CLINICAL PRIVILEGE WHITE PAPER

Practice area 158 CLINICAL PRIVILEGE WHITE PAPER Background Psychiatry Psychiatrists specialize in the detection, diagnosis, treatment, and prevention of mental, emotional, and addiction disorders. Because modern psychiatry recognizes the relationship between mind and body, psychiatrists are uniquely qualified to consider the many causes of a patient s feelings and symptoms. For example, they are trained to pay special attention to issues of stress, physical illness, behavioral change, and prevention. In most states, psychiatrists are the only mental health providers who can prescribe medication. (New Mexico and Louisiana passed legislation granting psychologists prescription privileges, although both states require these practitioners to complete additional training.) The American Board of Psychiatry and Neurology (ABPN) states that, in addition to prescribing medication, psychiatrists are qualified to order and analyze diagnostic laboratory tests take detailed medical histories review medical records evaluate and treat psychological and interpersonal problems help individuals/families cope with stress, crises, and other life problems Psychiatrists treat patients using psychotherapy/psychoanalysis, medication, hospitalization, or a combination of these treatments depending on a patient s needs. They also often act as consultants to primary care physicians and nonmedical psychotherapists (e.g., psychologists, social workers, physician assistants, or nurse practitioners). After completing four years of psychiatry residency training, usually in a hospital inpatient setting, psychiatrists may begin optional fellowship training in a subspecialty. An exception is child psychiatry, for which the two-year fellowship training can begin after only three years of residency training. The effects of managed care on mental healthcare delivery, the use of antidepressants in children, technological advances (e.g., brain imaging and discoveries in molecular neurobiology), and the use of psychotropic medications (drugs capable of affecting the mind, emotions, and behavior) are just a few of the issues expected to affect psychiatry in coming years. For more information, see Clinical Privilege White Paper Child and adolescent psychiatry, Practice area 109, and Clinical Privilege White Paper Addiction medicine, Practice area 123. A supplement to Briefings on Credentialing 781/639-1872 08/05 1

Involved specialties Psychiatrists, neurologists, psychotherapists, family physicians, pediatricians, internists, and psychologists Positions of societies and academies APA The American Psychiatric Association (APA) publishes Guidelines for Psychiatric Practice In Public Sector Psychiatric Inpatient Facilities. According to the APA, the use of multidisciplinary teams consisting of nurses, psychiatrists, psychologists, and social workers is vital to the effective delivery of care in inpatient settings. The following factors affect the role of psychiatrists working in public psychiatric inpatient facilities, as outlined by the APA: Public sector psychiatric inpatient facilities diagnose and treat acutely and chronically mentally ill patients who are among the most severely ill psychiatric patients The care of these patients is a specialized area requiring a high level of expertise Mentally ill patients require comprehensive differential diagnostic evaluation, comprehensive and integrated treatment planning, and medical management in all three of the biological, psychological, and social spheres Medical problems often complicate this patient population s psychiatric problems, requiring prompt diagnosis, treatment, and management Treatment in such facilities often includes prescribing medication and other somatic therapies, which may require physical and physiological preparatory workup and continued monitoring for side effects and toxicities Psychiatrists have the necessary medical training and skills to evaluate physical problems and their relationship to psychological and social phenomena The physician is usually held legally responsible for the medical and psychiatric care provided in his or her delivery system and should have authority appropriate to that responsibility As a result, the APA guidelines state that public psychiatric inpatient facilities should operate under the supervision of a medical or clinical director who is a fully trained and qualified psychiatrist capable of providing oversight of patient diagnosis, treatment planning, and clinical care. In addition, the APA provides recommendations for the proper psychiatric and other medical evaluation and treatment of patients in public psychiatric inpatient facilities, as well as an outline of psychiatrists responsibilities on multidisciplinary teams. 2 A supplement to Briefings on Credentialing 781/639-1872 08/05

Positions of other interested parties ABPN The ABPN grants certification in general psychiatry. Applicants must meet the following minimum requirements: Graduate from an accredited medical school in the United States or Canada or of an international medical school listed by the World Health Organization. Hold an unrestricted license to practice medicine in at least one state, commonwealth, territory, or possession of the United States or province of Canada. If licenses are held in multiple jurisdictions, all licenses must meet this requirement. Have satisfactorily completed the specialized training requirements in psychiatry in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the Royal College of Physicians and Surgeons of Canada. This training must adhere to all ABPN requirements. In addition, the ABPN states that applicants must have satisfactorily completed an ACGME-accredited first postgraduate year plus three full years of postgraduate specialized residency training in an ACGME-accredited psychiatry program. According to the ABPN, the following training paths are acceptable: 1. Three-year psychiatry residency program: A broad-based clinical year of ACGME-accredited training in internal medicine, family practice, or pediatrics; or an ACGME-accredited transitional year program that includes a minimum of four months of primary care; or an ACGME-accredited residency in a clinical specialty requiring comprehensive and continuous patient care. In addition to any of these paths, three full years of postgraduate, specialized residency training in an ACGME-accredited psychiatry program are required. 2. Four-year psychiatry residency program: Four years of training in an ACGME-accredited program in psychiatry is acceptable. The first postgraduate year in psychiatry must include at least four months internal medicine, family practice, and/or pediatrics training. This training must be in a clinical setting that provides comprehensive and continuous patient care. No more than one month of this requirement may be fulfilled by an emergency medicine rotation if that rotation predominantly involves medical evaluation and treatment, rather than surgical procedure. Neurology rotations may not be used to fulfill this four-month requirement. ABPN subspecialty certification in the following areas of psychiatry requires additional training: Addiction psychiatry Child and adolescent psychiatry Clinical neurophysiology Forensic psychiatry A supplement to Briefings on Credentialing 781/639-1872 08/05 3

