Practice area 158 Clinical PRIVILEGE WHITE PAPER Psychiatry Background 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. 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). Graduate training programs in psychiatry accredited by the American Osteopathic Association (AOA) are three years in duration, and those accredited by the Accreditation Council for Graduate Medical Education (ACGME) are four years in duration. Subspecialties of psychiatry that can be pursued following this training include: Addiction psychiatry (see Clinical Privilege White Paper, Addiction medicine Practice area 109) Child and adolescent psychiatry (see Clinical Privilege White Paper, Child and adolescent psychiatry Practice area 109) Clinical neurophysiology (see Clinical Privilege White Paper, Clinical neurophysiology Practice area 423) Forensic psychiatry Geriatric psychiatry Hospice and palliative medicine (see Clinical Privilege White Paper, Hospice and palliative medicine Practice area 406) Pain medicine (see Clinical Privilege White Paper, Pain medicine Practice area 108) Psychosomatic medicine Sleep medicine (see Clinical Privilege White Paper, Sleep medicine Practice area 117)
Involved specialties Psychiatrists Positions of specialty boards ABPN 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 Further, the conditions that psychiatrists treat, according to the ABPN, include: Depressive disorders Anxiety disorders Substance abuse disorders Psychoses Developmental disabilities Sexual dysfunctions Adjustment reactions The ABPN grants board certification in psychiatry to physicians who meet the following requirements: Are graduates of 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. Have satisfactorily completed specialized training requirements in psychiatry in programs that are accredited by the ACGME or certified by the Royal College of Physicians and Surgeons of Canada. This training must adhere to all board requirements. Submit a completed official application form including all required attachments and the appropriate application and examination fees by the specified deadlines. Pass the appropriate specialty certification examination(s). The ABPN is implementing a new certification process. For residents who began training as a PGY-1 on July 1, 2007, or as a PGY-2 on July 1, 2008, the Psychiatry Part II (oral) examination will be eliminated. The psychiatry certification process 2
will consist of a single computerized examination (Psychiatry Certification Examination) in 2011. Residents who began training as a PGY-1 before July 1, 2007, or as a PGY-2 before July 1, 2008, must pass both the Part I (computer-administered) and Part II (oral) examinations in order to become board-certified in psychiatry. Candidates who do not pass the Psychiatry Part I examination in 2013* or earlier or who do not complete the certification process by December 31, 2016, will be required to submit documentation of satisfactory performance in the evaluation of clinical skills completed by the current program director of an ACGMEaccredited program as part of the ABPN credentialing process. In addition, such candidates will be required to pass the new Psychiatry Certification Examination. *The 2013 Part I examination will not be available for first-time takers. The current format Part I examination will be eliminated after 2013. AOBNP The AOA, under the discretion of the American Osteopathic Board of Neurology and Psychiatry (AOBNP), grants general certification in 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 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. 3
Positions of societies, academies, colleges and associations APA In its Guidelines for Psychiatric Practice in Public Sector Psychiatric Inpatient Facilities, the American Psychiatric Association (APA) outlines the roles and responsibilities for a staff psychiatrist at a public psychiatric inpatient facility, as assigned to him or her by the medical/clinical director or chief medical officer. Those duties include: Providing direct psychiatric services through the comprehensive evaluation, diagnosis, treatment planning, and treatment of assigned patients. Making final decisions regarding admissions and discharges of patients in accordance with medical standards. Ensuring appropriate psychoeducation for patients, families, staff, and community professionals and laypeople. Ensuring the involvement of families whenever possible, with the patient s consent, in treatment planning. Ensuring that clinicians in assigned services receive appropriate clinical supervision on a regular basis. Participating in administrative duties as assigned, which could include, for example, being a member of or chairing the quality assurance and/or utilization review committees. Providing psychiatric leadership to interdisciplinary teams. The staff psychiatrist s responsibility on a multidisciplinary inpatient team includes treatment team planning and regular reviews that comprehensively address the patient s biopsychosocial needs. Providing psychiatric in-service training to other clinical staff members. Serving as psychiatric liaison with community care providers, particularly with regard to continuity of patient care. Identifying and advocating needed resources, including staff, to the medical director. A staff psychiatrist must be board-certified or board-qualified. If he or she is working on a subspecialty unit, appropriate subspecialty training and/or supervision is required. In the same document, the APA also lists the guidelines for proper psychiatric and other medical evaluation and treatment of patients. They stipulate that: Each patient should receive timely, comprehensive psychiatric evaluation, diagnosis, and treatment planning in the biological, psychological, and social spheres. 4
