three methods . There are also many ways to delineate privileges incorrectly ! For example , a large paragraph or list of procedures will not meet CMS requirements and may allow a provider to request privileges for something they are not qualified nor competent to perform . Also , when bundling privileges , per the CMS , the provider must be given the ability to opt out of any services and / or procedures .
Proper delineation of privileges must :
• Meet ACGME , or other training program requirements
• Be separated into systems or subgroups of privileges , which are considered to have transferrable skills or equivalent competencies
• List required qualifications / criteria for each system or subgroup , or specific privileges ( if applicable ) to ensure they can be met
• Provide providers with the ability to “ opt out ” of a privilege within a system or subgroup of privileges
• Not allow the option for “ writing in ” a privilege not listed , since the necessity and criteria must first be evaluated and established by the organization
• List requirements for monitoring or initial professional practice evaluation ( IPPE ) for new privileges , such as focused professional practice evaluation ( FPPE ), proctoring , or other comparable method , if the organization ’ s accrediting body requires it or as best practice
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