Recent public statements by CMS representatives have raised questions about the mechanism a hospital should use to authorize/approve temporary privileges. Specifically, that the CMS Conditions of Participation (“CoPs”) do not allow the CEO to sign off on temporary privileges and that only the governing body can grant privileges (including temporary privileges). These statements have caused a great deal of discussion in the field.
We at The Greeley Company are monitoring the discussion and provide the following analysis:
- The CMS CoPs require that a hospital’s Governing Body approve each practitioner’s Medical Staff privileges. Neither the CoPs nor the corresponding CMS interpretive guidelines specify the method that must be used for such Governing Body approval. Most Governing Bodies appoint a Chief Executive Officer (“CEO”) to act on its behalf to award privileges on a temporary basis (e.g., until the next Board or Board Committee meeting for new applicants or when necessary to meet urgent patient care needs) . . . just as the Board empowers the CEO to enter into contracts and perform other governance functions on the Board’s behalf.
The Greeley Company is working with CMS, The Joint Commission, Healthcare Facilities Accreditation Program (HFAP), the American Health Lawyers Association, and others to resolve this situation. We recognize that hospital Boards must have a reliable and safe mechanism to award privileges in the face of urgent patient care needs: whether it be to treat patients during a community-wide disaster, to enable a sub-specialist to perform a rare or new procedure on a hospital’s patient, or to assure that there are sufficient physicians to examine and treat patients presenting to the emergency department. Awarding temporary privileges has been a mechanism used for decades to safely and reliably meet this need. We also recognize the Board’s responsibility to oversee the Medical Staff credentialing and privileging process and to assure that each practitioner to whom it awards privileges is fully qualified (by credentials and proof of current competence).
We will continue our discussions and keep our consultants and clients advised in the days and weeks ahead.