first process is titled Ongoing Professional Practice Evaluation. This process requires ongoing continuous evidence-based evaluation of each physician s performance. The process is to be designed for timely identification and resolution of potential problems and replaces the previous renewal process that evaluated physicians every other year. The OPPE must be a clearly defined process based on monitors recommended by individual departments and approved by the medical staff. The results of OPPE will be used to decide if current privileges should be continued, revoked, or limited The second process is titled Focused Professional Practice Evaluation. This process focuses on a specific detailed area(s) of a pathologist s performance and may be used to accomplish the following: Privilege new pathologists Grant new privileges for a pathologist already established at a facility Facilitate the resolution of a potential concern Initiate general quality improvement Initiate quality improvement for a specific privilege or physician need identified by the OPPE The FPPE must be clearly defined and consistently applied. The process must have criteria for conducting the monitoring process and methods for matching the monitoring to a specific privilege and for establishing duration of monitoring. Triggers that would indicate the need for focused monitoring or additional monitoring must also be clearly defined. 5 Interventions to resolve performance issues must be clearly delineated and consistently applied. 6 Both OPPE and FPPE are to address the 6 areas of general competency developed by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS). At this time the use of the 6 areas of competency for evaluating physicians is a relatively new and a developing concept. In developing or reevaluating current privileging standards, pathologists or facilities may want to check the ACGME Web site ( accessed October 31, 2008) for the latest information and tools regarding the 6 general competencies. The General Competencies section of this paper elaborates on this topic and identifies 614 Arch Pathol Lab Med Vol 133, April 2009 Delineation of Pathology Clinical Privileges Catalano et al

3 potential standards and evaluation options for each competency which may be applied to the practice of pathology. EVALUATION ALTERNATIVES Both OPPE and FPPE are evidence-based processes that imply the need for evaluation of a pathologist s performance. Pathologists may want to be proactive in working with their facilities and use, whenever possible, performance evaluation measures already in place. With pathologists long-standing and ongoing emphasis on quality assurance and improvement, a number of such measures are typically already in place. In addition, direct proctoring of specific or all activities can be a valuable evaluation tool for FPPE. Measures that apply to the performance of the pathology laboratory may be useful for evaluating pathologists in their role as laboratory medical directors. Example measures for OPPE and FPPE that may be useful to pathologists: Laboratory accreditation process Results from proficiency testing Results from correlation studies Inspection results including any noted deficiencies and documentation of corrective action Maintenance of certification activities Record review Checklist Global rating of performance 360-degree evaluations Portfolio Procedure and/or case logs Completion of self-assessment modules Continuing medical education Quality assurance and improvement activities Typical quality assurance activities Turnaround-time measurements Correlation of frozen-section diagnosis with final diagnosis Error rates Peer-review monitoring Discrepancy rates with other facility overreads Proficiency testing results Direct proctoring of specific or all activities Q-PROBES Q-TRACKS Laboratory management index program Maintenance of licensure activities Physician satisfaction survey results Patient satisfaction survey results, if appropriate For more information on maintenance of certification evaluation activities see Toolbox of Assessment Methods produced jointly by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties at assess/asshome.asp (accessed October 31, 2008). GENERAL COMPETENCIES This section reviews the general competencies as defined on February 13, 2007, and identifies standards and evaluation options for each competency as may be applied to the practice of pathology. This list of options is not inclusive but is provided as background information to assist pathologists in developing, with their facilities, the OPPE and FPPE criteria and processes for pathology privileging. Each facility should establish its own appropriate evaluation methods and may wish to investigate the availability of other options. Not all options listed will be reasonable for all facilities. 