Tips for Avoiding Privileging Disputes

Scope-of-practice issues have been and will continue to be a crucial battleground for family physicians. Although turf battles typically originate from political and economic motives rather than true quality-of-care concerns, they are not to be taken lightly. They can ultimately limit a physician's scope of practice. At the heart of this struggle is the process of credentialing and privileging, which, if done correctly, ensures both quality patient care and the ability of qualified, well-trained family physicians to provide that care. If it were easy, you would not be reading this article, which tackles the question "What do I do when faced with a privileging battle?"

The best way to guarantee you never lose a privileging conflict is to never have one in the first place. Your hospital should have a privileging process that is fair and grants privileges based on documented training, experience and current clinical competence. Privileging based on any other factors is contrary to the written standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). When privileging battles go to court, they are won principally because the privileging process deviated from this standard. Specialty designation in and of itself is not grounds for granting or denying any privilege, period.

You must be completely familiar with your institution's privileging process and bylaws and, if needed, must work to change them so that they are equitable. The following elements are essential to a fair process:

Your hospital should provide a full clinical department of family medicine, not merely an administrative department. The department of family medicine must function in exactly the same manner as any other department in the hospital and must have membership standards that keep it from becoming a dumping ground for hard-to-place physicians. Ideally, membership in the department would be limited to family physicians who are residency trained and board certified, those who are board certified although not residency trained and those who have several years of experience and demonstrated competence as family physicians even though they are not residency trained or board certified.

The privileging and credentialing processes in the family medicine department must occur exactly as they do in any other department, without exception. For starters, family physicians must be credentialed and considered for privileges by their own departments, just as other specialists are. Privilege recommendations from the department of family medicine should then be forwarded directly to the credentials committee; the assent or approval of other departments is not needed.

When the recommended privileges fall outside the normal scope of practice of the department making the recommendation, the use of hospital-wide criteria can be very helpful. At our hospital we have established criteria for Cesarean section, which any physician - regardless of specialty - uses when applying for that privilege. As a result, the family medicine department may evaluate applicants and send recommendations directly to the credentials committee without going through the obstetrics/gynecology department. The establishment and use of hospital-wide criteria does not preclude any department from seeking input and advice from any other department.

No department owns any privilege. The role of clinical departments and credentials committees must be limited to evaluating physicians' applications for privileges and forwarding recommendations to the next level. Legally, only the governing board of the hospital has the right to grant privileges, taking under advisement the recommendations from both the physician's department and the credentials committee. Governing boards have recently been held accountable in court for the privileges they grant, bringing to an end the days when recommendations from the medical staff were simply "rubber stamped." Hospital boards have a fiduciary responsibility to the institution and the community to take credentialing and privileging very seriously, which brings the process out into the open. This is as good for patient care as it is for family medicine departments.

Sometimes physicians in another hospital department will refuse to consult with family physicians, a passive-aggressive turf war of sorts. To prevent such problems, work on adding a statement such as the following to your hospital bylaws:

"It shall be the policy of the medical staff that all staff physicians have access to consultation when deemed necessary and that such consultation, when requested in a timely and appropriate manner, shall not be unreasonably refused."

Finally, the bylaws must state that all departments, along with having the authority to recommend privileges, have the obligation of conducting meaningful peer review of their members on an ongoing basis. Charts should be peer reviewed in the department that recommended the privilege in question. For example, a case under review due to a complication in diabetes management should be reviewed in the department that originally recommended the physician's privileges. Family medicine departments should not be any different than other departments when it comes to peer review (except, perhaps, in striving to do it better).

So you've completed the above steps, or are working on them, and still someone on the Dark Side balks at your providing maternity care, reading echocardiograms or taking care of your patients in the intensive care unit. What now?

Well, first remember that the AAFP stands unequivocally in support of the concept that all physicians obtain privileges consistent with their documented training, experience and current clinical competence. The AAFP Commission on Quality is charged, in part, with providing information and assistance to AAFP members in credentialing and privileging matters and has developed an extensive "Protocol for Handling Hospital Privilege Problems." (This protocol and many other helpful documents can be accessed on the AAFP Web site.)

Over the years, the framework for credentialing and privileging has evolved dramatically. The concept of privileging across department lines was unique to family medicine until the advent of fiber optics. Fiber optic procedures revolutionized privileging in that, for the first time, our non-family-medicine colleagues had to cross department lines to gain their privileges. They soon realized why family physicians were correct in demanding the right to privilege their own members, and they now insist on this for themselves. The idea of a surgeon going to the obstetrics/gynecology department for laparoscopy privileges or an internist going to the surgery department for colonoscopy privileges was and is unthinkable.

While this new paradigm of privileging brings new opportunities for family physicians, it also comes with some challenges. First, privileging is unquestionably a local issue. This cannot be overstated. If the privileging principles outlined by the JCAHO are followed, conflicts will almost certainly be resolved within the committee structure of your hospital. This reality explains why the AAFP, as a national organization, can be of only limited help. The AAFP can be most useful by providing the knowledge that helps members work effectively in their hospital structure. Local efforts by the physicians involved are the best way to effect change and successfully conclude privilege struggles.

The AAFP state chapter is ideally situated to provide help to members facing privilege disputes. Physicians seem to under utilize or overlook altogether their state chapters and the significant influence they can bring to bear. Instead, physicians should involve their state chapters at the earliest possible time so that they can intervene on behalf of those caught up in privileging disputes. A united front presented by a state organization that is part of a national organization has tremendous potential for effecting a positive outcome.

The credentialing and privileging process can be rough business, but our scope of practice defines who we are and what we do as family physicians. As a specialty we are currently trying to determine what the future of family medicine will be, drawing on the best minds from all aspects of our discipline. Many are convinced that a diminished scope of practice would not bode well for the future of our specialty. Although we all must learn to "pick our battles," appropriate and fair privileging, which ensures family medicine's scope of practice, is clearly a battle worth fighting and winning.

"Excerpted with permission from Fighting for Hospital Privileges. Family Practice Management 2004;Vol11(3):69-74. Copyright © American Academy of Family Physicians. All rights reserved."