In the January 2000 issue I wrote about credentialing and its process.  In this edition the focus will be on credentialing’s kissing cousin, privileging.  These are separate issues.  Credentialing is whether a physician is qualified to be on the medical staff.  This depends on paperwork and may be done from any location in a multi-hospital system. After credentialing, the person applies for the ability (privilege) to treat certain specific conditions or perform specific procedures. The medical staff process of determining the competency to treat or perform the requested activities is called privileging. This must be done at each individual institution since it requires close monitoring.

The privileging process may be done in various ways.  The traditional method is to use a laundry list of all procedures and treatments.  The applicants check the boxes next to the procedure or treatment that they wish to do.  The applicants then have the burden to show they have the qualifications to do the procedures requested.  Once the applicants show they have the qualifications the burden goes to the medical staff to show why any requested privileges are rejected or subject to any supervision.  This method allows the applicants to request only those items they wish and permits the medical staff to recommend to the board whether or not to grant privileges on individual items.  It also lets new applicants to come off supervision early on some items but be supervised on those procedures that do not have enough numbers to be evaluated.  The potential problem is if the applicants forget to mark a procedure they will not be allowed to do that procedure. Another potential downside is the need of the medical staff to check the competency of the individual to perform each requested procedure or treatment. Also, if the requestor is a surgeon he/she will need to check not only the surgical procedure boxes but the medical and possibly the pediatric and OB/GYN ones as well.

The other method is called core privileging.  Here the applicant picks a predetermined group of procedures or treatments that are common to that specialty.  An example would be a urologist picking core urologic procedures.  These would include all general urology endoscopic and open procedures as well as the pre and postoperative care and the ability to consult and care for patients with non-operative urologic conditions. The burden then is on the medical staff to include or exclude all pertinent procedures in core privilege list.  The prototype for this is the U.S. Navy.  Their site can be found by the following:; then click on credentialing; followed by active duty credential and privilege program; BUMED instructions; and finally 6320.66B and a large .pdf (Adobe) file will download. 

If any procedure requires special qualification such as LASER or lithotripsy, these procedures would be asked for specifically with a showing of the specific required training.  If however the medical staff has stated that a certain number of any one type of case, such as radical cystectomy, is required, this type of case should not be a part of the core procedures. The verified numbers of these cases may be totaled from various institutions.

It makes no difference which method is used.  In order to apply for either, the applicants must show they have the training, education, experience and current competence for the requested privileges.  The medical staff needs to have predetermined criteria that meet minimum standards and then verify the qualifications of the applicant against these criteria. These criteria should apply to specialty or procedure, not to a specific department.  This allows for all qualified physicians to perform a procedure or treatment and take away the “turf war”.  Another deterrent to a dispute among physicians is setting realistic minimum standards that can be met by any qualified group or individual.  The requirements need to be fair to all and related to the quality of care. If the applicant does not meet these threshold criteria the request is incomplete and not denied and fair hearing procedures are not needed. If the threshold criteria are met and the request is denied, then the due process and fair hearing requirements are available to the applicant.

In order to show training and education the medical staff should look at the background of the individual. Board certification is also, along with experience, reasonable criteria but, according to Medicare, may not be the sole criteria in granting credentials or privileges.

Current competence is determined by current letters of recommendation which include information on the physician’s health and performance improvement reports, including physician specific data as compared to the aggregate in at least mortality, morbidity, medication usage and blood usage.  The medical staff has the general criteria for all on the staff and then each department may add other performance improvement criteria. Competence may also include proctoring and possibly the number of procedures performed if there are nationally recognized standards, or patients treated.  It makes no difference if an applicant has performed each procedure requested since many skills cross over between disciplines and procedures.

Proctoring for any new privileges is the way to ensure that the physician is currently competent in the requested privilege.  This may be done retrospectively in low risk situations or prospectively and/or concurrently in higher risk situations. The proctor should be an unbiased member of the medical staff with unsupervised privileges in the requested area.  The proctor should fill out a standard proctoring form and return the form to the medical staff office. Each department /division should determine, in a fair manner, the number of cases that need proctoring.  It should be enough that quality is assured but fair to the one asking for the privilege. The person being proctored should be kept abreast periodically of their progress toward the goal of removing proctoring.