1. Patient Care to provide patient care that is compassionate, appropriate, and effective for the promotion of health, prevention of illness, treatment of health problems, and care at the end of life. 7 Standard. Provides compassionate, appropriate, and effective patient care. 8 Pathologist demonstrates a satisfactory level of diagnostic competence and the ability to provide appropriate and effective consultation in the context of pathology services. Pathologist provides patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Pathologist works cooperatively with health care professionals, including those from other disciplines, to provide patient-focused care. 9 Pathologist demonstrates informed decision-making. Pathologist educates colleagues and patients to improve patient care. Pathologist facilitates learning for colleagues and other health care professionals. Pathologist effectively uses information technology to provide patient care. 10 Turnaround-time standards for professional services meet or exceed facilities accrediting body standards Participation in patient-safety improvement initiatives Laboratory inspection results and certification status 2. Medical Knowledge to demonstrate knowledge of established and evolving biomedical, clinical, epidemiologic, and social-behavioral sciences as well as the application of this knowledge to patient care and the education of others. 7 Standard. Demonstrates knowledge about established and evolving biomedical, clinical, and cognate sciences and their application to patient care. 8 Pathologist demonstrates knowledge about established and evolving biomedical, clinical, and cognate sciences (eg, epidemiologic, social and behavioral) and the application of this knowledge to patient care and to pathology. Pathologist demonstrates an investigatory and analytic thinking approach to clinical and pathology situations. Pathologist has knowledge of and applies the basic and clinically supportive sciences appropriate to pathology. 9 Participation in performance improvement program and quality assurance program Arch Pathol Lab Med Vol 133, April 2009 Delineation of Pathology Clinical Privileges Catalano et al 615

4 Participation in correlation studies Continuing medical education (CME) (35 category I CME credits per 2-year period or more, if required by state licensure) Board certification and, when applicable, maintenance of certification status 3. Practice-Based Learning and Improvement to be able to review and evaluate their patient care and laboratory practices, to appraise and assimilate scientific evidence, and to continuously improve patient care and laboratory practices by constant self-evaluation and lifelong learning. 8 Pathologists are expected to demonstrate the skills and develop habits that meet the following goals for themselves and their laboratories: Identifying strengths, deficiencies, and limits in their knowledge and expertise Setting goals for learning and improvement Identifying and performing appropriate learning activities Improving practices by using quality improvement methods to systematically analyze and implement appropriate changes to current practices Incorporating formative evaluation feedback into daily practice Locating, appraising, and assimilating evidence from scientific studies related to their patients health problems Using information technology to optimize learning Educating patients, families, students, residents and other health professionals. 7 Standard. Investigates and evaluates his or her diagnostic and laboratory practices and those of the laboratory and appraises and assimilates scientific evidence in improving laboratory practices and patient care. Pathologist demonstrates the ability to investigate and evaluate his or her diagnostic, consultative, and laboratory practices and to appraise and assimilate scientific evidence and improve the laboratory s practices and patient care. Pathologist locates, appraises, uses, and assimilates evidence and information from internal and external scientific studies related to the laboratory s practices and patients health problems. Pathologist applies knowledge of study designs and statistical methods to the appraisal of clinical studies. Pathologist uses information technology to manage information and support his or her practice. 9 Pathologist evaluates laboratory practices and patient care for process and outcome improvement and initiates steps to facilitate improvement. Laboratory accreditation Logs including case and time logs such as those used to record services not included in the medical record (ie, laboratory director services) Report of initiatives beyond standard and expected services Participation in interlaboratory performance improvement and quality assurance programs Response and documentation of corrective action for incident reports 4. Interpersonal and Communication Skills to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of health care teams. Standard. Demonstrates interpersonal and communication skills that result in effective information exchange and collaboration with patients, their families, and professional associates. 