Physical medicine and rehabilitation

Transcription

1 Practice area 156 Clinical PRIVILEGE WHITE PAPER Background Physical medicine and rehabilitation The American Board of Medical Specialties (ABMS) defines physical medicine and rehabilitation (PM&R), also referred to as physiatry or rehabilitation medicine, as the medical specialty concerned with evaluating, diagnosing, and treating patients with physical disabilities. According to the ABMS, these disabilities may arise from conditions affecting the musculoskeletal system, such as neck and back pain or other painful conditions affecting the limbs (e.g., carpal tunnel syndrome). Such disabilities may also result from neurological trauma (e.g., spinal cord injury, head injury, or stroke) or from diseases. A physician certified in PM&R is often called a physiatrist. The physiatrist s primary goal is to achieve maximum restoration of patients physical, psychological, social, and vocational function through comprehensive rehabilitation. According to the Accreditation Council for Graduate Medical Education (ACGME), training for this specialty lasts four years and consists of at least three years of training in PM&R in addition to one year of training in fundamental clinical skills. Eligible physicians may seek certification in PM&R through ABMS or American Osteopathic Association (AOA) certifying boards. Currently, the ABMS has granted the American Board of Physical Medicine and Rehabilitation (ABPMR) the right to offer subspecialty certificates to ABPMR diplomates in the areas of: Brain injury medicine Hospice and palliative medicine (see Clinical Privilege White Paper Practice area 406) Neuromuscular medicine Pain medicine (see Clinical Privilege White Paper Practice area 108) Pediatric rehabilitation medicine (see Clinical Privilege White Paper Practice area 190) Spinal cord injury medicine Sports medicine (see Clinical Privilege White Paper Practice area 197) The AOA and the American Osteopathic Board of Physical Medicine and Rehabilitation (AOBPMR) offer physiatrists certificates of added qualifications in: Sports medicine Hospice and palliative medicine

2 Physicians specializing in PM&R may also request core privileges in spinal cord injury medicine. To be eligible for core privileges in spinal cord injury medicine, physicians must complete a 12-month fellowship program in spinal cord injury medicine, as well as satisfy other basic requirements. Involved specialties Physiatrists Positions of specialty boards ABPMR Certification through ABPMR is granted to applicants who meet the board s general requirements and pass a two-part examination. General requirements for board certification include: Graduation from a U.S. or Canadian medical school approved by the Liaison Committee on Medical Education or graduation from an osteopathic medical school approved by the AOA Possession of a current, valid, and unrestricted license to practice medicine in at least one jurisdiction in the United States, its territories, or Canada Satisfactory completion of the requirements of the board for graduate education Satisfactory compliance with rules and regulations of the board pertaining to completing and filing the application for examination and payment of required fees In addition to fulfilling the general requirements, physicians seeking board certification must successfully complete 48 months of training in PM&R residency accredited by the ACGME or the Royal College of Physicians and Surgeons of Canada following the completion of medical school. Twelve of the 48 months must consist of a coordinated program of experience in fundamental clinical skills such as an accredited transitional year, or include six months or more in accredited training in emergency medicine, family practice, internal medicine, obstetrics and gynecology, pediatrics, surgery, or any combination of these patient care experiences. The remaining months of this year may include any combination of accredited specialties or subspecialties. Training in fundamental clinical skills must be completed within the first two years of the four-year training program. Candidates are required to take and pass the Part I (computer-based) certification examination before applying for the Part II examination. The ABPMR also approves of dual specialty certification in pediatrics and PM&R, and internal medicine and PM&R. Both programs require at least 36 months of accredited training in general comprehensive PM&R. 2

