Core Privileging and Credentialing: Hospitals' Approach to Gynecologic Surgery.

STUDY OBJECTIVE: Privileging and credentialing requirements are determined by medical staff leadership at the hospital level to ensure clinicians provide safe healthcare services. No standardized guidelines exist for gynecologic surgery. The objective of this study is to examine the variability of the criteria used to grant surgical privileges and credentials for gynecologic procedures at 5 high-volume academic and community-based US hospitals. DESIGN: We conducted a cross-sectional study (Canadian Task Force classification III). SETTING: Data was obtained from obtained from 5 geographically diverse hospital systems. INTERVENTION: We examined criteria for designating core gynecologic privileges, credentialing, and other training requirements as well as minimum and annual case numbers for initial granting and maintenance of surgical privileges. MEASUREMENTS AND MAIN RESULTS: Major inconsistencies in privileging were found across the 5 institutions. Hospitals varied widely in procedures designated as core versus those requiring advanced training. Institutions greatly contrasted in the case numbers and temporal factors used to define experience. Of particular concern was absent privileging criteria for 38.4% to 76.9% of minor procedures, 26.7% to 46.7% of endoscopic procedures, and 6.67% to 56.7% of major procedures. Initial and maintenance privileging requirements for special procedures (i.e., robotic-assisted surgery) were likewise discrepant, with minimum annual case numbers ranging from 3 to 48 across hospitals. CONCLUSION: Considerable variability exists in the criteria used by hospitals for granting and maintaining surgical privileges for gynecologic procedures. Standardization will likely require efforts at a national leadership level.

[Mitigating the moral risks of private medicine in public hospitals (SHARAP) through regulation and accountability].

BACKGROUND: SHARAP (the Hebrew acronym for private medical service) is an arrangement that allows patients in certain Israeli hospitals to choose their physicians in return for a fee paid, either privately or through some form of parallel insurance. At present, SHARAP is legally precluded from government hospitals but the issue is a source of public debate and the introduction of SHARAP into public hospitals owned by the government and health funds is supported by the Israel Medical Association and MK Yakov Litzman. While advantages to patients, hospitals and medical practitioners are acknowledged, these arrangements carry moral risks related to justice and fair allocation of resources, problems relating to conflicts of interests, the potential for exploitation of patients by physicians with private privileges and the potential for corrupt behaviors. AIM: To address the questions: Do the advantages of these arrangements justify the moral risks involved in the introduction of private medicine into public hospitals? Secondly, can these moral risks be mitigated through regulation without undermining the advantages accrued? METHOD: Ethical and public health policy evaluation based on empiric data and international experience. RESULTS: The potential advantages to patients, providers, hospitals and government of a SHARAP program in public hospitals may be undermined if the implementation does not incorporate regulatory structures. Appropriate regulatory precautions may mitigate most of these concerns adequately to allow all parties to enjoy benefits whilst diminishing actual harm incurred though injustice, conflicts of interest and exploitation.

Hospital privileges for psychologists in the era of competencies and increased accountability.

After campaigning to be granted hospital privileges decades ago, new issues are emerging that are affecting psychologists' hospital privileges. Some of the forces shaping hospital privileges emanate from within the field of psychology, where there has been a movement to more closely examine psychologists' competences. Other forces impinging on hospital privileges are external to psychology, most notably the Joint Commission, which has promulgated new standards for hospital-based practitioners across disciplines. This article discusses the effects of these new standards on the practice of psychology and describes the findings of a survey examining how privileges are currently obtained and maintained within hospitals.

A systematic review of the psychology literature addressing hospital practice.

Hospitals, with their unique practice constraints and opportunities, are one of the most important arenas wherein the field of clinical psychology has developed throughout its history. However, there have been few efforts to comprehensively examine the literature on this topic. This is a literature worth examining, not only out of historical interest but also in the effort to provide direction for the field. Accordingly, systematic, scoping review methods were used to address the question: What does the psychology literature tell us about the nature and evolution of psychology practice in hospitals? The review identified 115 papers on this topic dating from 1916-2017, primarily in the form of practice commentaries and case studies. Analysis of the papers revealed 2 broad themes. One involved the nature of hospital practice, which concentrated on the major domains of assessment, psychotherapy and research activities along with issues related to training. The second involved structural and policy-related considerations such as cost-effectiveness and reimbursement models, leadership, the structure of practice, relationship to physicians, and hospital privileges. Implications of the review include the need for better data on the hospital practices of psychologists and continued work on role definition and the unique value of psychology. Other implications include direction for training models, practice models such as stepped care and a compromise between program and department-based management, privileges, and mental health reform. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A profile of Colorado nurse--midwives: implications for health care.

Nurse-midwives provide significant health care to underserved and vulnerable women, yet there is limited information about the nature of nurse-midwifery practices and compensation for services. This study reports the results of a Colorado statewide survey of nurse-midwives (N = 217). Electronic survey was utilized to detail practice in seven areas: demographics, type of practice, compensation, leadership, legislative priorities,teaching involvement, and practice satisfaction. Responses (N = 114) were analyzed using SPSS 13.0. Results found wide variation in compensation and practice types. Respondents largely worked in urban settings, cared for low to moderate risk patients, and were generally older and White. Restriction from medical staff membership, prescriptive authority constraints, and liability issues were practice limitations. While teaching a wide variety of learners, nurse-midwives do limited mentoring of nurse-midwifery students, a finding which is concerning given the decreasing numbers of nurse-midwives. Findings are compared to known national data, with implications for the provision of health care services detailed.

US hospital-based direct access with radiology referral: an administrative case report.