10 Pathologist communicates effectively with patients, families, physicians, other health professionals, healthrelated agencies, and, when appropriate, the public, across the range of socioeconomic and cultural backgrounds encountered in his or her practice. Pathologist creates and sustains a therapeutic and ethically sound relationship with patients, colleagues, and other health care professionals. Pathologist uses effective listening skills. Pathologist builds relationships and appropriately empowers others. Pathologist acts in a consultative role to other physicians and health professionals, as appropriate. Pathologist works effectively as a colleague or leader with others (including medical staff, nursing service, administration, other pathologists, and laboratory staff). Pathologist maintains comprehensive, timely, and legible medical records. 7 Results from survey of medical, professional, and other facility staff members and from patients meet or exceed facility standards 5. Professionalism to demonstrate behavior that reflects a commitment to continuous professional development and ethical practice, an understanding and sensitivity to the diversity of the patient population, and a responsible attitude toward their patients, their profession, and society. Standard. Demonstrates a commitment to carrying out professional responsibilities and an adherence to ethical principles. 9 Pathologist demonstrates a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. 9 Pathologist demonstrates compassion, integrity, and respect for others. Pathologist demonstrates responsiveness to patient needs that supersedes self-interest. Pathologist demonstrates a sense of accountability to patients, colleagues, society and the profession. Pathologist demonstrates respect for patient privacy and autonomy. Pathologist demonstrates sensitivity and responsiveness to a diverse patient population, including but not lim- 616 Arch Pathol Lab Med Vol 133, April 2009 Delineation of Pathology Clinical Privileges Catalano et al

5 ited to diversity in culture, age, sex, race, religion, sexual orientation, and disabilities. 7 Peer attestations by the following health care professionals: Chief of medical staff Medical executive committee Key nonlaboratory medical staff Laboratory staff Hospital or facility administration/staff 6. Systems-Based Practice to demonstrate an awareness and responsiveness to the larger context and system of health care, with the ability to call effectively on other resources in the system to provide optimal health care. 8 Standard. Demonstrates awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. 8 Pathologist understands how his or her pathology services and professional practices affect other health care professionals and organizations. 9 Pathologist demonstrates understanding of and contribution to local, regional, and national health care systems and supports health care system effectiveness. 10 Pathologist works effectively in various health care delivery settings and systems. Pathologist incorporates considerations of cost awareness and risk-benefit analysis in patient- and/or population-based care, as appropriate. Pathologist is an advocate for quality patient care and optimal patient care systems. Pathologist works to enhance patient safety and improve patient care quality. Pathologist participates in identifying system errors and implementing potential system improvements. 7 Laboratory inspection checklist Logs including case and time logs used to record services not included in the medical record (ie, laboratory director services) Report of initiatives beyond standard and expected services Establishing cost-effective laboratory and pathology policies and procedures for the laboratory and facilities it serves CAP PATHOLOGIST PRIVILEGE DELINEATION FORM SAMPLE This outline is a sample privilege delineation form and is offered by the College of American Pathologists as a method of privilege delineation for individuals in pathology. However, the CAP recognizes that other adequate methods are in current use or will be devised in the future. I. DOCUMENTATION Attach documentation of the following: Education, training, and experience in pathology to document basic qualifications and conditions for medical staff membership and privileges as defined in the medical staff bylaws Current licensure to practice medicine in the appropriate state(s) Freedom from any impairment that may adversely affect performance Training and current competency for requested privilege Professional liability insurance in accordance with requirements II. CERTIFICATION OR EQUIVALENT Primary specialty certification (anatomic pathology and/ or clinical pathology), certification date, and, if required by certification, recertification date(s). Not currently certified but has current board qualification status and has been declared qualified to be admitted to American Board of Pathology (ABP) examination by ABP s Credentials Committee. Subspecialty or areas of special competence (forensic pathology, immunopathology, dermatopathology, etc) and date(s) of certification If you claim either primary or subspecialty competence in pathology by virtue of equivalent education, experience, or demonstrated competence, please document these on a separate sheet and submit with this request for privileges. III. REQUEST FOR PRIVILEGES Cross off any privileges that do not apply and initial the section if any privileges are crossed off. a. Basic Privileges Anatomic Pathology