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Co-Author: Sally Pelletier, CPMSM, CPCS   

Are your patients and practitioners protected in the ambulatory environment?  Are you vulnerable for non-compliance with regulatory or accreditation requirements?

Peer Review & Privileging for Ambulatory Settings

Healthcare is delivered in a variety of locations.  The hospital’s four walls are no longer the boundaries for patient care, yet the focus of best practices, quality initiatives, and technology resources is still inpatient facilities.

Is the same diligence due in the ambulatory setting?  Is it happening?

Initial and ongoing proficiency verification is absent, even at the most basic levels in these settings.  Ambulatory-based data repositories are nonexistent or sub-optimal.

While the argument could be made that patients are less acute and procedures less invasive in the ambulatory setting than in the inpatient setting, consider that the migration of care to the ambulatory environment is both dynamic and pervasive.  Care, services, and treatments that would have been unheard of just a few years ago outside of the hospital are now commonplace in clinics and outpatient centers.

Accreditors include privileging and peer review in their top findings for non-compliance for ambulatory settings that are not affiliated with a hospital or healthcare system.  According to The Joint Commission in 2016, privileging was the number one most challenging standard for Office-Based Surgery Practices.  Close behind at number two was Ambulatory Care Standards with 60% and 47% failing to meet requirements respectively.

If you are a hospital or healthcare system with affiliated ambulatory sites of care, you may be at risk for non-compliance.  One key indicator for determining whether the requirements of privileging and peer review apply in these settings is to identify whether they are set up as provider based clinics.  If the hospital and the ambulatory sites in question all operate under the same CMS Certification Number (CCN), then CMS (and applicable accreditors with deemed status) consider these sites part of the hospital.  Thus, the same regulatory requirements and accreditation standards (i.e. criteria-based, site-specific privileging, FPPE, OPPE, Peer Review) apply to all individuals providing a medical level of care.

Have you heard from your medical staff leaders that the care provided in those clinics is not the medical staff’s responsibility?  Not true.

If you are a standalone ambulatory facility or one connected with a hospital or health system, there are scenarios where there is a regulatory obligation, or, at the very least, a responsibility to patient safety and care quality to be met.  Are you clear on where you stand?  Let’s have that conversation.

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