College of American Pathologists Considerations for the Delineation of Pathology Clinical Privileges.
Hospitals have a responsibility to ensure that physicians on their medical staff who are practicing their profession have the appropriate training, skills, and competency to treat patients. Hospitals seek to place the patients’ interests first and to limit physicians’ professional treatment to their areas of competency. Hospitals do this through the concept of clinical privileges, which carefully delineate the scope of practice of each physician in the hospital. Such delineation of privileges is required by the Joint Commission (JC) and is overseen by the medical staff of each hospital. As of January 1, 2008, facilities accredited by the JC are required to meet new standards for privileging physicians at their facilities. The new standards require the use of more formal, detailed, evidence-based processes to evaluate physicians. To meet these standards, the JC now requires the development of both ongoing professional practice evaluation (OPPE) processes to evaluate physicians on an ongoing basis and focused professional practice evaluation (FPPE) processes for granting a physician initial privileges, granting of new privileges, and addressing concerns regarding existing privileges. After addressing general considerations and qualifications in the privileging of pathologists, we will describe these processes in more detail. The evaluation processes and delineation of pathology privileges are developed by the medical staff and are the responsibility of the hospital. The information contained herein is for background purposes only. The College of American Pathologists (CAP) does not make any specific recommendations, and each hospital, with assistance from its medical staff and pathology department, should make its own determination as to what is most appropriate for its specific circumstances.