Geriatric psychiatry Neurodevelopmental disabilities Pain medicine Psychosomatic medicine Vascular neurology AOA The American Osteopathic Association (AOA), under the discretion of the American Osteopathic Board of Neurology and Psychiatry (AOBNP), grants general certification in neurology and psychiatry. The AOBNP defines psychiatry as the branch of osteopathic medicine that deals with disorders of the psyche of organic and functional nature, including all accepted therapies, assessments, and diagnostic studies. Applicants for certification in general psychiatry must graduate from an AOA-accredited college of osteopathic medicine be licensed to practice in the state or territory where one s practice is conducted show evidence of conformity to the AOA s code of ethics be a member in good standing of the AOA or the Canadian Osteopathic Association for the two years immediately prior to certification satisfactorily complete an AOA-approved internship complete three years of AOA-approved psychiatry training after the required one year of internship pass appropriate oral, written, and clinical examinations exams In addition, the AOBNP grants certification of special qualifications in child and adolescent psychiatry and child and adolescent neurology; as well as certification of added qualifications in addiction medicine, neurophysiology, and sports medicine. JCAHO The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has no formal position on the delineation of privileges in psychiatry. However, in its 2005 Comprehensive Accreditation Manual for Hospitals, the JCAHO states (MS.4.10), The organized medical staff has a credentialing process that is defined in the medical staff bylaws. In the rationale for MS.4.10, the JCAHO says credentials review is the process of obtaining, verifying, and assessing the qualifications of an applicant to provide patient care, treatment, and services for a healthcare organization. The credentials review process is the basis for making appointments to membership of the medical staff; it also provides information for granting clinical privileges to licensed independent practitioners (LIP) and other practitioners credentialed and privileged through the hospital s medical staff process. 4 A supplement to Briefings on Credentialing 781/639-1872 08/05

The JCAHO further states (MS.4.20), There is a process for granting, renewing, or revising setting-specific privileges. In the rationale for standard MS.4.20, the JCAHO says essential information needs to be gathered in the process of granting, renewing, or revising clinical privileges. The information will dictate the type(s) of care, treatments, and services or procedures that a practitioner will be authorized to perform. Privileges are setting-specific because they require consideration of setting characteristics, such as adequate facilities, equipment, number, and type of qualified support personnel and resources. Setting-specific decisions mean that privileges granted to an applicant are based not only on the applicant s qualifications, but also on consideration of the procedures and types of care, treatment, and services that can be performed within the proposed setting. All LIPs are privileged through the medical staff process. The JCAHO further states (MS.4.40), At the time of renewal of privileges, the organized staff evaluates individuals for their continued ability to provide quality care, treatment, and services for the privileges requested as defined in the medical staff bylaws. In the rationale for MS.4.40, the JCAHO says the process for renewal of privileges involves the same steps as those outlined under standard MS.4.20 for granting initial privileges, and it additionally requires the medical staff to evaluate practitioners ability to perform the privileges requested based on their performance during the period of time they have been practicing at the organization. A hospital reviews the performance of each practitioner for every setting under the control of the hospital where the individual practices. Current competence is determined by the results of performance improvement activities and peer recommendations. Evidence of current ability to perform privileges requested is required of all applicants for renewal of clinical privileges. CRC draft criteria Minimum threshold criteria for requesting core privileges in psychiatry The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding this practice area. Basic education: MD or DO Minimum formal training: Applicants must have completed an ACGME/AOA-accredited residency training program in psychiatry. Required previous experience: Applicants must be able to dem- A supplement to Briefings on Credentialing 781/639-1872 08/05 5

