Anesthesia services must be provided in a well-organized manner, under the direction of one individual who is a qualified doctor of medicine (M.D.) or doctor of osteopathy (D.O.), the director of anesthesia services (§482.52 Condition of Participation: Anesthesia Services). The Anesthesia Service and its director are also responsible for planning, directing and supervising all activities of the anesthesia service. The Department of Anesthesia has the responsibility and authority, through its director, for developing policies and procedures governing the provision of all categories of anesthesia services, including specifying the minimum qualifications for each category of practitioner who is permitted to provide anesthesia services. The medical staff bylaws or rules and regulations must include criteria for determining the anesthesia service privileges to be granted to an individual practitioner and a procedure for applying the criteria to individuals requesting privileges, as required by the regulations at §482. 22(c)(6) for any type of anesthesia services. The hospital’s governing body approves the specific anesthesia service privileges, including type and complexity of procedures, for each practitioner who furnishes anesthesia services.
It is the responsibility of the director of anesthesia services to evaluate staff, develop and maintain a quality assurance and performance improvement program at the department level that is integrated into the facility program and develop systems to monitor practitioner performance and recommend re-approval of privileges.
The MADOM and the QMDA Toolkit provide guidance, considerations and methods for the director of Anesthesia Services to review when developing local policies that are most appropriate for the local environment of care and the patient populations served. ASA frequently receives questions seeking guidance for maintenance and re-approval of privileges for practitioners following an absence from practice that may be of variable duration. The following is a preliminary collection of issues and sources to consider when developing a local policy that addresses these unique circumstances.