Can We Do That Here? Establishing the Scope of Surgical Practice at a New Safety-Net Community Hospital Through a Transparent, Collaborative Review of Physician Privileges  Sean M. O'Neill, MD, PhD, Sarah Seresinghe, BA, Arun Sharma, BA, Tara A. Russell, MD, MPH, L'Orangerie Crawford, PhD, Stanley K. Frencher, MD, MPH  Joint Commission Journal on Quality and Patient Safety  Volume 44, Issue 1, Pages 52-60 (January 2018) DOI: 10.1016/j.jcjq.2017.06.008 Copyright © 2017 The Joint Commission Terms and Conditions

Figure 1 The left column lists each step in order in the process of reviewing physician privileges at MLKCH. The first steps are at the top, and the final step is at the bottom of the figure. The process overall has taken between 6 and 12 weeks to complete, depending on the specialty field. The right column indicates the personnel and groups involved in the process at each step. This highlights the collaborative nature of the process. The “Key Steps” highlighted by the dashed box represent the meetings conducted first with surgeons, and then with a wider multidisciplinary group. The conduct of these meetings is illustrated in greater detail in Figures 2 and 3. MLKCH, Martin Luther King, Jr. Community Hospital; OR, operating room. Joint Commission Journal on Quality and Patient Safety 2018 44, 52-60DOI: (10.1016/j.jcjq.2017.06.008) Copyright © 2017 The Joint Commission Terms and Conditions

Figure 2 This figure illustrates the steps followed in conducting meetings to review surgeon privileges. The Medical Director of Surgical Quality acts as the meeting chair and leads the surgeons in reviewing a comprehensive list of procedures. For each procedure, two key questions are asked in order to guide open discussion. A decision is then reached by consensus to either include or exclude the procedure from the hospital. A revised list of procedures is then compiled. Joint Commission Journal on Quality and Patient Safety 2018 44, 52-60DOI: (10.1016/j.jcjq.2017.06.008) Copyright © 2017 The Joint Commission Terms and Conditions

Figure 3 This figure illustrates the steps followed in conducting the multidisciplinary meeting to review surgeon privileges. The Medical Director of Surgical Quality acts as the meeting chair, and leads the participants in reviewing the list of procedures that has already been reviewed by the surgeons (Figure 2). For each procedure, two key questions are asked, and a decision to either include or exclude the procedure from the hospital is reached by consensus after each one. A revised list of procedures is then compiled. Joint Commission Journal on Quality and Patient Safety 2018 44, 52-60DOI: (10.1016/j.jcjq.2017.06.008) Copyright © 2017 The Joint Commission Terms and Conditions