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Case Studies >
 Case
Study: Onsite Privilege Request Evaluation
Situation:
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A medium sized Level II Community Hospital’s Credentials Committee has received
a request for clinical privileges that have never been granted to that
specialty in the past
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A competing physician of another specialty who exercises the same privilege as
the one being requested has refused to act upon the request as a service leader
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Confusion abounds as to how to evaluate current competency of the privilege
requested
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The requesting physician is becoming angry over the lack of action on the
privilege request
QMCG Team Role: Conduct an onsite review and
evaluation of the privilege request as ad hoc members of the Credentials
Committee and:
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Review Credentials Committee documentation of process and progress to date
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Determine appropriateness of privilege request
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Evaluate all documentation submitted
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Pursue references and supplemental information needed
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Interview specific personnel and medical staff as needed
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Develop recommendations for the Credentials Committee while onsite
Present recommendations and options to committee the same day
Onsite Conclusions:
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QMCG drafted credentials committee recommendations for the board to review
and act upon
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QMCG continued to support the hospital by providing a physician to directly
observe first few procedures of the new privilege being exercised and determine
real time competency for the Board
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Created strategy to manage physician discourse with positive and firm
parameters
Hospital Accomplishments: Since the onsite and direct
observation consults, the hospital has:
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Successfully avoided a due process hearing
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Diffused escalating disruptive behaviors
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Strengthened the team work of the credentialing decisions by the Credentials
Committee
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Patients enjoy a new choice of a qualified physician to perform a procedure
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