Ensuring Competence in Endoscopy - American College of ...

The Elements of Performance for Standard MS.4.20 mandate that “[c]riteria
are developed that determine an applicant’s ability to provide patient
care, treatment, and services within the scope of privileges requested.” 34
Specifically, the criteria must include “evidence of current competence” and
“peer recommendations when required.” 35 Current competence is established
in the same manner as required for credentialing. 36 As for peer
recommendations, Standard MS.4.70 states that such information supplements
peer review data. Peer recommendations may come from/consist of
(1) a hospital performance improvement committee, the majority of whose
members are the applicant’s peers; (2) reference letters, written documentation,
or documented phone conversations about the applicant from peers
who are knowledgeable about the applicant’s professional performance and
competence; (3) a department or major clinical service chairperson who is a
peer; or (4) the medical staff executive committee. 37 Peer recommendations
must address (1) relevant training and experience and (2) current
competence—as previously described—as well as “any effects of health status
on privileges being requested.” 38
In addition, the Elements of Performance for Standard MS.4.20 demand
that, before granting privileges, the hospital medical staff must evaluate:
(a) challenges to any licensure or registration;
(b) voluntary and involuntary relinquishment of any license or registration;
(c) voluntary and involuntary termination of medical staff membership;
(d) voluntary and involuntary limitation, reduction, or loss of clinical
privileges;
(e) any evidence of an unusual pattern or an excessive number of professional
liability actions resulting in a final judgment against the
applicant;
(f) documentation as to the applicant’s health status;
(g) relevant practitioner-specific data compared to aggregate data, when
available; and
(h) morbidity and mortality data, when available. 39
Renewal or revising of privileges involves the same process as the initial
extension of privileges, as well as assessment of the applicant’s ability to perform
the requested privileges based upon his or her previous performance. 40
As noted above, JCAHO itself has been responsible for a shift to a national
standard of care. Further, as explained below, compliance with the pertinent
standards is extremely important for hospitals seeking to avoid liability.
34. Id. at MS-20.
35. Id.
36. Id. at MS-17.
37. Id. at MS-24.
38. Id.
39. Id. at MS-20.
40. Id. at MS-24.
20 Ensuring Competence in Endoscopy