Robroy MacIver, MD

Hospital privileges (credentials) are often treated as a footnote to board certification by new Thoracic graduates seeking the beginning of their procedural bliss. Without hospital privileges, though, new graduates cannot perform the technical accomplishments they have spent so long refining. In addition, these surgeons will not have access to the shared financial resources the hospital can afford.

Privileges are important not only from a revenue standpoint but they also play a role in defining the scope of one’s practice. As surgeons progress in their careers and want to expand their scope of clinical care, as well as gain new technologies, hospital privileges must be updated. In addition, continued and mandatory hospital review of the physician makes the process never ending.

Gaining hospital privileges efficiently requires understanding why they exist, the power privileges give and the complications that can occur with their use.

Hospital privileges are a method for the hospital to verify and maintain standards of the physicians working at the institution. The American College of Surgeons was the first to enact quality measures that hospitals voluntarily agreed to in 1917.

The Hill-Burton Act of 1946 caused states seeking federal funds for hospitals to maintain certain standards. Within the hospital it is the medical staff who must make up these standards for the credentialing process. The medical staff is made up of professionals, mainly doctors, guided by state regulations.

In the last decade a hospital’s Medical Staff has been under more scrutiny in dispensing privileges by certifying agencies such as The Joint Commission, CMS and the Healthcare Facility Accreditation Program among others.

One challenging aspect facing new graduates is that approval is based on the recommendations from outside institutions. For this reason, Medical Staff may require a more detailed case log, a review of case reports or even direct observation as part of their approval process.

For the majority of procedures, hospitals have umbrella approval dependent on specialty. Difficulties come into play when a new surgeon is bringing in new technologies. These new procedures must be individually approved. Medical staff must then rely on either industry-set guidelines or position papers written by organizations such as the American Association for Thoracic Surgery (AATS).

Examples of past guidelines include industry’s training program for endovascular stents and the position paper written by the AATS and Society of Thoracic Surgeons (STS) on credentialing for thoracoscopic procedures.

Graduates should review a hospital’s bylaws prior to beginning the process. Hospital bylaws will state policies, governance procedures, explain the privileging process, and give regulations for the hospital. Bylaws will vary between hospitals even in the same state and must be evaluated closely. Areas to focus on when reviewing them are: definitions, staff appointment categories, the privileging process, the bylaws amendment process, and the hearing process if privileges are denied.

Trouble often occurs when trying to gain privileges in overlapping fields. As technology allows and requires merging of previously separate fields, more and more "turf battles" are fought at the stage of gaining hospital privileges. For example, procedures such as percutaneous gastrostomy tubes, endovascular stents, and now endovascular valves can all technically be performed by multiple specialties. When and where these procedures are performed in the hospital is most commonly determined by hospital privileges. The medical staff therefore becomes entangled in maintaining medical credentials and settling disputes amongst specialties. Be prepared to state your case and prove your competence when embarking on such procedures!

More controversial is the ever-expanding role of so called economiccredentialing, which means the credentialing process is either directly or indirectly tied to economic rather than medical outcomes.

As physicians control approximately 80% of hospital spending, their economic role in the hospital is closely linked with their medical one. Hospitals are also increasingly linking anti-competition clauses limiting referral patterns and locations at which procedures may be performed with the credentialing process.

The increasing role of economics in credentialing is also seen at the oversight level in JCAHO’s Total Quality Management (TQM) initiative which takes efficiency of care delivered into consideration when making recommendations on physician recertification. State laws mirror this initiative with states such as Washington mandating that hospital’s Medical Staff are governed by certain "cost efficiencies".

Gaining credentials at a new hospital requires forethought and planning. Some tips on gaining an advantage in the process include:

1. Maintaining a private detailed procedural log even after graduation.

2. Enrolling in industry-sponsored training programs that give certification in new technologies.

3. Keep up to date on professional society training guidelines for specific procedures, especially procedures crossing specialties.

