4 min. read

The Delineation of Privileges, often called the DOP, is one of the most important and misunderstood documents in an Ambulatory Surgery Center. It determines exactly what procedures a provider is authorized to perform in your facility. A well-designed DOP reduces ambiguity, improves patient safety, and supports regulatory compliance. A poorly designed DOP invites survey deficiencies, scope of practice issues, and risk exposure.

This article explains what a DOP is, how procedures should be selected, what to do when a new procedure is introduced, and what elements belong on the form.

What Is a DOP?

A Delineation of Privileges is a formal document that lists every procedure or clinical activity a provider may perform within the ASC. It is tied to the provider’s training, experience, and competency. The DOP is approved through the medical staff review process and finalized by the Governing Body.

A DOP is designed to:

• Define the provider’s scope of practice
• Ensure the ASC only allows procedures it can support safely
• Confirm competency for each approved service
• Provide clear guidance for scheduling and clinical staff
• Demonstrate compliance during accreditation or CMS surveys
  

Surveyors routinely request DOPs early in the survey because they connect directly to patient safety.

How Procedures Get on the DOP List

Procedures appear on a DOP only after the ASC confirms that:

1. The procedure is within the provider’s specialty training
2. The provider has documented experience or competency
3. The ASC has the equipment, staffing, and resources to safely support the service
4. The MEC has reviewed and recommended the privilege
5. The Governing Body has granted final approval

DOPs should be tailored to the ASC’s actual capabilities. If the ASC does not perform a procedure, it should not appear on the DOP. (Please note that procedures performed in ASCs should also conform with state regulations and payer requirements).

What Happens if You Need to Add a New Procedure?

Adding a new procedure is a structured process. It should never be as simple as adding a line to the DOP. A compliant workflow includes:

Step 1: Clinical and Operational Assessment

The ASC must determine whether the new procedure is safe for the setting. This includes:

• Equipment requirements
• Staff competency and training
• Anesthesia needs
• Recovery time and monitoring needs
• Infection control considerations

Step 2: Competency Requirements

The Medical Director confirms that:

• The procedure is within the provider’s specialty and scope
• There is documented training or case experience
• FPPE criteria for new privileges are defined if needed

Step 3: Committee Review

The MEC reviews the request and makes a recommendation. This review must be documented in meeting minutes.

Step 4: Governing Body Approval

The Governing Body has final authority to approve new privileges and updated DOPs.

Step 5: Update the DOP Form

Once approved, the DOP is revised, version-dated and distributed. Outdated versions must be removed.

This process ensures safety, competency, and compliance with the Medical Staff Bylaws.

Best Practices for Listing Procedures on a DOP

A well drafted DOP is clear, organized, and easy to understand. Best practices include:

Use procedure categories

Group similar procedures to prevent lengthy and repetitive lists. Examples:

• Gastroenterology
• Ophthalmology
• Orthopedics
• Pain management
• General surgery

Avoid overly broad categories

Terms like “all procedures within the specialty” are not acceptable. They create ambiguity and are not defensible during surveys.

Use specific, recognizable terminology

Procedure wording should match:

• Coding language
• Clinical documentation
• ASC policy terminology

Ensure procedures reflect actual practice

Only list procedures the ASC is equipped to perform. If the ASC does not offer a service, it should not appear on the DOP.

Keep DOPs updated

Review DOP forms during:

• Annual review of policies
• Addition of new services
• Reappointment cycles
• Accreditation preparation

Outdated DOPs are a common survey deficiency.

Required Columns on a DOP and Why They Matter

A strong DOP includes organized columns that support accuracy and compliance. The core elements include:

1. Procedure or Privilege Name The specific procedure the provider is requesting. This avoids ambiguity and provides clear expectations for staff.

2. Requested by Provider A checkbox or signature confirming the provider is actively requesting each privilege. This demonstrates that the request originated with the provider, not the facility.

3. Criteria or Qualifications A brief description of what is required to perform the procedure. This may include:

• Board certification
• Training requirements
• Case log expectations
• Required equipment or support

Criteria documentation helps surveyors understand how competency is determined.

4. Medical Director Recommendation A column and signature line indicates whether the Medical Director recommends approval or not per privilege being requested. The DOP should clearly indicate if a specific privilege for a procedure requested is being denied. This validates clinical oversight.

5. MEC Action A section confirming the MEC reviewed and recommended privileges. This shows adherence to the bylaws and committee structure.

6. Governing Body Approval A signature confirming final approval. The Governing Body must approve all privileges.

7. Effective Dates Start and end dates must match the appointment cycle defined in the Medical Staff Bylaws. Missing or inconsistent dates are a common survey finding.

The DOP is a central document in supporting patient safety, demonstrating provider competency, and ensuring compliance with accreditation and regulatory requirements. When built with clear criteria, detailed procedure lists, and appropriate review pathways, the DOP becomes a powerful tool that protects patient safety as well as both the ASC and the providers who practice within it.