Granting of Privileges
Once the credentialing process is over, the committee must have a process of granting privileges. This may include allowing the healthcare professional to work with limited privileges, full privileges, or be denied privileges.[10]
It is important to grant privileges specific to the healthcare worker’s training and experience. For example, a family doctor who joins the hospital should not be allowed to perform a repair of lacerations or insert central lines. The hospital always has to consider the potential risks when generating privileges for newly credentialed healthcare workers.
The granting of privileges should be regularly updated. Plus, the privileged information should be available to other departments. For example, a general surgeon may call the operating room in the middle of the night wanting to perform an abdominal aortic aneurysm repair, a procedure usually done by the vascular surgeon, and the nurse may want to know if he or she has been granted privileges for doing this surgery. The emergency room may call to find out if a physician has admitting privileges.
No matter what decision is made to grant or deny privileges to a healthcare worker, the information should be relayed in writing within a specific time frame. Further, this information should also be made available to all appropriate external or internal entities within the hospital.
When privileges are denied, the healthcare institution should have a system for appeal for healthcare workers.
Professional Practice Monitoring and Evaluation
Once a healthcare worker has been credentialed and is granted privileges to practice medicine, most hospitals have developed a monitoring program or a proctoring period. This is vital for surgeons.[11] For example, a newly trained vascular surgeon must be proctored for 5 to 15 cases to determine his or her hand skills and assess his or her clinical competence and criteria for doing the surgery. To ensure that the proctoring is unbiased, the committee needs to develop guidelines which include the following:
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Identify what specific criteria will be proctored? Clinical skills, surgical technique
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How will proctoring be done, and for what period?
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Who will be in charge of the actual proctoring?
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Will the physician be given a warning of proctoring?
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In what circumstance would an external proctor be brought in?
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What if the healthcare professional fails proctoring? Will the privileges be rescinded? Will they only be able to assist or work under supervision, and for how long?
Performance Monitoring Methods
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Once a healthcare worker has been credentialed and his or her privileges are approved, the hospital must have established performance monitoring methods. This may be done with proctoring.
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The healthcare provider may be provided with potential cases and suggest treatment plans. This may be done verbally or by text.
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Another way to proctor is for a senior staff member to observe the healthcare provider perform a procedure or review their management of a patient in the clinic.
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In some cases, only a retrospective chart review of the patient medical records may be possible. This should be done randomly on all healthcare workers who look after patients to ensure that they are compliant with the format of writing medical notes, dating each entry, checking the laboratory parameters, and following up on any abnormal results.
External Review
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Today many hospitals are turning to external reviews of their healthcare workers in selected cases. This allows for unbiased evaluations. For example, when there is a perceived conflict of interest or need for more objectively about disciplinary action, a second opinion is necessary. For example, a newly recruited cardiac surgeon would like to perform a relatively new procedure that has not been accepted in mainstream cardiac surgery, but the senior cardiac surgeon feels that the procedure has a high risk, and the traditional method of doing surgery is safer. To prevent animosity and chaos in the department, sometimes in such cases, a second opinion from another expert may be required. Furthermore, sometimes, a second opinion may also help determine the healthcare worker’s state of mind. A physician’s behavior may be erratic, and he may not be performing up to par, but all his colleague feel that something is wrong with him. The physician is then sent for an internal mental evaluation, which he later claims was biased. In such cases, an independent medical examination may provide benefits as it helps to get an unbiased opinion.[12]
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External reviews are also useful when the number of healthcare workers is small, and no appropriate peer reviewer is available.
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It is also important to get an external review when the healthcare worker has appealed a decision or if litigation is likely.
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An external review is also helpful when the staff is experienced and relatively new.