4. Maintain open lines of communication with your medical staff and those vested in the procedures you are performing.

Hospitals will continue to seek guidance in the process of physician certification and granting of privileges. Once gained by a new graduate, it is imperative to realize that rules are not formed in a vacuum and that the Medical Staff must be engaged to help guide decisions that in the end will benefit the patient.☐

Hospital privileges (credentials) are often treated as a footnote to board certification by new Thoracic graduates seeking the beginning of their procedural bliss. Without hospital privileges, though, new graduates cannot perform the technical accomplishments they have spent so long refining. In addition, these surgeons will not have access to the shared financial resources the hospital can afford.

Privileges are important not only from a revenue standpoint but they also play a role in defining the scope of one’s practice. As surgeons progress in their careers and want to expand their scope of clinical care, as well as gain new technologies, hospital privileges must be updated. In addition, continued and mandatory hospital review of the physician makes the process never ending.

Gaining hospital privileges efficiently requires understanding why they exist, the power privileges give and the complications that can occur with their use.

Hospital privileges are a method for the hospital to verify and maintain standards of the physicians working at the institution. The American College of Surgeons was the first to enact quality measures that hospitals voluntarily agreed to in 1917.

The Hill-Burton Act of 1946 caused states seeking federal funds for hospitals to maintain certain standards. Within the hospital it is the medical staff who must make up these standards for the credentialing process. The medical staff is made up of professionals, mainly doctors, guided by state regulations.

In the last decade a hospital’s Medical Staff has been under more scrutiny in dispensing privileges by certifying agencies such as The Joint Commission, CMS and the Healthcare Facility Accreditation Program among others.

One challenging aspect facing new graduates is that approval is based on the recommendations from outside institutions. For this reason, Medical Staff may require a more detailed case log, a review of case reports or even direct observation as part of their approval process.

For the majority of procedures, hospitals have umbrella approval dependent on specialty. Difficulties come into play when a new surgeon is bringing in new technologies. These new procedures must be individually approved. Medical staff must then rely on either industry-set guidelines or position papers written by organizations such as the American Association for Thoracic Surgery (AATS).

Examples of past guidelines include industry’s training program for endovascular stents and the position paper written by the AATS and Society of Thoracic Surgeons (STS) on credentialing for thoracoscopic procedures.

Graduates should review a hospital’s bylaws prior to beginning the process. Hospital bylaws will state policies, governance procedures, explain the privileging process, and give regulations for the hospital. Bylaws will vary between hospitals even in the same state and must be evaluated closely. Areas to focus on when reviewing them are: definitions, staff appointment categories, the privileging process, the bylaws amendment process, and the hearing process if privileges are denied.

Trouble often occurs when trying to gain privileges in overlapping fields. As technology allows and requires merging of previously separate fields, more and more "turf battles" are fought at the stage of gaining hospital privileges. For example, procedures such as percutaneous gastrostomy tubes, endovascular stents, and now endovascular valves can all technically be performed by multiple specialties. When and where these procedures are performed in the hospital is most commonly determined by hospital privileges. The medical staff therefore becomes entangled in maintaining medical credentials and settling disputes amongst specialties. Be prepared to state your case and prove your competence when embarking on such procedures!

More controversial is the ever-expanding role of so called economiccredentialing, which means the credentialing process is either directly or indirectly tied to economic rather than medical outcomes.

As physicians control approximately 80% of hospital spending, their economic role in the hospital is closely linked with their medical one. Hospitals are also increasingly linking anti-competition clauses limiting referral patterns and locations at which procedures may be performed with the credentialing process.

The increasing role of economics in credentialing is also seen at the oversight level in JCAHO’s Total Quality Management (TQM) initiative which takes efficiency of care delivered into consideration when making recommendations on physician recertification. State laws mirror this initiative with states such as Washington mandating that hospital’s Medical Staff are governed by certain "cost efficiencies".

Gaining credentials at a new hospital requires forethought and planning. Some tips on gaining an advantage in the process include:

1. Maintaining a private detailed procedural log even after graduation.

2. Enrolling in industry-sponsored training programs that give certification in new technologies.

3. Keep up to date on professional society training guidelines for specific procedures, especially procedures crossing specialties.

4. Maintain open lines of communication with your medical staff and those vested in the procedures you are performing.

Hospitals will continue to seek guidance in the process of physician certification and granting of privileges. Once gained by a new graduate, it is imperative to realize that rules are not formed in a vacuum and that the Medical Staff must be engaged to help guide decisions that in the end will benefit the patient.☐

Hospital privileges (credentials) are often treated as a footnote to board certification by new Thoracic graduates seeking the beginning of their procedural bliss. Without hospital privileges, though, new graduates cannot perform the technical accomplishments they have spent so long refining. In addition, these surgeons will not have access to the shared financial resources the hospital can afford.

