Jack Egnatinsky, MD, is one of three medical directors at the Accreditation Association for Ambulatory Health Care and has been an active surveyor with the organization since 1996.
Q: One challenge ASCs are facing is in regards to privileges granted to physicians for performing various surgeries or procedures. How do ASCs ensure the privileges outlined by the governing body are consistent with the organization's list of privileges at reappointment?
Dr. Jack Egnatinsky: What typically happens when physicians are applying for privileges is they have a list of privileges they are requesting. Most of the time, the list is prepared for that specialty, and physicians check off privileges they are qualified to do in the ASC. Then someone in the governing body, could be the medical director or the facility owner, has to look at the privilege list and make a recommendation to the rest of the governing body about whether that individual should or should not get the privileges they request.
Generally, one of the mistakes we find frequently is no one has checked off the privileges they are recommending for approval. In theory, someone should sign off on each privilege requested so that we know they reviewed it and confirm that they are qualified on a line-by-line basis.
I recommend that the requested privileges be signed or initialed line by line. I say initials or signature because anyone can mark an "x", and it could be changed or tampered with at some time in the future. This way it clearly shows that they have reviewed this line by line to make sure that individual is qualified for that privilege.
Both CMS and accreditation organizations require that ASCs have a list of all of the procedures that they do in the center. The best and simplest way to compile that list is from privileges that are granted to all physicians at the time of appointment and reappointment. If a physician wants to add a new procedure to the list, it needs to be added to the list if it is granted. What organizations forget to do is update that list every time they have their physicians' reappointment.
Learn more about the AAAHC.
Q: One challenge ASCs are facing is in regards to privileges granted to physicians for performing various surgeries or procedures. How do ASCs ensure the privileges outlined by the governing body are consistent with the organization's list of privileges at reappointment?
Dr. Jack Egnatinsky: What typically happens when physicians are applying for privileges is they have a list of privileges they are requesting. Most of the time, the list is prepared for that specialty, and physicians check off privileges they are qualified to do in the ASC. Then someone in the governing body, could be the medical director or the facility owner, has to look at the privilege list and make a recommendation to the rest of the governing body about whether that individual should or should not get the privileges they request.
Generally, one of the mistakes we find frequently is no one has checked off the privileges they are recommending for approval. In theory, someone should sign off on each privilege requested so that we know they reviewed it and confirm that they are qualified on a line-by-line basis.
I recommend that the requested privileges be signed or initialed line by line. I say initials or signature because anyone can mark an "x", and it could be changed or tampered with at some time in the future. This way it clearly shows that they have reviewed this line by line to make sure that individual is qualified for that privilege.
Both CMS and accreditation organizations require that ASCs have a list of all of the procedures that they do in the center. The best and simplest way to compile that list is from privileges that are granted to all physicians at the time of appointment and reappointment. If a physician wants to add a new procedure to the list, it needs to be added to the list if it is granted. What organizations forget to do is update that list every time they have their physicians' reappointment.
Learn more about the AAAHC.