ACFAS Principles for Hospital Privileging and Due Process Rights

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Hospital bylaws are written documents that govern each individual hospital. These bylaws state policies and governance procedures, identify staff levels of appointment, describe the credentialing and privileging process and provide the rules and regulations for the hospital. Bylaws can vary significantly from one hospital to another and must be evaluated closely prior to applying for hospital privileges.

Hospitals are governed by state law that specifically identify, within statutory law, who is eligible to hold medical staff positions within a hospital. In many cases, the statute grants to the individual hospitals the right to determine the types of providers who may obtain privileges. For foot and ankle surgeons interested in pursuing privileges, state podiatric association hospital committees or legal counsel can be helpful in finding and reviewing relevant statutory law.

Important Principles for Foot and Ankle Surgeons:
  1. Obtain a copy of the hospital bylaws and thoroughly analyze key areas: definitions, staff appointments by categories, the credentialing and privileging process, the bylaws amendment process and the fair hearing and/or appeal process, if denied privileges.
  2. Become familiar with the state laws for scope of practice.
  3. Become knowledgeable of the section department rules.
  4. Become familiar with JCAHO medical staff standards.
  5. Become knowledgeable about specific regulations or rules relative to extension of additional privileges.
  6. Become familiar with the organizational hierarchy and activity level of pertinent staff members.
  7. Keep track of surgical delivery and patient quality of care issues.
  8. Develop a working relationship with the medical staff office, medical executive members, section department chairman and orthopedic surgeons.
  9. Know the exact make-up of the relevant committees such as surgery, credentials, executive, the hospital administration, etc. Doctors of Podiatric Medicine (DPMs) should try to determine the names, specialty, and training of each member on these committees. Open discussions with these individuals can lay the groundwork for obtaining hospital privileges.
  10. Attend various medical staff, committee and board of directors meetings.
  11. Learn how other medical staff members, such as orthopedic surgeons, go about obtaining additional privileges with continuing education i.e. foot and ankle arthroscopy, exostectomy, insertion of implants, amputation and so forth.
  12. Bylaws may contain provisions which prohibit or restrict foot and ankle surgeon’s scope of practice. Learn what the procedures are for amending existing hospital bylaws. List any provisions which require amending and propose changes to the appropriate bodies of the hospital administration.
  13. Determine who will review request for clinical privileges and what the procedures for fair hearing are if current privileges are not aligned with scope of practice.
If the bylaws are found to be ambiguous, it is up to the foot and ankle surgeon to resolve any issues of hospital privileging at their local institutions. DPMs must demonstrate and portray themselves not only as podiatrist but as medical and surgical specialists.

(Note: This document is solely to be used as a guideline. The College does not provide legal advice, and recommends that members seek legal consultation from an attorney.)