3 AOBPMR To be eligible for certification in PM&R through the AOBPMR, the applicant must: Be a graduate of an AOA-accredited college of osteopathic medicine, holding the degree of Doctor of Osteopathic Medicine or Doctor of Osteopathy. Maintain an unrestricted license to practice in the state or territory where his or her practice is conducted. Be able to show evidence of conformity to the standards set forth in the AOA Code of Ethics. Have been a member in good standing of the AOA or the Canadian Osteopathic Association for a continuous period of at least two years immediately prior to the date of certification. Have satisfactorily completed an internship of at least one year in a hospital approved for intern training by the AOA, or by acceptable alternative pathways prescribed by the AOA. Have completed a period of not less than three years of specialty training in PM&R approved by the AOA, after one year of an AOA-approved internship. Alternately, the applicant may be an ABMS-certified DO seeking AOA certification under the appropriate alternative pathway. Practice as an osteopathic physiatrist for a period of at least one full-time year subsequent to the minimum three years of residency training, or must have completed an acceptable one year of full-time fellowship training, or an acceptable combination of these, subsequent to the minimum three years of residency training. Candidates must past both a written and an oral examination to achieve certification. Positions of societies, academies, colleges, and associations AAPM&R The American Academy of Physical Medicine and Rehabilitation (AAPM&R) is a national medical society that represents physicians who are specialists in the field of PM&R. According to the academy, physiatrists are required to complete a minimum of four years of graduate education. That includes a residency in PM&R lasting three years and a one-year internship spent in the development of fundamental clinical skills. PM&R residents must spend a minimum of one year and no more than two years caring for hospitalized patients. This may include a combination of the following general rehabilitation areas: Severe deconditioning and general disability Neurologic disorders (e.g., multiple sclerosis, amyotrophic lateral sclerosis, Guillain-Barré syndrome, and myasthenia gravis) Complicated amputations, arthritis, and fractures 3

4 Post-arthroplasty Stroke Brain injury (e.g., traumatic, neoplastic, or ischemic) Spinal cord injury (e.g., traumatic, neoplastic, or ischemic) Pediatrics (e.g., cerebral palsy, spina bifida, muscular dystrophy, and trauma) The remainder of the residency is filled with outpatient rotations that may include the following: Amputee Arthritis Burn rehabilitation Cancer rehabilitation Cardiopulmonary rehabilitation Chronic pain management Electives Electromyography (EMG) General consultation Geriatrics Hand clinic Impairment evaluation Industrial rehabilitation Injection clinic Musculoskeletal clinic Pediatric clinic Prosthetics and orthotics Spine center Sports medicine Work hardening Wound care center According to the academy, fellowships are available in pediatric rehabilitation, spinal cord injury, head injury, stroke, sports medicine, musculoskeletal rehabilitation, pain medicine, EMG, and research. These are typically one to two years in length. ACGME In its Program Requirements for Graduate Medical Education in Physical Medicine and Rehabilitation, the ACGME states that physicians seeking specialization in this field must complete an ACGME-accredited residency in PM&R lasting four years, three of which must be in PM&R. Further requirements state that: Of these three years, no more than six months can be composed of electives. No more than one month of elective time may be taken in a non-acgmeaccredited program without prior approval. One of the four years must be spent on fundamental clinical skills. This year of training must consist of an accredited transitional year program or include at least six months in accredited training in family medicine, internal 4

5 medicine, emergency medicine, OB-GYN, pediatrics, surgery, or any combination of these patient care experiences. The remaining months of this year may include any combination of accredited specialties and subspecialties. Accredited training in any of the specialties or subspecialties selected must last at least four weeks. No more than eight weeks may be in nondirect patient care experiences, such as pathology, radiology, and research. Training in fundamental clinical skills must be completed within the first two years of the four-year training program. Programs may provide three or four years of training. Requirements state that: A three-year program is responsible for 36 months of PM&R training and ensuring that residents appointed at the postgraduate year-two level receive satisfactory training in fundamental clinical skills A four-year program is responsible for the quality of the integrated educational experience for the entire training program, including 12 months of training in fundamental clinical skills, which may not include more than four weeks of PM&R With regard to patient care, residents must be able to provide care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents must have a sufficient variety, depth, and number of clinical experiences. However, these clinical activities must not compromise the educational requirements of the training program. Residents must also: Have at least 12 months direct and complete responsibility for inpatient management on the PM&R service. Spend at least 12 months of their training in the care of outpatients. This must include significant experience in the care of patients with musculoskeletal disorders, and it excludes time spent in EMG training. Have increasing responsibility in patient care, leadership, teaching, and administration. Clinical experiences should allow for progressive responsibility with lesser degrees of supervision as the resident advances and demonstrates additional competencies. The program director must establish written guidelines for supervision of more junior residents by more senior residents when this occurs and of all residents by attending physicians with attention to the acuity, complexity, and severity of patient illness. Supervision must include faculty review of a clearly written patient history and physical examination and a meaningful continuous record of the patient s illness, background, management strategies, as well as lucid presentations of the case summary. Develop the attitudes and psychomotor skills required to: Modify history-taking technique to include data critical to the recognition of functional abilities, and physical and psychosocial impairments that may cause functional disabilities Perform the general and specific physiatric examinations, including EMG, nerve conduction studies, and other procedures common to the practice of PM&R 5

