Delineation of Hospital Privileges

The ultimate responsibility for delineating clinical privileges in the hospital setting rests with the institution's governing board and is discharged through the organized medical staff. Privilege delineation is an institutional function aimed at matching the clinical privileges accorded to each member of the medical staff with his/her demonstrated ability to perform, thereby ensuring patient safety and promoting the quality of patient care. Board certification may be used to provide evidence of training and, to a certain degree, medical proficiency and judgment, but should not be used alone as a device for defining the scope of practice privileges accorded, but is one element in addition to training, clinical expertise and experience, and the needs of the local community.

The American Academy of Otolaryngology-Head and Neck Surgery, Inc. is on record as favoring the granting of surgical privileges as outlined by the Joint Commission on Accreditation of Healthcare Organizations, i.e. that the medical staff has devised a reasonable method of delineating clinical privileges that indicate:

Adopted 1985
Reviewed 9/16/95
Revised 9/16/95
Revised 12/17/97
Submitted for Review 3/1/98
Reaffirmed 3/1/98

Guidelines are not a substitute for the experience and judgment of a physician and are developed to enhance the physicians' ability to practice evidence-based medicine.

Important Notice

The American Academy of Otolaryngology-Head and Neck Surgery, Inc. and Foundation (AAO-HNS/F) Policy Statements are guidelines only. In no sense do they represent a standard of care. The applicability of an indicator for a procedure, and/or of the process or outcome criteria, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these guidelines will not ensure successful treatment in every situation. The AAO-HNS emphasizes that these policies should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results.