Credentialing and Privileging

by | Patient Safety and Quality Improvement and the Department and Hospital

Patient Safety and Quality Improvement Lexicon

Every healthcare organization is charged with providing the proper environment and adequate resources to support safe patient care. Credentialling is the process by which a healthcare organization assesses and confirms the qualifications of a clinician. Privileging is performed in conjunction with credentialing and is the process whereby the clinician identifies specialty-specific services and procedures they plan to provide patients within the healthcare organization.  

Credentialing may include:

  • Verification of education/training (undergraduate, medical school, residency, fellowship, etc.)
  • Verification of current state licensure
  • Verification of current Drug Enforcement Administration (DEA) license
  • Review of National Practitioner Data Bank Reports
  • Criminal background check
  • Verification of prior employment
  • Peer or supervisor evaluations that demonstrate clinical and professional competency.

Application for privileges may include:

  • Specialty training or certification
  • Procedure log (date/time of procedures performed)
  • Record of proctored cases

Hospitals and healthcare organizations who accept Medicare and Medicaid are required to have detailed credentialing and privileging processes outlined in their Medical Staff Bylaws.1 The Hospital’s Medical Staff Bylaws must include the:

  • Membership categories (ex. Physician, Dentist, Nurse Practitioner, etc.)
  • Preapplication and application process
  • Specific grounds for denying applications
  • Process for handling incomplete applications, including any gaps noted within applications
  • Requirement that credentials and privileges are time-limited and cannot exceed 2 years.
  • Specific limitations of privileges granted under temporary, emergency, disaster or locum tenens circumstances
  • Requirement that, upon approval, the provider agrees to the conditions and expectations listed within their application
  • Processes to complete FPPE (focused professional performance evaluation), OPPE (ongoing professional performance evaluation) and peer review to ensure clinician competence at initial appointment and subsequent reappointments
  • Program for handling impaired or disruptive providers.

Proper credentialing and privileging are essential for health care quality, patient safety and risk management. Future work will include the development of national standards for credentialing by discipline.

References

  1. Centers for Medicare and Medicaid Services: Conditions of Participation: Medical Staff (42 C.F.R., 481.12) https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482
    Centers for Medicare and Medicaid Services: Conditions of Participation: Governing Body (42 C.F.R., 481.12) https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482

Further Reading:

Health Resources and Services Administration. (2018, August 20). Health center program compliance manual. Retrieved from https://bphc.hrsa.gov/programrequirements/compliancemanual/introduction.html

National Association Medical Staff Services. (2014). NAMSS comparison of accreditation standards 2014. Retrieved from https://www.namss.org/Portals/0/Education/Instructor%20Resources/NAMSS%20Comparison %20of%20Accreditation%20Standards%202018.pdf 

National Association Medical Staff Services. (2014). The ideal credentialing standards: Best practice criteria and protocol for hospitals. Retrieved from https://www.namss.org/Portals/0/Regulatory/NAMSS%20Roundtable%20Credentialing%20Best %20Practice%20Criteria%20White%20Paper.pdf