6 Make sound clinical judgments Design and monitor rehabilitation treatment programs to minimize and prevent impairment and maximize functional abilities Prevent injury, illness, and disability Residents must attain competence in the following areas of patient care: History and physical examination pertinent to PM&R. Assessment of neurological, musculoskeletal, and cardiopulmonary systems. Assessment of disability and impairment and familiarity with the ratings of disability and impairment. Data gathering and interpreting of psychosocial and vocational factors. Performance of electrodiagnostic studies. In general, involvement in approximately 200 electrodiagnostic consultations per resident, under appropriate supervision, represents an adequate number. Therapeutic and diagnostic injection techniques. Prescriptions for orthotics, prosthetics, wheelchairs and ambulatory devices, special beds, and other assistive devices. Written prescriptions with specific details appropriate to the patient for therapeutic modalities, therapeutic exercises, and testing performed by physical therapists, occupational therapists, and speech-language pathologists. It is necessary to provide for an understanding and coordination of psychologic and vocational interventions and tests. Familiarity with the safety, maintenance, and actual use of medical equipment common to the various therapy areas and laboratories. Pediatric rehabilitation. Geriatric rehabilitation. The ACGME further states that residents must have progressive responsibility in diagnosing, assessing, and managing the conditions commonly encountered by the physiatrist in the rehabilitative management of patients of all ages in the following areas: Acute and chronic musculoskeletal syndromes, including sports and occupational injuries Acute and chronic pain management Congenital or acquired myopathies, peripheral neuropathies, motor neuron and motor system diseases, and other neuromuscular diseases Hereditary, developmental, and acquired central nervous system disorders, including cerebral palsy, stroke, myelomeningocele, and multiple sclerosis Rehabilitative care of traumatic brain injury Rehabilitative care of spinal cord trauma and diseases, including management of bladder and bowel dysfunction and pressure ulcer prevention and treatment Rehabilitative care of amputations for both congenital and acquired conditions Sexual dysfunction common to the physically impaired Post-fracture care and rehabilitation of postoperative joint arthroplasty Experience in evaluation and application of cardiac and pulmonary rehabilitation 6

