SDS Accreditation Update: How one agency meets privileging standards
How one agency meets privileging standards
Organizations accredited by the Accreditation Association for Ambulatory Health Care (AAAHC) consistently struggle with the credentialing and the privileging standards, says Stephen Kaufman, RN, senior director of accreditation at the AAAHC.
"The documentation of credentials and the granting of privileges must be done in a complete and timely manner," he says. "In addition to showing documentation, the approval of a surgeon’s credentials and the granting of privileges must be reflected in the governing board’s meeting minutes to fully comply with the standard."
At Orthopedic Surgical Center of the North Shore in Peabody, MA, AAAHC surveyors who visited recently were pleased with the credentialing and privileging process, says John M. Powell, chief executive officer. "We handle the credentials verification ourselves by verifying licenses, contacting medical schools, and obtaining other documentation we need," he says.
They grant privileges based upon what the surgeon is permitted to do according to his or her board certification and training and any state regulations that might apply, explains Powell. The training and experience of the surgeon is only one part of the privileging decision, he adds. "We also look at the specific procedures we are staffed and equipped to handle in our facility, and we look at the type of patient that might need the service," he says. "We don’t allow any high-risk patients, and we look carefully at the appropriateness of the procedure for our setting."
They are discussing a spinal procedure with a surgeon who currently is performing all of the surgeries at the hospital, says Powell. While his facility might be able to provide the operating room time, the equipment, and the staff, Powell says he is getting input from all areas to see if they can be sure the patients can be given all of the necessary care in the outpatient surgery facility.
"We don’t want to accept these patients, then find ourselves transferring them to the hospital because it is more complicated and requires more care than we anticipated," he adds.
Powell’s facility does not base privileges at the surgery center on privileges the surgeon has at other facilities, and that is the right approach, says Kaufman. "An outpatient surgery facility cannot just copy the list of privileges from another facility or a hospital," he says. "The privileges must be granted specifically for the facility, based upon the facility’s capabilities."
Organizations accredited by the Accreditation Association for Ambulatory Health Care (AAAHC) consistently struggle with the credentialing and the privileging standards, says Stephen Kaufman, RN, senior director of accreditation at the AAAHC.Subscribe Now for Access
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