Patient diagnosis, ordering, consultation, laboratory medical direction in the following disciplines: Surgical pathology (including intraoperative consultations), cytopathology, autopsy pathology, molecular pathology, and associated ancillary studies. Clinical Pathology Patient diagnosis, ordering, consultation, laboratory medical direction in the following clinical pathology disciplines: hematology and coagulation; blood bank and immunohematology; microbiology; serology; molecular pathology; clinical chemistry (including the subdivisions of special chemistry, automated chemistry, endocrinology, radioimmunoassay, toxicology, and electrophoresis); clinical microscopy; and other routine clinical pathology functions. b. Procedural Privileges Bone Marrow Aspiration and/or Biopsy Procedures Fine-Needle Aspiration and/or Biopsy Procedures Ultrasound-guided Fine-Needle Aspiration and/or Biopsy Procedures Venous Phlebotomy Arch Pathol Lab Med Vol 133, April 2009 Delineation of Pathology Clinical Privileges Catalano et al 617

6 Arterial Puncture Venous Injection of Contrast Dyes, Isotopes Apheresis c. Other Privileges Prescribe Blood Products To request additional privileges, please document these on a separate sheet and submit with this request for privileges. IV. GENERAL COMPETENCIES Provide documentation of demonstrated competency in each area of general competency.* i. Patient Care ii. Medical/Clinical Knowledge iii. Practice-based Learning and Improvement iv. Interpersonal and Communication Skills v. Professionalism vi. Systems-based Practice * See General Competencies section for suggestions regarding documentation options for each competency. V. APPROVAL Signature of Physician Signature of Approval Date Date GOING FORWARD To improve patient care, hospitals will continue to work to ensure that their are appropriately trained, skilled, with current competency to treat their patients. With pathologists ongoing emphasis on quality assurance and quality improvement, they are well positioned to adapt to and contribute to the development and refinement of the new physician evaluation standards, processes, and measures. Members of the CAP Practice Management Committee include Jared Jon Abbott, MD, PhD; Brent D. Benjamin, MD; Alfred Wray Campbell, MD; Matthew David Carr, MD; Edward W. Catalano Jr, MD; Robert De La Torre; Ronald J. Elin, MD, PhD; Miriam Natalie Grunkemeier, MD; Patricia L. Hughey; Robert L. Hunter, MD, PhD; Edward H. Lipford, MD; Kimberly A. Monnin, MD; Stephen Gerard Ruby, MD, MBA; and Michael L. Talbert, MD. References 1. The Joint Commission. History Tracking Report: 2009 to 2008 Requirements, Accreditation Program: Hospital, Chapter: Medical Staff. Standard MS E5809C585D82/0/HAP MS 09 to 08.pdf. Accessed July 18, American Board of Pathology. Requirements for Primary and Subspecialty Certification Professional Education. ProfessionalEd. Accessed October 31, Organized Medical Staff at Lexington Medical Center (LCHSD). Department of Pathology and Laboratory Medicine: Delineation of Privileges Form. Accessed October 31, The Joint Commission. History Tracking Report: 2009 to 2008 Requirements, Accreditation Program: Hospital, Chapter: Medical Staff. Standard MS EP 3. E5809C585D82/0/HAP MS 09 to 08.pdf. Accessed July 18, The Joint Commission. History Tracking Report: 2009 to 2008 Requirements, Accreditation Program: Hospital, Chapter: Medical Staff. Standard MS EP MS 09 to 08.pdf. AccessedJuly 18, The Joint Commission. History Tracking Report: 2009 to 2008 Requirements, Accreditation Program: Hospital, Chapter: Medical Staff. Standard MS EP MS 09 to 08.pdf. Accessed July18, Accreditation Council for Graduate Medical Education. Common Program Requirements: General Competencies. February 13, org/outcome/comp/generalcompetenciesstandards21307.pdf. Accessed October 31, University of Maryland Medical System. Summary Evaluation: Resident/Fellow Performance Form. assessment.doc. Accessed October 31, Penn State Pathology & Laboratory Medicine. Residency Program: Five Month Residency Rotation in Blood Bank and Transfusion Medicine. Accessed October 31, Hickey WF. Maintenance of Certification (MOC) Requirements for Pathologists 2007 Update. Presented at CAP 07 The Pathologists Meeting; September 30 October 3, 2007; Chicago, IL. Bibliography Accreditation Council for Graduate Medical Education and American Board of Medical Specialties Toolbox of Assessment Methods. acgme.org/outcome/assess/toolbox.pdf. Accessed October 31, American Board of Pathology. Maintenance of Certification Materials. Accessed October 31, The Joint Commission. Medical Staff Section of FAQs. jointcommission.org/accreditationprograms/hospitals/standards/faqs/default. htm. Accessed October 31, The Joint Commission on Accreditation of Healthcare Organizations Hospital Accreditation Standards. Available at Joint Commission Resource Store (to purchase search for title). Accessed October 31, Raab SS, Grzybicki DM, Zarbo RJ, Meier FA, Geyer SJ, Jensen C. Anatomic pathology databases and patient safety. Arch Pathol Lab Med. 2005;129(10): Arch Pathol Lab Med Vol 133, April 2009 Delineation of Pathology Clinical Privileges Catalano et al