When new procedures, such as minimally invasive CABG are introduced a process should be instituted to determine if privileges are granted. The first step is the hospital and medical staff determining whether the facility has the need for the treatment or procedure. The physician who wishes the procedure should submit information regarding the procedure, indications, benefits, risks and necessary equipment to the department.  The department chief should forward the request to the credentials committee with any comments. The credentials committee should conduct its own investigation and forward its recommendation to the medical executive committee. The MEC would then forward it’s recommendation to the hospital administration and the Board. The next step is for the medical staff to determine the criteria for the procedure.  The last part of the process is to determine whether a requesting physician meets these qualifications.

In the development of privileging criteria, the individual department/section will develop their criteria and forward these to the medical executive committee. The medical executive committee reviews the criteria and makes sure there are no contradictions with other criteria in the rules and regulations and forward the final draft to the board.  Once approved by the board, they become policy of the medical staff. If the department or section alone set the criteria and this led to an exclusion of another physician there could be an anti-competitive antitrust violation.  Also you need to follow your policies.  If you do not have a policy for a type of situation, you need to develop one and then follow it.  The JCAHO wants to see your bylaws, rules and regulations and policies to make sure you are following them.

The medical staff should realize that more primary physicians are staying in their offices and referring all patients needing hospitalization. These physicians are still important to your staff.  There is nothing wrong with credentialing them to be on your staff but not give them any privileges.  Many of these physicians enjoy coming to the hospital to visit with their patients and colleagues.  This encourages continuing loyalty and communication.  Since they have no privileges they do not need to be on your call roster. This is better than their resignation from your medical staff and possibly referring patients to another facility. They may even be on your active medical staff if you have a concurring policy. If you use patient contacts as one of the criteria for active staff (a poor criteria and if present one you should consider removing) you may define referrals to the hospital for lab, x-ray or admission as patient contacts.

An often overlooked area is with physicians working in a practice owned or controlled by a hospital.  These physicians must also be granted outpatient privileges.  These may be an extension of the hospital privileges or be a separate set specifically for that group, such as with a physician without hospital privileges working for the hospital owned or controlled clinic.

Temporary privileges are dangerous.  They should be used only for a specific time and possibly only for a specific patient.  Those with temporary privileges must have their basic credentials verified prior to be given any privileges.  There should be a policy as to who grants these privileges and under what specific circumstances, as well as what are the verified criteria (see MS 5.14. 4).

All the above really comes down to one thing. Is that person being granted the privilege competent to care for any patient, including you or your family?  If the answer to the question is “no” and the person is granted privileges, you should reevaluate the criteria used for the privileging.


As mentioned in my last newsletter JCAHO has new criteria that are currently in effect for peer review.  They have also posted new criteria for the medical staff in physician health, telemedicine, appointment (fast tracking), fair hearings, history and physicals, and privileging.  Please go to their web site, to see these new standards.


In a recent decision a federal district court stated that if a person comes to the hospital in an unstable state, the hospital must stabilize the patient prior to discharge or transfer.  This is true no matter how long it takes.  The patient in this case was involved in an auto accident and was admitted to the hospital in an unstable state.  She was hospitalized for six weeks and then transferred to a long-term care facility.  She deteriorated immediately and was re-hospitalized at another acute care facility. The court stated that the original hospital must stand trial for the transfer since a reasonable jury could find that the patient was still unstable on the day of the transfer and suffered damages as a result of the EMTALA violation.


On September 25, 2000 the OIG issued the final rules regarding small physician office compliance.  It is imperative that you and your medical staff be familiar with these rules as next year the OIG will have units in every state to better investigate health issues.  Go to

I hope this tome on the privileging process, JCAHO, EMTALA and the new Compliance rules is helpful and thought provoking.  If I may be of any help to you or your medical staff with any of the above privileging, Joint Commission standards, EMTALA, Compliance or any other medical staff matters please contact me. This is especially true for any new or revised bylaws, rules, or policies.  The AMA recommends the medical staff have independent legal advice in this area. I am enclosing a card for your convenience.

For those of you attempting or thinking about medical staff reorganization, I recommend you visit They have some excellent ideas on restructuring of the medical staff and the use of medical staff web sites.  One of their principals is Howard Lang, M.D., a past president of the California Medical Association and a strong advocate of medical staff autonomy. You will also find my article on disruptive physicians on the site.

I also have a new web site with past articles and links to other sites.  This site will be updated on a regular basis. The site is

I hope you will bookmark the site and also sign up for the newsletters and articles on-line instead of by “snail mail” and finally always remember the words of Dizzy Dean “It puzzles me how they know what corners are good for filling stations.  Just how did these fellows know there was gas and oil under there?” 

DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.