Each patient should be medically screened and his or her history reviewed to ensure that the full range of medical and surgical considerations is taken into account in determining the diagnosis and appropriate treatment; medical/ surgical consultation should be ensured when indicated. A psychiatrist may prescribe or adjust psychotropic medication only after his or her direct evaluation of the patient, except in times of emergency; in the latter case, timely direct evaluation should follow. A patient receiving medications should have his or her medications reevaluated by a psychiatrist as clinically appropriate and at least monthly, although preferably more frequently. Patients not receiving medications should be reevaluated by a psychiatrist at timely, clinically appropriate intervals. The frequency, process, content, and duration of any psychiatric evaluation or intervention should be based on patient need and not on administrative or fiscal considerations. Quality assurance and a utilization review of patients should include appropriate medical/psychiatric participation. The APA also recognizes the importance of telepsychiatry in providing patients in underserved and remote areas with access to services they otherwise would not have available. The APA defines telepsychiatry or telemedicine as a form of video conferencing that can provide psychiatric services to patients living in remote locations or otherwise underserved areas. It can connect patients, psychiatrists, physicians, and other healthcare professionals through the use of television cameras and microphones. The APA says that psychiatrists can use telemedicine to provide services such as diagnosis and assessment; medication management; and individual and group therapy. Additionally, psychiatrists can use telemedicine for consultative services between psychiatrists, primary care physicians, and other healthcare providers. Telepsychiatry also provides patients with second opinions in areas where only one psychiatrist is available. Lastly, the APA publishes Guidelines for Psychiatrists in Consultative, Supervisory or Collaborative Relationships with Nonphysician Clinicians, which outlines the role and responsibilities of psychiatrists in consultative, supervisory, and collaborative relationships with other healthcare professionals. 5
ACGME According to the ACGME, physicians may enter psychiatry programs at either the first-year or second-year postgraduate level. Physicians entering at the second-year postgraduate level must document successful completion of a clinical year of education in an ACGME-accredited specialty requiring comprehensive and continuous patient care, such as a program in internal medicine, family medicine, or pediatrics, or a transitional year program. According to the ACGME, residents in psychiatry must have competence in: Formulating a clinical diagnosis for patients by conducting patient interviews Eliciting a clear and accurate history Performing physical, neurological, and mental status examinations, including appropriate diagnostic studies Completing a systematic recording of findings Relating history and clinical findings to the relevant biological, psychological, behavioral, and sociocultural issues associated with etiology and treatment Developing a differential diagnosis and treatment plan for all psychiatric disorders in the current standard nomenclature The didactic curriculum must include the following specific components: The biological, genetic, psychological, sociocultural, economic, ethnic, gender, religious/spiritual, sexual orientation, and family factors that significantly influence physical and psychological development throughout the life cycle. Fundamental principles of the epidemiology, etiologies, diagnosis, treatment, and prevention of all major psychiatric disorders in the current standard diagnostic statistical manual, including the biological, psychological, sociocultural, and iatrogenic factors that affect the prevention, incidence, prevalence and long-term course and treatment of psychiatric disorders and conditions. Comprehensive discussions of the diagnosis and treatment of neurologic disorders commonly encountered in psychiatric practice, such as neoplasm, dementia, headaches, traumatic brain injury, infectious diseases, movement disorders, multiple sclerosis, seizure disorders, stroke, intractable pain, and other related disorders. The use, reliability, and validity of the generally accepted diagnostic techniques, including physical examination 6
