MMHA 5500 Week 3 Credentialing and Privileges Memo Example

Memorandum

To: Governing Body, Lakeside Surgery Center

From: Administrator

Date: Week 3

Re: Verification results and privilege recommendations for an orthopedic surgeon and a certified registered nurse anesthetist

Purpose

This memo asks the governing body to act on requests for clinical privileges from two applicants, Dr. A, an orthopedic surgeon, and B, a certified registered nurse anesthetist, and reports what was verified, how and what remains open. Applicants are identified by letter in this composite example. Federal conditions for coverage require that a surgery center's governing body grant privileges in accordance with recommendations from qualified medical personnel and only after reviewing practitioners' credentials (42 C.F.R. § 416.45); this memo is the record of that review.

Verification Results

Every item below was verified with the primary source, the board, school, agency or data bank that issued or holds it, not from copies supplied by the applicant. Dates are the dates verification was received.

Table 1

Primary Source Verification by Item and Applicant

The Data Bank Query

The National Practitioner Data Bank holds reports of malpractice payments, adverse licensure and certification actions and certain adverse privileging actions. Hospitals are required to query it when granting privileges; other health care entities with formal peer review may query it voluntarily (Health Resources and Services Administration, 2018). The center queries for every applicant as a matter of policy, because a report could reveal an action in another state that a single license lookup would miss. Both queries returned no reports.

Privileges Requested and the Center's Scope

Dr. A requests privileges for total hip and total knee replacement, knee arthroscopy, shoulder arthroscopy and rotator cuff repair, which the center performs or will perform under the new total joint service line, and for spinal fusion, which the center does not perform. The recommendation is to grant the first five and decline spinal fusion on scope: the center has neither the equipment nor the recovery capability for it. The decision is not a judgment about Dr. A's competence, and the letter to the applicant should say so.

B requests privileges for general anesthesia, regional anesthesia including peripheral nerve blocks and monitored anesthesia care, under the supervision arrangements in the center's anesthesia policy and state law. All three are within the center's scope and are recommended. Federal conditions for coverage require that anesthesia in a surgery center be administered by a qualified anesthesiologist, or by a nurse anesthetist supervised by the operating practitioner or an anesthesiologist, unless the state has opted out of the supervision requirement (42 C.F.R. § 416.42). The center's anesthesia policy assigns supervision to the anesthesiologist on site, and B's privileges should be granted on that basis. If the state's position on supervision changes, the anesthesia policy and these privileges should be reviewed together.

Open Items

Two items remain open. Dr. A's one closed malpractice claim, with no payment, was reviewed by the medical director, who found no pattern of concern; the governing body should note the review. B's peripheral nerve block privileges should be granted with focused review of the first ten cases, as the center's policy requires for any new privilege, since the applicant's recent experience is mainly in a hospital setting. Neither item prevents approval.

Recommendation

The administrator recommends that the governing body grant Dr. A privileges for the five procedures within the center's scope, decline spinal fusion on scope and grant B the three requested anesthesia privileges with focused review of the first ten nerve block cases. Privileges would run for two years, the center's reappointment cycle, subject to ongoing professional practice evaluation. Verification files are available for any member's review before the vote.

After Approval

Approval begins a cycle rather than ending one. Both practitioners will be included in the center's ongoing professional practice evaluation, which reviews case outcomes, complications, unplanned transfers and peer concerns for every credentialed practitioner. For Dr. A, the first ten total joint cases at the center will be reviewed by the medical director, since the total joint service line is new to the center even though the procedures are not new to the surgeon. For B, the focused review of nerve blocks will be completed and reported to the governing body within six months. Licenses, certifications and DEA registrations will be tracked for expiration, and each will be reverified with the issuing source before it lapses, so that no practitioner works at the center on an expired credential. At reappointment in two years, the data bank will be queried again and the cycle repeated.

References

Condition for coverage: Medical staff, 42 C.F.R. § 416.45 (2024).

Condition for coverage: Surgical services, 42 C.F.R. § 416.42 (2024).

Health Resources and Services Administration. (2018). NPDB guidebook. U.S. Department of Health and Human Services.