Privileging Process - Core or Bundled Privileging Model
Are they any specific considerations when using a core/bundle model for privileging ?
Any examples are for illustrative purposes only.
The Joint Commission does not define or prohibit the use of a core/bundled privileging model. Organizations adopting this model must consider the following:
Defining the process
The core/bundled privilege must clearly and accurately define the specific activities/procedures/privileges to be included in the core/bundle and reflect only activities/procedures/privileges performed at the organization from which privileges have been requested.
Implementation
The applicant's education, training and current competence to perform each activity listed in the core/bundle must be evaluated as required per the standards in the Medical Staff Chapter of the manual. There also needs to be a clearly defined method for the applicant to request deletion of specific privileges if they don't wish for them to be granted.
If the organization's evaluation determines that the applicant is not competent to perform certain activities, then they must modify the core/bundle that is granted to reflect only the specific privileges granted to the applicant.
In accordance with the medical staff standards, the applicant and all appropriate internal and/or external persons or entities (as defined by the organization and applicable law) are to be notified of the granting decision, i.e., whether the full core/bundle or a modified bundle has been granted (see MS.06.01.09 EP 3). If the core/bundle was modified, the notification must detail the specific modifications.
CMS Position
In November 2004, CMS issued their position on privileging which addresses the concept of core/bundle privileging and remains current. It is in line with the Joint Commission expectation. Organizations are also encouraged to determine if any state-specific law/regulation exist that address the use of a core/bundled privileging model.
Additional Resources
CMS Survey and Certification Letter - November 12, 2004: Centers for Medicare & Medicaid Services (CMS) Requirements for Hospital Medical Staff Privileging. Ref: S&C-05-04
The Joint Commission does not define or prohibit the use of a core/bundled privileging model. Organizations adopting this model must consider the following:
Defining the process
The core/bundled privilege must clearly and accurately define the specific activities/procedures/privileges to be included in the core/bundle and reflect only activities/procedures/privileges performed at the organization from which privileges have been requested.
Implementation
The applicant's education, training and current competence to perform each activity listed in the core/bundle must be evaluated as required per the standards in the Medical Staff Chapter of the manual. There also needs to be a clearly defined method for the applicant to request deletion of specific privileges if they don't wish for them to be granted.
If the organization's evaluation determines that the applicant is not competent to perform certain activities, then they must modify the core/bundle that is granted to reflect only the specific privileges granted to the applicant.
In accordance with the medical staff standards, the applicant and all appropriate internal and/or external persons or entities (as defined by the organization and applicable law) are to be notified of the granting decision, i.e., whether the full core/bundle or a modified bundle has been granted (see MS.06.01.09 EP 3). If the core/bundle was modified, the notification must detail the specific modifications.
CMS Position
Additional Resources
Manual:
Hospital and Hospital Clinics
Chapter:
Medical Staff MS
Last reviewed by Standards Interpretation: February 04, 2022
Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: April 11, 2016
This Standards FAQ was first published on this date.
This page was last updated on February 04, 2022
with update notes of: Review only, FAQ is current
Types of changes and an explanation of change type:
Editorial changes only: Format changes only. No changes to content. |
Review only, FAQ is current: Periodic review completed, no changes to content. |
Reflects new or updated requirements: Changes represent new or revised requirements.
Get Extra Help with Books and E-books
Browse our gallery of books and e-books to find trusted prep and readiness resources, practical checklists and toolkits, and resources on specialized health care topics.
Stay Informed with Online Education
Online education is the most convenient and cost-effective way to educate your staff and minimize expenses without the need to leave your organization.
Reach Your Safety Goals with eProducts
Assessing and sustaining compliance with accreditation standards or CMS CoPs can be a challenge, but it doesn’t have to be. Rely on our proven software solutions developed by our team of industry experts.
Joint Commission Virtual Assistant