of the patient, laboratory testing, imaging, neurophysiologic and neuropsychological testing, and psychological testing. The use and interpretation of psychological testing under the supervision and guidance of a qualified clinical psychologist. Residents should have experience with the interpretation of the psychological tests most commonly used, some of which should be with their own patients. AOA The AOA publishes Basic Standards for Residency Training in General Psychiatry. The training requirements state that: Residents must take on responsibility for and be the primary treating clinician involved in the diagnosis and management of significant numbers of patients with major psychiatric disorders. There must be provisions for experience in the treatment of common medical and neurological disorders. There must be two months of supervised clinical experience in neurology. Residents must gain experience treating patients with a wide range of severe acute and chronic major psychiatric disorders. Residents must have major responsibility over 24 hours for the diagnosis and treatment of appropriate numbers of such patients on an inpatient, partial hospitalization, or day treatment service for at least four months and not more than 12 months. There must be an outpatient (ambulatory) psychiatry training experience lasting at least 12 months continuously. There must be experience in managing outpatients with severe and chronic psychiatric disorders as well as higher-functioning patients with whom insight-oriented and cognitive therapies are useful. There must be training in various forms of individual psychotherapy, including psychodynamic, cognitive, behavioral, biological, and short-term therapies. Residents must have a long-term psychotherapy experience with some patients seen weekly for at least one year. Residents must have a child and adolescent psychiatry experience of at least two months under the direction of child and adolescent psychiatrists. There must be direct responsibility for the evaluation and management of both children and adolescents with a range of psychiatric disorders. A consultation-liaison experience must be provided with a minimum duration of four months. There must be 7
experience involving patients on medical-surgical services during the weekday. Emergency psychiatry services must be available. Residents must, under the direction of qualified faculty, participate in the evaluation, triage, and management of patients presenting to the psychiatric emergency service. This experience must include training in the management of and contact with patients who are suicidal and who present the threat of physical violence. During the rotation, residents must have training in forensic issues of relevance to emergency psychiatry. There must be an experience with geriatric patients with various psychiatric disorders in which residents have primary responsibility for diagnosis and treatment. There must be an experience with patients with substance abuse problems. Residents must have experience with detoxification and management as well as an understanding of community resources. Residents must have an experience dealing with patients with forensic psychiatric issues. Civil commitment during on-call responsibilities will not be considered a sufficient experience to fulfill this requirement. There must be experience with couples, families, and groups. Residents must be in some settings where psychological and neuropsychological testing is used. Some experience should be with their own patients, and there must be opportunities for residents to gain a basic understanding of common psychological and neuropsychological tests. Clinical training must include interaction with managed care organizations, medical ethics, and practice management. Residents must interact with other mental health professionals, including but not limited to psychologists, social workers, and psychiatric nurses. Positions of accreditation bodies CMS CMS has no formal position concerning the delineation of privileges for psychiatry. However, the CMS Conditions of Participation (CoP) define a requirement for a criteria-based privileging process in 482.22(c)(6), stating, The bylaws must include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges. 8
482.12(a)(6) states, The governing body must assure that the medical staff bylaws describe the privileging pro cess. The process articulated in the bylaws, rules or regula tions must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners that considers: Individual character Individual competence Individual training Individual experience Individual judgment The governing body must ensure that the hospital s bylaws governing medical staff membership or the granting of privileges apply equally to all practitioners in each professional category of practitioners. Specific privileges must reflect activi ties that the majority of prac titioners in that category can perform competently and that the hospital can support. Privileges are not granted for tasks, procedures, or activities that are not conducted within the hospital, regardless of the practitioner s ability to perform them. Each practitioner must be individually evaluated for requested privileges. It