QUESTION:    Can we grant temporary privileges under the Joint Commission’s “important patient care need” standard so a physician on our staff can learn a new procedure?

ANSWER:    The Joint Commission has stated that temporary privileges may not be granted to a physician to allow that physician to learn a new procedure. The Joint Commission’s rationale is that the grant of clinical privileges signifies that an individual is competent to perform a procedure. Granting privileges to learn a procedure – even if those privileges are designated as “temporary” – would create confusion as to the meaning of clinical privileges.

The Joint Commission authorizes two types of temporary privileges:

(1)        “new applicant” temporary privileges, which may be granted when an applicant for initial appointment is awaiting approval by the Medical Executive Committee and Board of Directors; and

(2)        “important patient care need” temporary privileges, which are typically used for locum tenens physicians and similar purposes.

In either case, the physician requesting the privileges must be competent to perform them.

In 2007, the Joint Commission’s Standards Interpretation Group (“SIG”) stated that a physician coming to a hospital to learn a procedure “would not qualify as an important patient care need to justify the use of important patient care need temporary privileges.” The SIG went on to say that “[t]he only temporary privileges that could be granted would be full new applicant temporary privileges.” But if “new applicant” temporary privileges are to be used, the applicant must establish that he or she meets all applicable criteria for the privileges in question. In other words, there really is no way to use temporary privileges to allow a physician to learn a new procedure.

The Joint Commission has also pointed out that if a physician “will not be participating in any manner with the procedure,” but will only be doing “standby observation,” there would be no need to credential or privilege the physician. Of course, doing “standby observation” will generally not be sufficient to learn a new procedure.