BACKGROUND AND PURPOSE: Legislative gains in the US allow physical therapists to function in expanded scopes of practice including direct access and referral to specialists. The combination of direct access with privileges to order imaging studies directly offers a desirable practice status for many physical therapists, especially in musculoskeletal focused settings. Although direct access is legal in all US jurisdictions, institutional-based physical therapy settings have not embraced these practices. Barriers cited to implementing direct access with advanced practice are concerns over medical and administrative opposition, institutional policies, provider qualifications and reimbursement. This administrative case report describes the process taken to allow therapists to see patients without a referral and to order diagnostic imaging studies at an academic medical center. Nine-month implementation results show 66 patients seen via direct access with 15% referred for imaging studies. Claims submitted to 20 different insurance providers were reimbursed at 100%. DISCUSSION: While institutional regulations and reimbursement are reported as barriers to direct access, this report highlights the process one academic medical center used to implement direct access and advanced practice radiology referral by updating policies and procedures, identifying advanced competencies and communicating with necessary stakeholder groups. Favorable reimbursement for services is documented.

Limitation of private attending pediatricians' neonatal intensive care privileges in level III institutions throughout the United States.

OBJECTIVE: To determine the privileges of Private Attending Pediatricians (PAP) in caring for newborns requiring intensive (ITC), intermediate (IMC), or continuing (CC) care in Level III neonatal intensive care units (NICUs) throughout the United States. DESIGN: A two-page mail questionnaire was sent to 429 Level III NICUs to obtain the statement best describing the PAPs' privileges, the number of PAP, and some of the PAPs' functions. Level III NICUs were classified by geographic region as Eastern, Central, or Western United States. RESULTS: Responses were received from 301 NICUs (70%) representing 48 states, the District of Columbia, and > 9000 PAP. Twenty-two institutions had no PAP. In the remaining 279 institutions, 96% (267/279) had restricted the PAPs' privileges partially or completely. In 32% (88/279), the PAP were not allowed to render any type of NICU care. In 18% (51/279) of the institutions, the PAP were allowed to render CC only. In 27% (76/279) of the institutions, the PAP were allowed to render IMC and CC only. Limitation of PAPs' privileges were reported in all geographic areas in the U.S., were more pronounced in the Eastern than the Central or Western sections of the country, and were noted in institutions with small (< or = 10) as well as large (> or = 60) numbers of PAP. Limitation of PAPs' privileges was determined by the PAP him/herself in many institutions. Proficiency in resuscitation was considered to be a needed skill. Communication with parents of an infant under the care of a neonatologist was encouraged. CONCLUSIONS: The PAPs' privileges were limited partially or completely in most Level III NICUs. Knowledge of this restricted role impacts significantly on curriculum design for pediatric house officers, number and type of health care providers required for Level III NICUs and future house officer's career choices.

Training and privileging for new procedures.

Hands-on training for advanced laparoscopic procedures is more difficult to obtain than for basic laparoscopy, but because morbidity and mortality rates for these technically demanding procedures are higher, adequate training is essential and obtained, ideally, through a formal fellowship in advanced laparoscopy. Shorter preceptorships can provide adequate training but are more difficult to find. Few advanced laparoscopic procedures are experimental, but the safety of each must be ensured before a hospital awards privileges for their performance. Vigilance regarding local and national outcomes of these new procedures is essential in this rapidly evolving field.

A different perspective on quality.

Evaluation of physicians in the credentialing processes of hospitals has generally been viewed as focused upon whether the physicians will provide services to patients at the appropriate level of professional performance and will not engage in disruptive behavior at the institution. Three measures--exclusive contracting, medical staff planning, and exclusive credentialing--have been employed, singly or in combination, at many hospitals to restrict or to deny medical staff appointments and clinical privileges to professionally qualified and competent physicians. Because the hospitals have articulated links, when employing these restrictive measures in making credentialing decisions, to the public's interest in their being able to provide good quality services to the communities they serve, the hospitals have usually been successful in litigation brought by physicians who have been denied staff appointment or specific clinical privileges.

Comprehensive gynecologic endoscopic hospital privileging program. Implementation and assessment.

OBJECTIVE: To describe a comprehensive gynecologic endoscopic privileging program at an urban teaching hospital and evaluate its effect on complication rates. STUDY DESIGN: In 1996, a gynecologic endoscopy privileging program was instituted. Initially, experienced surgeons were invited to apply for advanced privileges based on submission of a case list. Afterwards, new applications were approved by proctorship. Since 1995, charts have been reviewed using the following indicators; operating time, estimated blood loss, length of stay, readmission, diagnosis of cancer, reexploration and admission for hysteroscopic fluid overload. Cases were also independently identified when a major vascular or visceral injury occurred. RESULTS: Among the 3,880 gynecologic endoscopic procedures performed during the review period, 2,702 medical records were randomly screened. Following institution of the program, there was no change noted in rates of hysteroscopic fluid overload, readmission, reexploration or unrecognized diagnosis of cancer. However, a decrease was noted in excess blood loss (odds ratio [OR] 0.6, 90% confidence interval [CI] 0.4, 0.9) and operating time greater than four hours (OR 0.6, CI 0.4, 0.9). Length of hospital stay was also reduced in the year following implementation of the privileging process (OR 0.2, CI 0.1, 0.3). Fifty-four cases of visceral or major vascular injury occurred during the three-year period. The risk of visceral injury revealed a trend from 1.9% to 1.0% after institution of the privileging process (OR 0.5, CI 0.3, 1.0). CONCLUSION: Establishment of a comprehensive gynecologic endoscopic hospital privileging program was associated with a reduction in rates of excess blood loss and operating times and a decreasing trend in visceral injuries.