7 as related to physiatric responsibilities Pulmonary, cardiac, oncologic, infectious, immunosuppressive, and other common medical conditions seen in patients with physical disabilities Diseases, impairments, and functional limitations seen in the geriatric population Rheumatologic disorders treated by the physiatrist Medical conditioning, reconditioning, and fitness Tissue disorders such as burns, ulcers, and wound care With regard to medical knowledge, the ACGME states that residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social behavioral sciences, as well as the application of this knowledge to patient care. Residents must: Have didactic instruction that is well organized, thoughtfully integrated, based on sound educational principles, and carried out and attended on a regularly scheduled basis. It must expose residents to topics appropriate to their level of training. Systematically organized didactic instruction includes a series of lectures by faculty, seminars, assigned reading, journal clubs, and clinical case conferences. Active participation by faculty in the didactic program is required. Have teaching rounds with faculty at least five times per week. These rounds must include patient contact with those hospitalized in inpatient rehabilitation facilities. Gain knowledge about the diagnosis, pathogenesis, treatment, prevention, and rehabilitation of those neuromusculoskeletal, neurobehavioral, cardiovascular, pulmonary, and other system disorders common to this specialty in patients of both sexes and all ages. Have education in the principles of bioethics as applied to medical care, and participate in decision-making involving ethical issues that arise in the diagnosis and management of their patients. Have adequate and systematic instruction in basic sciences relevant to PM&R such as anatomy, physiology, pathology, and pathophysiology of the neuromusculoskeletal, cardiovascular, and pulmonary systems; kinesiology and biomechanics; functional anatomy; electrodiagnostic medicine; fundamental research design and methodologies; and instrumentation related to the field. This instrumentation should pertain to physiologic responses to the various physical modalities and therapeutic exercises, and the procedures commonly employed by physiatry. This instruction should be correlated with clinical training but should, when appropriate, include basic science faculty. There must be an accessible anatomy laboratory for dissection or an equivalently structured program in anatomy. Review pertinent laboratory and imaging materials for the patient. The opportunity to observe directly and participate in the various therapies in the treatment areas must occur regularly throughout the residency program, including the proper use and function of equipment and tests. Observe and gain fundamental understanding of orthotics and prosthetics, 7

8 including fitting and manufacturing, through instruction and arrangements made with appropriate orthotic-prosthetic facilities. Learn the principles of pharmacology as they relate to the indications for and complications of drugs utilized in PM&R. AOA In its Basic Standards for Residency Training in Physical Medicine and Rehabilitation, the AOA states that residency training for physicians specializing in PM&R should be a minimum of three years, of which no more than six months can be elective. Regarding patient care, the AOA states that the clinical curriculum must include a variety, depth, and number of clinical experiences. The volume of clinical responsibilities must not, however, compromise the educational atmosphere of the program. Additionally, the training program must include an amount of time spent in providing primary care of patients hospitalized on the PM&R service. Residents must: Devote at least 12 months of their residency experience to the primary care of inpatients hospitalized on the PM&R service. Devote a minimum of 12 months to the care of outpatients. Be provided with the opportunity to review pertinent laboratory, biopsy, and imaging studies of their patients. Have a regular opportunity to observe and directly participate in therapies that occur in various treatment areas throughout their training. This would include proper use and function of equipment. Have the opportunity to observe and gain fundamental understanding of orthotics and prosthetics, including fitting and manufacturing, through exposure to appropriately certified orthotists and prosthetists. Observe and gain a basic understanding of the types of patients served, referral patients, and services available in the continuum of rehabilitation care. This includes subacute and skilled facilities; sheltered workshops; vocational facilities; schools for the multiple handicapped, deaf, and blind; independent living facilities for the physically impaired; day hospitals; nursing homes; home health care services; and community reentry services. This can be accomplished through didactic lectures and on-site visits to facilities. Interact with healthcare consumer groups. The AOA further states that the clinical curriculum must follow specific learning objectives and allow for the comprehensive development of measurable competencies for each resident in the following areas: History and physical examination pertinent to PM&R. Assessment of the neurologic, musculoskeletal, and cardiovascular systems. Determining impairment and disability. Data gathering and interpreting of psychosocial and vocational factors. Performance of EMG, nerve conduction, and somatosensory evoked potential studies. Each resident must perform 200 electrodiagnostic consultations 8

