Service Chief recommendations in performance-based clinical privileging

A medical facility is responsible for the standards of practice of its medical staff and can be found liable if it was negligent in appointing or reappointing a member of the staff who is incompetent. Joint Commission standards require that recommendations for consideration of initial, renewal, or revision of clinical privileges be made based upon peer evaluations of professional performance, judgment, and clinical and technical skills. Valid recommendations involve two discrete steps: collecting data and evaluating that data. The most pertinent data are those of current competence. The responsibility of interpreting the data rests with the Department or Service Chief. It is his clinical experience that enables him to evaluate a providers' care, in light of accepted standards of practice, for a specialty and for a specific region. Subsequently, in order for the Credentials Committee to make a meaningful performance-based privileging recommendation to the military treatment facility Commander, a summary must be written by the Department/Service Chief, incorporating all of the relevant data and the evaluation of those data. Based on the objective data with the accompanying evaluation, the summary must conclude that the provider is physically and mentally capable of performing the procedures requested, including having the social skills necessary to relate with others in the total care of the patient, and that his training, experience, and recent past performance is consistent with the prudent delivery of care. Continuous performance improvement strategies must support this process by organizing hospital committee structures, ancillary staffing, and information management processes to support a decision-making process based on facts.