You've been treating a woman throughout her pregnancy, first for morning sickness, and later for a variety of minor complaints. The woman has come to really trust you and acupuncture/Oriental medicine.
While getting the patient ready for delivery, she asked you if acupuncture could help reduce the pain of delivery or hasten a stalled delivery. You told her that depending on the situation, it could, so the woman has asked you to attend her delivery. However, she's going to deliver the baby in a hospital, and the hospital won't let you attend - at least not as a health care provider - because you don't have hospital privileges. What can you do?
Depending on the hospital and its policies, you may not be able to do anything for this particular patient. However, if you don't want to be faced with this same situation in the future, you might want to consider applying for hospital privileges now.
I can think of several situations in which an acupuncturist might be able to help their patients with acupuncture and/or Oriental medicine even after they've been hospitalized. These situations range from acupuncture anesthesia for minor surgery to postoperative pain control to treating nausea as a reaction to chemotherapy. You might also consider the services you can offer to the hospital's Western medical providers, many of whom have patients with problems amenable to treatment with traditional Oriental medicine. This represents a major opportunity, not only in terms of market, but also for the advancement of integrative care.
What Are Hospital Privileges?
Simply put, hospital privileges mean the right to work within a particular hospital as a professional health care provider. In general, there are two levels of hospital privileges: full medical staff privileges and affiliate staff privileges. The former allows a practitioner to admit, treat and discharge patients from the facility. The latter grants permission to provide services to patients who have been admitted to the facility, but not to independently admit or discharge patients. A provider with affiliate privileges can work in conjunction with a provider with full privileges to have the affiliate's patients admitted and discharged under the name of the fully privileged provider. Hence, affiliate staff privileges will adequately meet the needs of most acupuncturists.
Applying for Hospital Privileges
The standards of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) allow hospitals to grant privileges to nonphysician licensed health care providers, but they do not require hospitals to do so. Most hospitals grant affiliate privileges to a variety of allied health care providers, but not specifically to acupuncturists. The first step, therefore, involves educating the medical staff about acupuncture and acupuncturists. What are acupuncture's indications, contraindications, benefits and risks? What is the research basis? What training do you have? What techniques will you use? It helps at this point to have a champion or two on the hospital staff who can vouch for both you and acupuncture/Oriental medicine. You will need the support of providers in the department you intend to work in. In general, I have found greater initial support from the medical staff than from hospital administrators and executives.
You will need to obtain and fill out the hospital's staff privileges application. Review the form with the hospital's medical staff office if you have any questions about the specific nature of requested information, and also to confirm that the form is relevant to assessing the qualifications of an acupuncturist. You must provide several types of documentation, such as your personal and academic history (including continuing education, research and teaching); board certification; copies of your current license(s) as a health care practitioner; your social security number; and proof of current malpractice insurance. If you already have (or have had) staff privileges elsewhere, you will probably be required to show that you remain in good standing or that your privileges were not adversely revoked. You will need to respond to questions about your physical and mental health; drug or alcohol addictions; any criminal history; and previous or pending malpractice lawsuits. In addition, you will be required to provide personal and professional references. And, of course, you can expect to pay a fee.
After submitting the above materials in support of your application, the hospital will verify your information. Next, you will probably be asked to appear in person before the credentialing committee for an oral interview. This provides you with a formal opportunity to introduce yourself and also educate the committee about acupuncture and Oriental medicine. Depending on the outcome of that interview, the credentialing committee typically makes a recommendation to the executive committee or directly to the hospital's board of directors, where a final decision is made. If you application is denied and you with to appeal the hospital's decision, you can find out about the appeals process from the medical staff office. The JCAHO requires accredited hospitals to have an appeals process.
Once you have been granted affiliate (or associate) staff privileges, you will then be given clinical privileges. Clinical privileges specify exactly what procedures a practitioner can and cannot perform while treating patients in the hospital. Clinical privileges are determined primarily by the hospital, although they are delimited by your state acupuncture law's definition of scope of practice and by JCAHO accreditation standards. The hospital may not have seriously defined clinical privileges for acupuncturists. Therefore, after ascertaining the nature of their particular concerns, you should attempt to resolve this problem by presenting a proposal of the clinical privileges you seek. That proposal should define precisely what procedures and tools you will be limited to using. It might also define limits to your herbal materia medica and/or circumstances requiring consultation with an MD.
For instance, an acupuncturist might be allowed to do acupuncture but not moxibustion, or acupuncture but not Chinese herbal medicine. They might be allowed to treat patients with certain diagnoses but not others. Some restrictions placed on practitioners may be negotiable; others may not. In some cases, it may be only a matter of educating the committee members in charge of drafting your clinical privileges. However, being forbidden to do moxibustion due to smell, the potential fire hazard, and the potential for setting off smoke alarms and/or sprinkler systems usually cannot be negotiated away. Instead, the acupuncturist can adapt to the needs of the institutional setting by using infrared or other smokeless heating devices.
Many medical providers with staff privileges have strictly defined clinical privileges, including nurse practitioners and even general practitioner MDs. For instance, GPs are often required to consult specialists in certain circumstances or with certain diagnoses. Acupuncturists seeking staff privileges should not feel singled out by the limits of clinical privileges. They are not meant to be discriminatory; they are meant to protect both the patient and the hospital. They also serve to protect the practitioner by ensuring they do not do anything dangerous or for which they are not qualified.
In addition, clinical privileges are not necessarily set in stone. Once you have gotten into the system and have shown your professionalism, competence and therapeutic effectiveness, the hospital may be willing to expand your privileges over time. The first issue is getting your foot in the door. Later, once you have built strong working relationships, you will be in a better position to negotiate.
Whether or not your state requires acupuncturists to carry malpractice insurance, you can be certain the hospital to which you apply for privileges will. They need to know they will not be solely financially responsible for the defense and outcomes of any malpractice suits resulting from your actions on their premises. In my experience, the amount of coverage hospitals require for obtaining privileges are larger than those required by states that mandate acupuncturist malpractice insurance. For instance, Colorado requires a minimum of $500,000 per single incident, but Denver General Hospital requires $1 million. Therefore, if you apply for hospital privileges and do not yet have malpractice insurance, be sure to purchase the right kind, in the right amounts, to meet the requirements of the hospital to which you are applying.
Acupuncture and Oriental medicine are appropriate for many inpatients, as well as ambulatory care patients. The hospital door should no longer be seen as a glass wall denying entry to nonphysician acupuncturists. Granted that at times, this is still a heavy door to open, but some of that weight is due to our own reluctance to open it. In fact, I have found my acupuncture practice simpler, more rewarding and, in certain regards, of higher quality when working as a team player inside those doors than when working as a solo practitioner in a private practice.
Although obtaining hospital staff privileges may seem stressful and time-consuming, it is a great boon to our patients when they are seriously in need. Some of the other benefits of obtaining hospital privileges include heightened visibility within your community; increased credibility with patient and other health care providers; and the ability to give and get advice and support from other health care providers. Perhaps the greatest benefit of obtaining hospital privileges, however, is the ability to actively participate in the creation of a new integrative medicine for the 21st century.
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