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Privileging - Organ Procurement Team

Is a health care organization required to perform credentials review and grant clinical privileges to members of transport teams and donor surgical teams for clinical intervention provided in the health care organization?  

Any examples are for illustrative purposes only.

No. Transport Teams, such as for Neonatal ICU patients, trauma victims, long-term care facility residents, or burn patients, and Donor Surgical Teams, often contain licensed independent practitioners who would otherwise require clinical privileges to work within the facility. These teams often consist of individuals who are on rotational assignments, who may only infrequently visit the health care organization for a very brief period specifically for the purpose of transporting a patient. They often cover large territories and a large number of health care organizations. The Teams work as part of the health care organization's plan for continuity of care.

Their work is too limited to undergo effective performance improvement activity review at each site that would be meaningful for the renewal of clinical privileges.

The patient, although still in the health care organization, is transferred to the responsibility of the Team. When that occurs, the responsibility for the performance of the Team members as it applies to the patient (and as required by Joint Commission standards), passes to the Team.

Teams work in health care organizations on the basis of an agreement, whether a contract, memorandum of understanding, or regional governmental authority. It is the health care organization's responsibility to ensure that the agreement provides for qualified individuals who are properly authorized by their organizations.

Note: While this answer provides an exception to the usual procedures required for credentials review, privileging, competency, and job descriptions, it does not remove the health care organization from its obligation to ensure that it enters into agreements that comply with Joint Commission standards.
Last updated on June 22, 2020
Manual: Hospital and Hospital Clinics
Chapter: Medical Staff MS

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