Privileging and Reappointment: Back to Compliance

The past 19 months have been consumed by the global pandemic, affecting everything we do. From scaled-back services to shutdowns, delayed procedures, and shifting priorities, COVID-19 has changed the landscape of ambulatory surgery centers (ASCs) across the nation.

As organizations are settling into a different routine, here are a few reminders from the Ambulatory Surgery Center program of Accreditation Commission for Health Care (ACHC) on how to get back to and stay in compliance with medical staff privileging and appointment and reappointment requirements. The information that follows was condensed from ACHC Standards 06.00.03, 06.00.04, 06.01.02, and 06.01.03.

The governing body must ensure the following is completed prior to appointment or reappointment of medical staff and is documented in the credential record:

• Primary source verification of medical staff for the following:
  • License(s).
  • Medical schools and residency and other training programs.
  • Malpractice insurance and history.
  • Board certification, per bylaws.
  • National Professional Data Bank and Office of Inspector General queries (sanctions/disciplinary action).
  • Criminal background check (initial applications only).
  • Healthcare/affiliation work history.
  • Professional references.
• Signed attestation to comply with bylaws/policies.
• Medical staff recommendations.
• Board-reviewed medical staff recommendations.
• Comprehensive list of services within their scope of practice granted to be performed in the ASC.

The governing body must ensure the granted appointment or reappointment time period for medical staff does not exceed 36 months, or is shorter, per the organization’s policy. To reflect the appointment/reappointment, the credential record must include:

• Awarded privileges.
• Dates of appointment or reappointment.
• Current competence.
• Clinical activity.
• Procedural log.
• Peer review activities.

Because committees have been put on hold or delayed during the COVID-19 public health emergency, ACHC has found that medical staff privileging and appointment and reappointment requests are not being granted in compliance with the standards. ASC organizations are reminded that any individual provider whose privileges, whether initial or renewal, are not currently active should not be providing any services until their medical staff appointment or reappointment has taken place.

Have a Suggestion?

If there are specific topics you would like to see addressed in the “Did You Know” newsletter, please drop us a note at info@achc.org. Write “DYK ASC suggestion” in your subject line. We look forward to hearing from you!

Join Our Growing Team

We're excited to be growing!  We are looking for nurses and physicians in leadership positions who are interested in becoming Ambulatory Surgery Center Contract Surveyors.  If you are interested in learning about the eligibility requirements and Surveyor responsibilities, please contact Marci Ramahi at mramahi@achc.org.

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ACHC Charity Golf Tournament

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Register by January 1 and save up to $200.

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