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 because 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. A family physician needs to know what to 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's privileging process should grant 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 Health Care Organizations. When privileging battles go to court, they are won principally because the privileging process deviated from this standard. Specialty designation is not grounds for granting or denying any privilege.
You must be completely familiar with your hospital'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 just 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:
The privileging and credentialing processes in the hospital's family medicine department must occur exactly as they do in any other department, without exception.
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. For example, an 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 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. To prevent such problems, request that a statement such as the following be added 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."
The bylaws must state that all departments have the obligation of conducting meaningful peer review of their members on an ongoing basis, along with having the authority to recommend privileges.
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.
Privileging is unquestionably a local issue. If the privileging principles outlined by the Joint Commission on Accreditation of Health Care Organizations are followed, conflicts will almost certainly be resolved within the committee structure of your hospital. 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.
Your state chapter is ideally situated to provide help to members facing privilege disputes. Involve your chapter 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.
Learn more about resolving privilege problems.
Excerpted and adapted with permission from Fighting for Hospital Privileges. Family Practice Management 2004;Vol11(3):69-74. Copyright © American Academy of Family Physicians. All rights reserved.
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Avoiding Privileging Disputes