can not be assumed that every practitioner can perform every task, activity, or privilege specific to a specialty, nor can it be assumed that the practitioner should be automatically granted the full range of privileges. The individual practitioner s ability to perform each task, activity, or privilege must be individually assessed. CMS also requires that the organization have a process to ensure that practitioners granted privileges are work ing within the scope of those privileges. CMS CoPs include the need for a periodic appraisal of practitioners appointed to the medical staff/granted medical staff privileges ( 482.22[a][1]). In the absence of a state law that establishes a time frame for the periodic appraisal, CMS recommends that an appraisal be conducted at least every 24 months. The purpose of the periodic appraisal is to determine whether clinical privileges or membership should be continued, discontinued, revised, or otherwise changed. 9
The Joint Commission The Joint Commission (formerly JCAHO) has no formal position concerning the delineation of privileges for psychiatry. However, in its Comprehensive Accreditation Manual for Hospitals, The Joint Commission states, The hospital collects information regarding each practitioner s current license status, training, experience, competence, and ability to perform the requested privilege (MS.06.01.03). In the introduction for MS.06.01.03, The Joint Commission states that there must be a reliable and consistent system in place to process applications and verify credentials. The organized medical staff must then review and evaluate the data collected. The resultant privilege recommendations to the governing body are based on the assessment of the data. The Joint Commission introduces MS.06.01.05 by stating, The organized medical staff is respon sible for planning and implementing a privileging process. It goes on to state that this process typically includes: Developing and approving a pro cedures list Processing the application Evaluating applicant-specific information Submitting recommendations to the governing body for applicant-specific delineated privileges Notifying the applicant, relevant personnel, and, as required by law, external entities of the privi leging decision Monitoring the use of privileges and quality-of-care issues MS.06.01.05 further states, The decision to grant or deny a privilege(s) and/or to renew an existing privilege(s) is an objective, evidence-based process. The EPs for standard MS.06.01.05 include several requirements as follows: The need for all licensed independent practitioners who provide care, treatment, and services to have a current license, certification, or registration, as required by law and regulation Established criteria as recommended by the organized medical staff and approved by the governing body with specific evaluation of current licensure and/or certification, specific relevant training, evidence of physical ability, professional practice review data from the applicant s current organization, peer and/or faculty recommendation, and a 10
review of the practitioner s performance within the hospital (for renewal of privileges) Consistent application of criteria A clearly defined (documented) procedure for processing clinical privilege requests that is approved by the organized medical staff Documentation and confirmation of the applicant s statement that no health problems exist that would affect his or her ability to perform privileges requested A query of the NPDB for initial privileges, renewal of privileges, and when a new privilege is requested Written peer recommendations that address the practitioner s current medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism A list of specific challenges or concerns that the organized medical staff must evaluate prior to recommending privileges (MS.06.01.05, EP 9) A process to determine whether there is sufficient clinical performance information to make a decision related to privileges A decision (action) on the completed application for privileges occurs within the time period specified in the organization s medical staff bylaws Information regarding any changes to practitioners clinical privileges are updated as they occur The Joint Commission further states, The organized medical staff reviews and analyzes information regarding each requesting practitioner s current licensure status, training, experience, current competence, and ability to perform the requested privilege (MS.06.01.07). In the EPs for standard MS.06.01.07, The Joint Commission states that the information review and analysis process is clearly defined and that the decision process must be timely. The organization, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a request for privileges. The criteria must be consistently applied and directly relate to the quality of care, treatment, and services. Ultimately, the governing body or delegated governing body has the final authority for granting, renewing, or denying clinical privileges. Privileges may not be granted for a period beyond two years. 11