onstrate that they have provided inpatient, outpatient, or consultative services for at least 30 patients during the past 12 months. References Core privileges in psychiatry Special requests for psychiatry A letter of reference should come from the director of the applicant s psychiatry residency program. Alternately, a letter of reference regarding competence should come from the psychiatry department chair at the institution where the applicant most recently practiced. Privileges include the ability to admit, evaluate, diagnose, and provide treatment in inpatient, outpatient, and consultative settings to individuals above the age of 15 who suffer from mental, behavioral, or emotional disorders. Privileges can also include but are not limited to the ability to supervise multidisciplinary teams of allied health professionals (e.g., psychologists, psychiatric nurse practitioners, physician s assistants, and pharmacists) in the treatment of patients. provide counseling for individuals, groups, and families. screen, diagnose, and manage patients for mild/moderate addiction, intoxication, and withdrawal. (Note: While some hospitals grant addiction therapy privileges as part of general psychiatry, the treatment of patients with severe addiction; i.e., beyond mild to moderate, requires additional training.) provide brief intervention, addiction counseling, and medication management for patients with substance-related disorders. manage psychiatric complications and screen, diagnose, and refer patients for dual diagnoses. provide short- and long-term psychotherapy, psychodynamic therapy, and the concurrent use of medications and psychotherapy. Threshold criteria should be established for special requests including but not limited to hypnosis amytal interviews management of severely symptomatic chemical dependency, including detoxification/withdrawal electroconvulsive therapy (See Clinical Privilege White Paper Electroconvulsive therapy, Procedure 01, for a full explanation of the granting of this privilege.) Reappointment Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanisms. Applicants must be able to demonstrate that they have maintained competence by showing evidence that they have provided inpatient, outpatient, or consultative services for at least 30 6 A supplement to Briefings on Credentialing 781/639-1872 08/05

patients annually over the reappointment cycle. In addition, continuing education related to psychiatry should be required. For more information For more information about this practice area, contact: Clinical Privilege White Papers Advisory Board James F. Callahan, DPA Executive vice president and CEO American Society of Addiction Medicine Chevy Chase, MD Sharon Fujikawa, PhD Clinical professor, Dept. of Neurology University of California, Irvine Medical Center Orange, CA John N. Kabalin, MD, FACS Urologist/Laser surgeon Scottsbluff Urology Associates Scottsbluff, NE American Board of Psychiatry and Neurology 500 Lake Cook Road, Suite 335 Deerfield, IL 60015-5249 Telephone: 847/945-7900 Fax: 847/945-1146 Web site: www.abpn.com American Osteopathic Association 142 East Ontario Street Chicago, IL 60611 Telephone: 312/202-8000 Fax: 312/202-8200 Web site: www.do-online.osteotech.org American Psychiatric Association 1000 Wilson Boulevard, Suite 1825 Arlington, VA 22209-3901 Telephone: 703/907-7300 Fax: 703/907-1085 Web site: www.psych.org Joint Commission on Accreditation of Healthcare Organizations One Renaissance Boulevard Oakbrook Terrace, IL 60181 Telephone: 630/792-5000 Fax: 630/792-5005 Web site: www.jcaho.org Publisher/Vice President: Suzanne Perney sperney@hcpro.com Group Publisher: Kathryn Levesque klevesque@hcpro.com John E. Krettek Jr., MD, PhD Neurological surgeon Vice president for medical affairs Missouri Baptist Medical Center St. Louis, MO Michael R. Milner, MMS, PA-C Senior physician assistant consultant Phoenix Indian Medical Center Phoenix, AZ Senior Managing Editor: Edwin B. Niemeyer eniemeyer@comcast.net Beverly Pybus Senior consultant The Greeley Company Marblehead, MA Richard Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Marblehead, MA The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 2005 HCPro, Inc., Marblehead, MA 01945. A supplement to Briefings on Credentialing 781/639-1872 08/05 7

Privilege request form Psychiatry To be eligible to request clinical privileges in psychiatry, applicants must meet the following minimum threshold criteria: Basic education: MD or DO Minimum formal training: Applicants must have completed an ACGME/AOA-accredited residency training program in psychiatry. Required previous experience: Applicants must be able to demonstrate that they have provided inpatient, outpatient, or consultative services for at least 30 patients during the past 12 months. References: A letter of reference should come from the director of the applicant s psychiatry residency program. Alternately, a letter of reference regarding competence should come from the psychiatry department chair at the institution where the applicant most recently practiced. Core privileges: Core privileges in psychiatry include the ability to admit, evaluate, diagnose, and provide treatment in inpatient, outpatient, and consultative settings to individuals above the age of 15 who suffer from mental, behavioral, or emotional disorders. Privileges can also include but are not limited to the ability to - supervise multidisciplinary teams of allied health professionals (e.g., psychologists, psychiatric nurse practitioners, physician s assistants, and pharmacists) in the treatment of patients. - provide counseling for individuals, groups, and families. - screen, diagnose, and manage patients for mild/moderate addiction, intoxication, and withdrawal. (Note: While some hospitals grant addiction therapy privileges as part of general psychiatry, the treatment of patients with severe addiction; i.e., beyond mild to moderate, requires additional training.) - provide brief intervention, addiction counseling, and medication management for patients with substance-related disorders. - manage psychiatric complications and screen, diagnose, and refer patients for dual diagnoses. - provide short- and long-term psychotherapy, psychodynamic therapy, and the concurrent use of medications and psychotherapy. Reappointment: Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanisms. Applicants must be able to demonstrate that they have maintained competence by showing evidence that they have provided inpatient, outpatient, or consultative services for at least 30 patients annually over the reappointment cycle. In addition, continuing education related to psychiatry should be required. I understand that by making this request I am bound by the applicable bylaws or policies of the hospital, and hereby stipulate that I meet the minimum threshold criteria for this request. Physician s signature: Typed or printed name: Date: 8 A supplement to Briefings on Credentialing 781/639-1872 08/05