9 under appropriate supervision. Physiatric injection techniques. Prescriptions for orthotics, prosthetics, wheelchairs and ambulatory devices, special beds, and other assistive devices. Written prescriptions for and appropriate supervision of therapeutic modalities. Testing and treatment provided by physical therapists, occupational therapists, and speech-language pathologists, and the understanding and coordination of psychological and vocational interventions and tests. The use, safety, calibration, and maintenance of medical equipment common to various therapies. A formal experience in the evaluation and rehabilitation of cardiovascular and pulmonary systems as related to physiatric practice. Analysis of growth and development relating to the rehabilitation of children. Collaboration with other medical professionals and members of the allied health team, including management techniques consistent with the resident s leadership role. The clinical curriculum must also provide the resident with opportunities for progressive responsibility in diagnosing, assessing, and managing the conditions commonly encountered by the physiatrist, including: Acute musculoskeletal pain syndrome, including sports and occupational injuries Chronic pain management Congenital or acquired myopathies, peripheral neuropathies, and motor system diseases Brain injury and other trauma Hereditary, developmental, and acquired central nervous systems disorders including cerebral palsy, stroke, myelomeningocele, and multiple sclerosis Spinal cord trauma and diseases, including management of bowel and bladder dysfunction and pressure ulcer prevention and treatment Amputations of both congenital and acquired conditions in patients of all ages Sexual dysfunction common to the physically impaired Post-fracture and joint arthroplasty care Pulmonary, cardiac, oncologic, and other common medical conditions seen in patients with physical disabilities Diseasesand impairments with functional limitations seen in the geriatric population, especially the frail elderly Rheumatologic disorders Medical conditioning, reconditioning, and fitness Palpatory diagnosis of somatic dysfunction and appropriate use of osteopathic manipulative treatment (OMT) Residents must make daily rounds on inpatients with faculty at least five times per week. With regard to medical knowledge, residents must receive adequate and systematic training in basic sciences relevant to rehabilitation such as: Anatomy Physiology 9

10 Pathology and pathophysiology of the neuromuscular, cardiovascular, and pulmonary systems Kinesiology Functional anatomy Physics Electronics Statistics Computer literacy and instrumentation related to the field Physiologic responses to the various physical modalities Therapeutic exercise Procedures commonly employed by physiatrists must be correlated with clinical training but must include basic science faculty when appropriate. An accessible anatomy laboratory for discussion is highly desirable Residents must also receive training in administration, unit management, cost containment, quality improvement, ethics, and teaching, and must participate in structured supervised research training. Positions of accreditation bodies CMS CMS has no formal position concerning the delineation of privileges for PM&R. However, the CMS Conditions of Participation (CoP) define a requirement for a criteria- based privileging process in (c)(6) stating, The bylaws must include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges (a)(6) states, The governing body must assure that the medical staff bylaws describe the privileging pro cess. The process articulated in the bylaws, rules or regula tions must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners that considers: Individual character Individual competence Individual training Individual experience Individual judgment The governing body must ensure that the hospital s bylaws governing medical staff membership or the granting of privileges apply equally to all practitioners in each professional category of practitioners. Specific privileges must reflect activi ties that the majority of prac titioners in that category can perform competently and that the hospital can support. Privileges 10

11 are not granted for tasks, procedures, or activities that are not conducted within the hospital, regardless of the practitioner s ability to perform them. Each practitioner must be individually evaluated for requested privileges. It cannot be assumed that every practitioner can perform every task, activity, or privilege specific to a specialty, nor can it be assumed that the practitioner should be automatically granted the full range of privileges. The individual practitioner s ability to perform each task, activity, or privilege must be individually assessed. CMS also requires that the organization have a process to ensure that practitioners granted privileges are work ing within the scope of those privileges. CMS CoPs include the need for a periodic appraisal of practitioners appointed to the medical staff/granted medical staff privileges ( [a][1]). In the absence of a state law that establishes a time frame for the periodic appraisal, CMS recommends that an appraisal be conducted at least every 24 months. The purpose of the periodic appraisal is to determine whether clinical privileges or membership should be continued, discontinued, revised, or otherwise changed. The Joint Commission The Joint Commission has no formal position concerning the delineation of privileges for PM&R. However, in its Comprehensive Accreditation Manual for Hospitals, The Joint Commission states, The hospital collects information regarding each practitioner s current license status, training, experience, competence, and ability to perform the requested privilege (MS ). In the introduction for MS , The Joint Commission states that there must be a reliable and consistent system in place to process applications and verify credentials. The organized medical staff must then review and evaluate the data collected. The resultant privilege recommendations to the governing body are based on the assessment of the data. The Joint Commission introduces MS by stating, The organized medical staff is respon sible for planning and implementing a privileging process. It goes on to state that this process typically includes: Developing and approving a pro cedures list Processing the application Evaluating applicant-specific information Submitting recommendations to the governing body for applicant-specific delineated privileges Notifying the applicant, relevant personnel, and, as required by law, external entities of the privi leging decision Monitoring the use of privileges and quality-of-care issues 11

