Did You Know?

This month, we are highlighting the importance of ensuring that surgical privileges are granted to all practitioners who are conducting surgical tasks, with a focus on individuals who may not traditionally be considered in the credentialing and privileging process. Such positions include Surgical Assistant, Surgical First Assistant, Registered Nurse First Assistant, Certified Nurse First Assistant, or Certified Surgical First Assistant.

Standard 08.00.11: The CAH designates the practitioners who are allowed to perform surgery for CAH patients, in accordance with its approved policies and procedures, and with State scope of practice laws. Surgery is performed only by a doctor of medicine or doctor of osteopathic medicine, including an osteopathic practitioner recognized under section 1101(a)(7) of the Social Security Act; (1) A doctor of dental surgery or dental medicine; or (2) A doctor of podiatric medicine. §485.639(a) §485.639(a) (1-3) §482.52(c) (1-2)

The requirement to have privileges includes these categories of practitioners:

• Doctor of Medicine/Doctor of Osteopathic Medicine
• Dentist
• Oral Surgeon
• Podiatrist
• Registered Nurse (RN) First Assistant
• Nurse Practitioner
• Surgical Physician Assistant
• Surgical Assistant

If a Critical Access Hospital uses categories of staff such as Surgical Assistant, Surgical First Assistant, Registered Nurse First Assistant, Certified Nurse First Assistant, or Certified Surgical First Assistant to conduct specific elements of surgical procedures (e.g., cutting tissue, suturing, providing hemostasis, etc.), the hospital must establish criteria, qualifications, and a credentialing process to grant specific privileges to individual practitioners based on each practitioner’s compliance with the privileging/credentialing criteria and in accordance with federal and state laws and regulations.

Tips for Compliance

• Ensure that surgical privileges are granted to each practitioner who is conducting surgical tasks in the Critical Access Hospital, including non-physician practitioners.
• When a practitioner may perform certain surgical procedures under supervision of a physician, the specific tasks/procedures to be performed and the degree of supervision required must be delineated in the practitioner’s surgical privileges and be included on the surgical roster.
• Ensure that surgical privileges are reviewed and updated in accordance with medical staff policies and at least every two years.

Each Critical Access Hospital should audit the surgical privileges granted by its governing body to ensure compliance with these requirements. These audits should be an essential part of your organization’s survey preparation process.

Here to Help

To download the most recent ACHC Accreditation Standards, log in to your customer portal account. If you have questions, please contact your Account Advisor or email us at customerservice@achc.org.