Criteria that determine a practitioner s ability to provide patient care, treatment, and services within the scope of the privilege(s) requested are consistently evaluated. The Joint Commission further states, Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privileges, or to revoke an existing privilege prior to or at the time of renewal (MS.08.01.03). In the EPs for MS.08.01.03, The Joint Commission says there is a clearly defined process facilitating the evaluation of each practitioner s professional practice, in which the type of information collected is determined by individual departments and approved by the organized medical staff. Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege. HFAP The Healthcare Facilities Accreditation Program (HFAP) has no formal position concerning the delineation of privileges for psychiatry. The bylaws must include the criteria for determining the privileges to be granted to the individual practitioners and the procedure for applying the criteria to individuals requesting privileges (03.01.09). Privileges are granted based on the medical staff s review of an individual practitioner s qualifications and its recommendation regarding that individual practitioner to the governing body. It is also required that the organization have a process to ensure that practitioners granted privileges are working within the scope of those privileges. Privileges must be granted within the capabilities of the facility. For example, if an organization is not capable of performing openheart surgery, no physician should be granted that privilege. In the explanation for standard 03.01.13 related to membership selection criteria, HFAP states, Basic criteria listed in the bylaws, or the credentials manual, include the items listed in this standard. (Emphasis is placed on training and competence in the requested privileges.) The bylaws also define the mechanisms by which the clinical departments, if applicable, or the medical staff as a whole establish criteria for specific privilege delineation. 12
Periodic appraisals of the suitability for membership and clinical privileges is required to determine whether the individual practitioner s clinical privileges should be approved, continued, discontinued, revised, or otherwise changed (03.00.04). The appraisals are to be conducted at least every 24 months. The medical staff is accountable to the governing body for the quality of medical care provided, and quality assessment and performance improvement (03.02.01) information must be used in the process of evaluating and acting on re-privileging and reappointment requests from members and other credentialed staff. DNV Det Norske Veritas (DNV) has no formal position concerning the delineation of privileges for psychiatry. MS.12 Standard Requirement (SR) 1 states, The medical staff bylaws shall include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to those individuals that request privileges. The governing body shall ensure that under no circumstances is medical staff membership or professional privileges in the organization dependent solely upon certification, fellowship, or membership in a specialty body or society. Regarding the Medical Staff Standards related to clinical privileges (MS.12), DNV requires specific provisions within the medical staff bylaws for: The consideration of automatic suspension of clinical privileges in the following circumstances: revocation/restriction of licensure; revocation, suspension, or probation of a DEA registration; failure to maintain professional liability insurance as specified; and noncompliance with written medical record delinquency/deficiency requirements Immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioner s Medicare/Medicaid status Fair hearing and appeal The Interpretive Guidelines also state that core privileges for general surgery and surgical subspecialties are acceptable as long as the core is properly defined. DNV also requires a mechanism (outlined in the bylaws) to ensure that all individuals provide services only within the scope of privileges granted (MS.12, SR.4). 13
Clinical privileges (and appointments or reappointments) are for a period as defined by state law or, if permitted by state law, not to exceed three years (MS.12, SR.2). Individual practitioner performance data must be measured, utilized, and evaluated as a part of the decision-making for appointment and reappointment. Although not specifically stated, this would apply to the individual practitioner s respective delineation of privilege requests. 