12 MS further states, The decision to grant or deny a privilege(s) and/or to renew an existing privilege(s) is an objective, evidence-based process. The EPs for standard MS include several requirements as follows: The need for all licensed independent practitioners who provide care, treatment, and services to have a current license, certification, or registration, as required by law and regulation Established criteria as recommended by the organized medical staff and approved by the governing body with specific evaluation of current licensure and/or certification, specific relevant training, evidence of physical ability, professional practice review data from the applicant s current organization, peer and/or faculty recommendation, and a review of the practitioner s performance within the hospital (for renewal of privileges) Consistent application of criteria A clearly defined (documented) procedure for processing clinical privilege requests that is approved by the organized medical staff Documentation and confirmation of the applicant s statement that no health problems exist that would affect his or her ability to perform privileges requested A query of the NPDB for initial privileges, renewal of privileges, and when a new privilege is requested Written peer recommendations that address the practitioner s current medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism A list of specific challenges or concerns that the organized medical staff must evaluate prior to recommending privileges (MS , EP 9) A process to determine whether there is sufficient clinical performance information to make a decision related to privileges A decision (action) on the completed application for privileges that occurs within the time period specified in the organization s medical staff bylaws Information regarding any changes to practitioners clinical privileges, updated as they occur The Joint Commission further states, The organized medical staff reviews and analyzes information regarding each requesting practitioner s current licensure status, training, experience, current competence, and ability to perform the requested privilege (MS ). In the EPs for standard MS , The Joint Commission states that the information review and analysis process is clearly defined and that the decision process must be timely. The organization, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a request for privileges. The criteria must be consistently applied and directly relate to the quality of care, treatment, and services. Ultimately, the governing body or delegated governing body has the final authority for granting, renewing, or denying clinical privileges. Privileges may not be granted for a period beyond two years. 12

13 Criteria that determine a practitioner s ability to provide patient care, treatment, and services within the scope of the privilege(s) requested are consistently evaluated. The Joint Commission further states, Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privileges, or to revoke an existing privilege prior to or at the time of renewal (MS ). In the EPs for MS , The Joint Commission says there is a clearly defined process facilitating the evaluation of each practitioner s professional practice, in which the type of information collected is determined by individual departments and approved by the organized medical staff. Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege. HFAP The Healthcare Facilities Accreditation Program (HFAP) has no formal position concerning the delineation of privileges for PM&R. The bylaws must include the criteria for determining the privileges to be granted to the individual practitioners and the procedure for applying the criteria to individuals requesting privileges ( ). Privileges are granted based on the medical staff s review of an individual practitioner s qualifications and its recommendation regarding that individual practitioner to the governing body. It is also required that the organization have a process to ensure that practitioners granted privileges are working within the scope of those privileges. Privileges must be granted within the capabilities of the facility. For example, if an organization is not capable of performing open-heart surgery, no physician should be granted that privilege. In the explanation for standard related to membership selection criteria, HFAP states, Basic criteria listed in the bylaws, or the credentials manual, include the items listed in this standard. (Emphasis is placed on training and competence in the requested privileges.) The bylaws also define the mechanisms by which the clinical departments, if applicable, or the medical staff as a whole establish criteria for specific privilege delineation. Periodic appraisals of the suitability for membership and clinical privileges is required to determine whether the individual practitioner s clinical privileges should be approved, continued, discontinued, revised, or otherwise changed ( ). The appraisals are to be conducted at least every 24 months. 13