Privileges are important not only from a revenue standpoint but they also play a role in defining the scope of one’s practice. As surgeons progress in their careers and want to expand their scope of clinical care, as well as gain new technologies, hospital privileges must be updated. In addition, continued and mandatory hospital review of the physician makes the process never ending.

Gaining hospital privileges efficiently requires understanding why they exist, the power privileges give and the complications that can occur with their use.

Hospital privileges are a method for the hospital to verify and maintain standards of the physicians working at the institution. The American College of Surgeons was the first to enact quality measures that hospitals voluntarily agreed to in 1917.

The Hill-Burton Act of 1946 caused states seeking federal funds for hospitals to maintain certain standards. Within the hospital it is the medical staff who must make up these standards for the credentialing process. The medical staff is made up of professionals, mainly doctors, guided by state regulations.

In the last decade a hospital’s Medical Staff has been under more scrutiny in dispensing privileges by certifying agencies such as The Joint Commission, CMS and the Healthcare Facility Accreditation Program among others.

One challenging aspect facing new graduates is that approval is based on the recommendations from outside institutions. For this reason, Medical Staff may require a more detailed case log, a review of case reports or even direct observation as part of their approval process.

For the majority of procedures, hospitals have umbrella approval dependent on specialty. Difficulties come into play when a new surgeon is bringing in new technologies. These new procedures must be individually approved. Medical staff must then rely on either industry-set guidelines or position papers written by organizations such as the American Association for Thoracic Surgery (AATS).

Examples of past guidelines include industry’s training program for endovascular stents and the position paper written by the AATS and Society of Thoracic Surgeons (STS) on credentialing for thoracoscopic procedures.

Graduates should review a hospital’s bylaws prior to beginning the process. Hospital bylaws will state policies, governance procedures, explain the privileging process, and give regulations for the hospital. Bylaws will vary between hospitals even in the same state and must be evaluated closely. Areas to focus on when reviewing them are: definitions, staff appointment categories, the privileging process, the bylaws amendment process, and the hearing process if privileges are denied.

Trouble often occurs when trying to gain privileges in overlapping fields. As technology allows and requires merging of previously separate fields, more and more "turf battles" are fought at the stage of gaining hospital privileges. For example, procedures such as percutaneous gastrostomy tubes, endovascular stents, and now endovascular valves can all technically be performed by multiple specialties. When and where these procedures are performed in the hospital is most commonly determined by hospital privileges. The medical staff therefore becomes entangled in maintaining medical credentials and settling disputes amongst specialties. Be prepared to state your case and prove your competence when embarking on such procedures!

More controversial is the ever-expanding role of so called economiccredentialing, which means the credentialing process is either directly or indirectly tied to economic rather than medical outcomes.

As physicians control approximately 80% of hospital spending, their economic role in the hospital is closely linked with their medical one. Hospitals are also increasingly linking anti-competition clauses limiting referral patterns and locations at which procedures may be performed with the credentialing process.

The increasing role of economics in credentialing is also seen at the oversight level in JCAHO’s Total Quality Management (TQM) initiative which takes efficiency of care delivered into consideration when making recommendations on physician recertification. State laws mirror this initiative with states such as Washington mandating that hospital’s Medical Staff are governed by certain "cost efficiencies".

Gaining credentials at a new hospital requires forethought and planning. Some tips on gaining an advantage in the process include:

1. Maintaining a private detailed procedural log even after graduation.

2. Enrolling in industry-sponsored training programs that give certification in new technologies.

3. Keep up to date on professional society training guidelines for specific procedures, especially procedures crossing specialties.

4. Maintain open lines of communication with your medical staff and those vested in the procedures you are performing.

Hospitals will continue to seek guidance in the process of physician certification and granting of privileges. Once gained by a new graduate, it is imperative to realize that rules are not formed in a vacuum and that the Medical Staff must be engaged to help guide decisions that in the end will benefit the patient.☐