QUESTION:        Our surveyor discovered that we granted a privilege to a physician for a procedure that we do not do at our facility. We corrected the privilege delineation form, but now we are wondering how to go about notifying the physician that we do not do this procedure.  Our surveyor said that we need to have documentation as to how we handled it. Help!

 ANSWER:        This happens from time to time, but it sounds like you are on top of correcting the forms.

In terms of notifying the physician, we would suggest that you simply inform her of the oversight and then follow that up with a memo or letter summarizing the situation (i.e., there was an oversight made by the Hospital in offering the privilege, the oversight was discovered and corrected, and, because the Hospital will no longer have this privilege on its form, she will no longer see it on her delineation of privileges going forward).

For the physician’s peace of mind, the memo or letter should make it clear that this is not a reduction or “relinquishment” of clinical privileges, so the situation will not trigger any reporting obligation, hearings, etc. Nor would it require the physician to give an affirmative response to any questions about reductions/relinquishments of privileges on an application form in the future.

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