14 The medical staff is accountable to the governing body for the quality of medical care provided, and quality assessment and performance improvement ( ) information must be used in the process of evaluating and acting on re-privileging and reappointment requests from members and other credentialed staff. DNV DNV has no formal position concerning the delineation of privileges for PM&R. MS.12 Standard Requirement (SR) #1 states, The medical staff bylaws shall include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to those individuals that request privileges. The governing body shall ensure that under no circumstances is medical staff membership or professional privileges in the organization dependent solely upon certification, fellowship, or membership in a specialty body or society. Regarding the Medical Staff Standards related to Clinical Privileges (MS.12), DNV requires specific provisions within the medical staff bylaws for: The consideration of automatic suspension of clinical privileges in the following circumstances: revocation/restriction of licensure; revocation, suspension, or probation of a DEA license; failure to maintain professional liability insurance as specified; and noncompliance with written medical record delinquency/deficiency requirements Immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioner s Medicare/Medicaid status Fair hearing and appeal The Interpretive Guidelines also state that core privileges for general surgery and surgical subspecialties are acceptable as long as the core is properly defined. DNV also requires a mechanism (outlined in the bylaws) to ensure that all individuals provide services only within the scope of privileges granted (MS.12, SR.4). Clinical privileges (and appointments or reappointments) are for a period as defined by state law or, if permitted by state law, not to exceed three years (MS.12, SR.2). Individual practitioner performance data must be measured, utilized, and evaluated as a part of the decision-making for appointment and reappointment. Although not specifically stated, this would apply to the individual practitioner s respective delineation of privilege requests. CRC draft criteria The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding this practice area. The core privileges and accompanying procedure list are not meant to be all-encompassing. 14

15 They define the types of activities, procedures, and privileges that the majority of practitioners in this specialty perform. Additionally, it cannot be expected or required that practitioners perform every procedure listed. Instruct practitioners that they may strikethrough or delete any procedures they do not wish to request. Minimum threshold criteria for requesting privileges in PM&R Basic education: MD or DO Minimal formal training: Successful completion of an ACGME- or AOA- accredited residency in PM&R (or a combined pediatric/pm&r or internal medicine/pm&r) and/or current certification or active participation in the examination process (with achievement of certification within [n] years) leading to certification in PM&R by the ABPMR or the AOBPMR Required current experience: Provision of inpatient, outpatient, or consultative services, reflective of the scope of privileges requested, for at least 24 patients during the past 12 months or successful completion of an ACGME- or AOAaccredited residency or clinical fellowship within the past 12 months References If the applicant is recently trained, a letter of reference should come from the director of the applicant s training program. Alternatively, a letter of reference may come from the applicable department chair and/or clinical service chief at the facility where the applicant most recently practiced. Core privileges in PM&R Core privileges for PM&R include the ability to admit, evaluate, diagnose, provide consultation to, and manage patients of all ages with physical and/ or cognitive impairments and disability. Privileges also include the ability to diagnose and treat patients with painful or functionally limiting conditions, the management of comorbidities and coimpairments, the performance of diagnostic and therapeutic injection procedures, electrodiagnostic medicine, and the prevention of complications of disability from secondary conditions. Physicians may also provide care to patients in the intensive care setting in conformance with unit policies, and may assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the following procedures list and such other procedures that are extensions of the same techniques and skills: Performance of history and physical exam Anesthetic and/or motor blocks (e.g., peripheral nerve, myoneural junction, sympathetic chain/ganglia, caudal, facet nerve/joint, epidural [interlaminar and transforaminal], sacroiliac joint) Arterial puncture 15