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. The core privileges and accompanying procedure list are not meant to be all-encompassing. They define the types of activities, procedures, and privileges that the majority of practitioners in this specialty perform. Additionally, it cannot be expected or required that practitioners perform every procedure listed. Instruct practitioners that they may strike through or delete any procedures they do not wish to request. Basic education: MD or DO Minimal formal training: Successful completion of an ACGMEor AOA-accredited residency in psychiatry and/or current certification or active participation in the examination process (with achievement of certification within [n] years) leading to certification in psychiatry by the ABPN or the AOBNP. Required current experience: Provision of inpatient, outpatient, or consultative services for at least 30 patients, reflective of the scope of privileges requested, during the past 12 months or successful completion of an ACGME- or AOA-accredited residency or clinical fellowship within the past 12 months. References Core privileges in psychiatry If the applicant is recently trained, a letter of reference should come from the director of the applicant s training program. Alternatively, a letter of reference may come from the applicable department chair and/or clinical service chief at the facility where the applicant most recently practiced. Core privileges in psychiatry include the ability to admit, evaluate, diagnose, treat, and provide consultation to patients (adults older than [n]) presenting with mental, behavioral, addictive, or emotional disorders (e.g., psychoses, depression, anxiety disorders, 14
substance abuse disorders, developmental disabilities, sexual dysfunctions, and adjustment disorders). Privileges include providing consultation with physicians in other fields regarding mental, behavioral, or emotional disorders; pharmacotherapy; psychotherapy; family therapy; behavior modification; consultation to the courts; and emergency psychiatry, as well as the ordering of diagnostic laboratory tests and prescribing medications. Privileges also include the performance of a history and physical exam. Practitioners may provide care to patients in the intensive care setting in conformance with unit policies. They may also assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. Special noncore privileges in psychiatry If desired, noncore privileges are requested individually in addition to requesting the core. Each individual requesting noncore privileges must meet the specific threshold criteria governing the exercise of the privilege requested, including training, required previous experience, and maintenance of clinical competence. Noncore privileges include: Hypnotherapy Electroconvulsive therapy (see Clinical Privilege White Paper, Electroconvulsive therapy Procedure 1) Reappointment Reappointment should be based on unbiased, objective results of care according to a hospital s quality assurance mechanism. Applicants must demonstrate that they have maintained competence by showing evidence that they have successfully provided inpatient, outpatient, or consultative services for at least 30 patients, reflective of the scope of privileges requested, annually over the reappointment cycle based on the results of ongoing professional practice evaluation and outcomes. In addition, continuing education related to psychiatry should be required. For more information Accreditation Council for Graduate Medical Education 515 North State Street, Suite 2000 Chicago, IL 60654 Telephone: 312/755-5000 Fax: 312/755-7498 Website: www.acgme.org 15
American Board of Medical Specialties 1007 Church Street, Suite 404 Evanston, IL 60201-5913 Telephone: 847/491-9091 or 800/776-2378 Fax: 847/328-3596 Website: www.abms.org American Board of Psychiatry and Neurology 2150 East Lake Cook Road, Suite 900 Buffalo Grove, IL 60089 Telephone: 847/229-6500 Fax: 847/229-6600 Website: www.abpn.org American Osteopathic Association 142 East Ontario Street Chicago, IL 60611 Telephone: 312/202-8000 Fax: 312/202-8200 Website: www.osteopathic.org American Osteopathic Board of Neurology and Psychiatry 2730 South Val Vista Drive, #146 Gilbert, AZ 85296 Telephone: 480/650-3206 Website: www.osteopathic.org American Psychiatric Association 1000 Wilson Boulevard, Suite 1825 Arlington, VA 22209 Telephone: 703/907-7300; 888/357-7924 Website: www.psych.org Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD 21244 Telephone: 877/267-2323 Website: www.cms.hhs.gov DNV Healthcare, Inc. 400 Techne Center Drive, Suite 350 Milford, OH 45150 Website: www.dnvaccreditation.com 16
Healthcare Facilities Accreditation Program 142 East Ontario Street Chicago, IL 60611 Telephone: 312/202-8258 Website: www.hfap.org The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL 60181 Telephone: 630/792-5000 Fax: 630/792-5005 Website: www.jointcommission.org Editorial Advisory Board Clinical Privilege White Papers Associate Group Publisher: Erin Callahan, ecallahan@hcpro.com Associate Editor: Julie McCoy, jmccoy@hcpro.com William J. Carbone Chief Executive Officer American Board of Physician Specialties Atlanta, GA Darrell L. Cass, MD, FACS, FAAP Codirector, Center for Fetal Surgery Texas Children s Hospital Houston, TX Jack Cox, MD Senior Vice President/Chief Quality Officer Hoag Memorial Hospital Presbyterian Newport Beach, CA Stephen H. Hochschuler, MD Cofounder and Chair Texas Back Institute Phoenix, AZ Bruce Lindsay, MD Professor of Medicine Director, Cardiac Electrophysiology Washington University School of Medicine St. Louis, MO Sally J Pelletier, CPCS, CPMSM President - Best Practices Consulting Group Intervale, NH Beverly Pybus Senior Consultant The Greeley Company, a division of HCPro, Inc. Marblehead, MA Richard A. 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 2011 HCPro, Inc., Marblehead, MA 01945. 17