​Guidelines for Delineation of Clinical Privileges in Anesthesiology

Developed By: Committee on Quality Management and Departmental Administration
Last Amended: October 17, 2018 (original approval: October 15, 2003)

The following guidelines are designed to assist physician anesthesiologists and organizations in developing a program for the delineation of clinical privileges in anesthesiology for anesthesiologists.

Anesthesiology is the practice of medicine. Clinical privileges in anesthesiology are granted to physicians who are qualified by training to provide anesthesia and perioperative medical care to patients as described by the American Board of Anesthesiology (ABA).¹ 

The granting, reappraisal and revision of clinical privileges should be awarded on a time-limited basis in accordance with medical staff bylaws and institutional/facility and governmental rules and regulations, as applicable.

To be awarded medical staff privileges in anesthesiology, a physician must fully meet certain required criteria.  It is possible to make all the following criteria mandatory or to have a mixture of required and optional criteria.  Organizations should determine which criteria to include and whether to include additional criteria based on the institution’s individual requirements and preferences.  For example, some facilities may decide that certification by the ABA is a requirement for clinical privileges in anesthesiology, while others may deem board certification to be desirable but not essential. Dependent on training, experience, and qualifications, physician anesthesiologists may also be granted core privileges to manage and care for patients who are critically ill, have chronic pain syndromes and/or require palliative care.  Similarly, some institutions may decide that subspecialty fellowship training is needed for certain clinical privileges, while others may not. Some organizations may wish to recognize residency training obtained or certification awarded outside the United States. Institutions granting subspecialty clinical privileges may wish to recognize experience as an alternative to formal training in a subspecialty of anesthesiology. Some institutions may wish to modify certain requirements for physicians who have recently completed their residency or fellowship training.

EXAMPLE CRITERIA TO BE CONSIDERED FOR DELINEATION OF CLINICAL PRIVILEGES IN ANESTHESIOLOGY

1.   EDUCATION

1.1 Graduation from a medical school accredited by the Liaison Committee on Medical Education (LCME), from an osteopathic medical school or program accredited by the American Osteopathic Association (AOA), or from a foreign medical school that provides medical training acceptable to and verified by the Educational Commission on Foreign Medical Graduates (ECFMG).

1.2 Completion of an anesthesiology residency training program approved by the Accreditation Council for Graduate Medical Education (ACGME) or by the AOA.

1.3 Permanent certification by the ABA or current recertification within the time interval required by the ABA.

1.4 Compliance with the ABA Maintenance of Certification in Anesthesiology Program (MOCA) for physicians with time-limited certification.

1.5 Compliance with relevant state or institutional requirements for CME.

1.6 At least 50 percent of CME hours in anesthesiology or its subspecialties.

1.7 Demonstration of competence in Advanced Life Support, Advanced Cardiac Life Support or the equivalent.

The following items are for organizations granting physicians clinical privileges to practice in a subspecialty of anesthesiology.

1.8 Completion of a fellowship approved by the ACGME (Adult Cardiothoracic, Anesthesiology Critical Care Medicine, Clinical Informatics, Hospice and Palliative Medicine, Obstetric Anesthesiology, Pain Medicine, Pediatric Anesthesiology, Regional Anesthesiology and Acute Pain Medicine and other fellowships, when available, as designated by the ACGME) ², or a fourth clinical year (CA-4) or fellowship of at least 12 months duration not accredited by the ACGME.

1.9 Current ABA certification in Critical Care Medicine, Hospice and Palliative Medicine, Pain Medicine, Pediatric Anesthesiology, Sleep Medicine and other certifications, when available, as designated by the ABA.³

1.10 Completion of the National Board of Echocardiography’s Advanced Perioperative Transesophageal Echocardiography Exam.

2.   LICENSURE

2.1 Current, active, unrestricted medical or osteopathic license in a United States state, district or territory of practice.  (Exception: Physicians employed by the federal government may have a current active medical or osteopathic license in any U.S. state, district or territory.)

2.2 Current, unrestricted Drug Enforcement Administration (DEA) registration (schedules II-V) or no history of revocation of DEA registration (schedules II-V) within the past five years.

2.3 Disclosure of any disciplinary action (final judgments) against any medical or osteopathic license or by any federal agency, including Medicare/Medicaid, in the last five years.

3.   PERFORMANCE ASSESSMENT

3.1 Member of an organization that reviews physician performance at the time of hire, when a new privilege is requested, or when a concern is raised about an existing privilege consistent with The Joint Commission (TJC) standards for Focused Professional Practice Evaluation (FPPE) or a similar requirement from another organization with deeming authority from CMS.

3.2 Active participation in an ongoing process that evaluates physician performance at least every 6 months in a manner consistent with TJC standards for Ongoing Professional Performance Evaluation (OPPE) or a similar requirement from another organization with deeming authority from CMS.  Participation in the ABA’s Maintenance of Certification program may be considered one of these requirements.

4.   PERSONAL QUALIFICATIONS

4.1 Agreement in writing to abide by the ASA “Guidelines for the Ethical Practice of Anesthesiology.”

4.2 Disclosure of any adjudicated violation of ASA “Guidelines for the Ethical Practice of Anesthesiology” or of any adjudicated ethical violation reported by any medical society or medical or osteopathic licensing organization.

4.3 Membership in a county, state or national medical association or in a state or national specialty society that requires members to subscribe to the AMA Principles of Medical Ethics or to the ASA “Guidelines for the Ethical Practice of Anesthesiology.”

4.4 Certification in writing that “I am in good health and have no physical or mental limitation, including alcohol or drug use, that could impair my ability to render quality patient care.”

4.5 Disclosure of record of felony or fraud conviction.

4.6 Scope and quality of clinical skills, as evidenced by ongoing peer review, that are deemed appropriate by the organization granting clinical privileges.

[1] American Board of Anesthesiology, Primary Certification Policy Book, 1.02 A. http://www.theaba.org/PDFs/BOI/2017-Primary-Certification-Policy-Book.

[2] Accreditation Council for Graduate Medical Education, Anesthesiology, http://www.acgme.org/Specialties/Overview/pfcatid/6/Anesthesiology.

[3] The American Board of Anesthesiology, Clinical Competence, http://www.theaba.org/TRAINING-PROGRAMS/Clinical-Competence/Clinical-Competence.