16 Arthrocentesis (both aspiration and injection [joints and bursae]) Chemolysis (paralytic and nonparalytic; intramuscular, peripheral nerve, and cauda equina) Impairment and disability evaluations Ergonomic evaluations Fitness-for-duty evaluations Independent medical evaluations Interventional pain treatment, including intrathecal medication administration and electrical stimulation Manipulation/mobilization (peripheral, spinal [direct/indirect], and cranial) Routine nonprocedural medical care Serial casting Soft tissue injections, including ligament, tendon, sheath, muscle, fascial, prolotherapy Work determination status Performance and interpretation of: Electrodiagnosis, including EMG and nerve conduction studies Ergometric studies Gait laboratory studies Muscle/muscle motor point biopsies Small, intermediate, or major joint arthrogram Radiological and lab procedures, including fluoroscopy Work physiology testing, including treadmill and pulmonary EKG monitoring Privileges for PM&R also include the following procedures for spinal cord injury medicine: Performance of history and physical exam Evaluation, prescription, and supervision of medical and comprehensive rehabilitation goals and treatment plans for spinal cord injuries and syndromes Management of abnormalities and complications in other body systems resulting from spinal cord injury Management of skin problems utilizing various techniques of prevention Treatment, with appropriate consultation, of complications, such as deep vein thrombosis, pulmonary embolus, autonomic hyperreflexia, substance abuse, pain, spasticity, depression, and the sequelae of associated illnesses and preexisting diseases Recognition, diagnosis, and coordination of treatment for respiratory complications Recognition, diagnosis, and treatment of orthostatic hypotension and other cardiovascular abnormalities Spinal cord rehabilitation (including neuromuscular, genitourinary, and other advanced techniques) Spinal immobilization 16

17 Special noncore privileges in PM&R If desired, noncore privileges are requested individually in addition to requesting the core. Each individual requesting noncore privileges must meet the specific threshold criteria governing the exercise of the privilege requested, including training, required previous experience, and maintenance of clinical competence. Noncore privileges include administration of sedation and analgesia. Reappointment Reappointment should be based on unbiased, objective results of care according to a hospital s quality assurance mechanism. To be eligible to renew privileges in PM&R, the applicant must have current demonstrated competence and an adequate volume of experience ([n 1 ] patients) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges. In addition, continuing education related to PM&R should be required. For more information Accreditation Council for Graduate Medical Education 515 North State Street, Suite 2000 Chicago, IL Telephone: Fax: Website: American Academy of Physical Medicine and Rehabilitation 9700 West Bryn Mawr Avenue, Suite 200 Rosemont, IL Telephone: Fax: Website: American Board of Medical Specialties 222 North LaSalle Street, Suite 1500 Chicago, IL Telephone: Website: 1 Healthcare organizations should define the minimum case/patient volume (the [n] ) required to maintain clinical competence as recommended by the applicable department chair and the medical executive committee and subject to approval by the governing board. 17

18 American Board of Physical Medicine and Rehabilitation 3015 Allegro Park Lane SW Rochester, MN Telephone: Fax: Website: American Osteopathic Association 142 East Ontario Street Chicago, IL Telephone: Fax: Website: American Osteopathic Board of Physical Medicine and Rehabilitation 142 East Ontario Street, 4th Floor Chicago, IL Telephone: , Ext Fax: Website: Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD Telephone: Website: DNV Healthcare, Inc. 400 Techne Center Drive, Suite 350 Milford, OH Website: Healthcare Facilities Accreditation Program 142 East Ontario Street Chicago, IL Telephone: Website: The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL Telephone: Fax: Website: 18

19 Editorial Advisory Board Clinical Privilege White Papers Associate Editorial Director: Erin Callahan, Managing Editor: Julie McCoy, William J. Carbone Chief Executive Officer American Board of Physician Specialties Atlanta, Ga. Darrell L. Cass, MD, FACS, FAAP Codirector, Center for Fetal Surgery Texas Children s Hospital Houston, Texas Jack Cox, MD Senior Vice President/Chief Quality Officer Hoag Memorial Hospital Presbyterian Newport Beach, Calif. Stephen H. Hochschuler, MD Cofounder and Chair Texas Back Institute Phoenix, Ariz. Bruce Lindsay, MD Professor of Medicine Director, Cardiac Electrophysiology Washington University School of Medicine St. Louis, Mo. Sally J. Pelletier, CPCS, CPMSM Director of Credentialing Services The Greeley Company, a division of HCPro, Inc. Danvers, Mass. Beverly Pybus Senior Consultant The Greeley Company, a division of HCPro, Inc. Danvers, Mass. Richard A. Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Danvers, Mass. The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 2012 HCPro, Inc., Danvers, MA