Credentialing,
Recredentialing, and
Privileging: The
Basics and Beyond
Kathy Matzka, CPMSM, CPCS
Consultant/Speaker
1304 Scott Troy Road
Lebanon, IL 62254
kathymatzka@kathymatzka.com
website: www.kathymatzka.com
Phone (618) 624-8124
BIOGRAPHICAL SKETCH, KATHY MATZKA, CPMSM, CPCS
Kathy Matzka, CPMSM, CPCS is a speaker, consultant,
and writer with over 25 years of experience in
credentialing, privileging, and medical staff services. She
holds certification by the National Association Medical Staff
Services (NAMSS) in both Medical Staff Management and
Provider Credentialing. Ms. Matzka worked for 13 years
as a hospital medical staff coordinator before venturing out
on her own as a consultant, writer, and speaker.
Ms. Matzka has authored a number of books related to
medical staff services including Medical Staff Standards
Crosswalk: A Quick Reference Guide to The Joint
Commission, CMS, HFAP, and DVN Standards, Chapter
Leader’s Guide to Medical Staff: Practical Insight on Joint
Commission Standards, Compliance Guide to Joint Commission Medical Staff
Standards, and The Medical Staff Meeting Companion Tools and Techniques for
Effective Presentations. For eight years, she was the contributing editor for The
Credentials Verification Desk Reference and its companion website The Credentialing
and Privileging Desktop Reference. She is co-author of the HcPro’s publication Verify
and Comply: Credentialing and Medical Staff Standards Crosswalk, Sixth Edition.
She has performed extensive work with NAMSS’ Library Team developing and editing
educational materials related to the field including CPCS and CPMSM Certification
Exam Preparatory Courses, CPMSM and CPCS Professional Development Workshops,
and NAMSS Core Curriculum. These programs are essential educational tools for both
new and seasoned medical services professionals. She also serves as instructor for
NAMSS.
Ms. Matzka shares her expertise by serving on the editorial advisory boards for two
publications - Briefings on Credentialing, and Credentialing & Peer Review Legal
Insider.
Ms. Matzka is a highly-regarded industry speaker, and in this role has developed and
presented hundreds of programs for professional associations, hospitals, and hospital
associations on a wide range of topics including provider credentialing and privileging,
medical staff meeting management, peer review, negligent credentialing, provider
competency, and accreditation standards.
In her spare time, Ms. Matzka takes pleasure in spending time with her family, listening
to music, traveling, hiking, fishing, and other outdoor activities.
Overview of Credentialing, Recredentialing & Privileging
Table of Contents
Application Process ......................................................................................................... 1
Exercise: Applying Criteria for Medical Staff Appointment .............................................. 3
Verification of Application Information ........................................................................... 12
Education and Training ................................................................................................. 12
Sample Letter for Verification of Training................................................................... 14
Peer Recommendations ................................................................................................ 17
Work History and Affiliations ......................................................................................... 21
Sample Letter: Facility Privileges and Competency Validation .................................. 22
Licensure....................................................................................................................... 24
Sample Policies and Procedures for Credentialing ....................................................... 25
Verification of Current Licensure and Licensure Sanctions ....................................... 26
Notification of Internal and External Parties Regarding Practitioner Privileges .......... 28
NPDB Query .............................................................................................................. 30
Identification of Excluded Providers ........................................................................... 31
Criminal Background Checks .................................................................................... 32
Using The AMA Physician and AAPA Physician Assistant Masterfile Query ............. 34
Liability History/Proof of Insurance ................................................................................ 35
Health Status/Ability to Perform .................................................................................... 36
Board Certification ......................................................................................................... 36
Verification Of Identity ................................................................................................... 38
Sample Policy and Procedure for Verification of Identity ........................................... 39
Privileges Resources..................................................................................................... 40
“Laundry List” Example .............................................................................................. 41
AAFP Core Privileges Example ................................................................................. 42
HCPro Core Privileges Example ................................................................................ 47
Modified Core Example Family Medicine ................................................................... 57
Work Sheet For Consideration of New Privilege ........................................................ 61
Structured Interview Questions ..................................................................................... 62
Documenting Recommendations .................................................................................. 63
Minutes Language ..................................................................................................... 63
Recommendation and Approval Form for Medical Staff Appointment and Clinical
Privileges ................................................................................................................... 64
Understanding Negligence in Credentialing .................................................................. 65
Overview of Credentialing, Recredentialing & Privileging
CREDENTIALING, RECREDENTIALING AND
PRIVILEING BASICS
APPLICATION PROCESS
Preapplication
Some organizations use a preapplication form to screen applicants to determine
membership eligibility. This form typically contains address, education, training,
licensure, board certification, amount of professional liability insurance, distance from
home or office to the healthcare facility and any other membership requirements the
organization may have. For instance, if a hospital requires the provider to be board
certified and he/she is not, this can be evaluated prior to the application process and the
provider can be notified that he/she is not eligible for appointment. On the other hand,
using a preapplication adds another step and may delay the appointment process.
Application Form Content
Organizations have individualized forms or may use a standardized form
developed by the healthcare network or State. The application form
typically contains the following information:








demographics - name, professional degree, DOB, social security
number, UPIN, home and office addresses, phone, fax, pager and
cellular phone numbers;
education and training information - names and addresses of
schools, internship, residency and fellowship programs, type of
program and name of program director;
ECFMG information if applicant is a foreign medical graduate;
current and past licensure and narcotics registrations;
board certification information including current status, name of specialty and
subspecialty boards;
peer references who have personal knowledge of the quality of medicine
practiced by the applicant;
current and past healthcare organization affiliations; and
military service, if applicable.
Professional Practice Questions
An applicant may have to answer questions regarding the following issues:



voluntary or involuntary loss of medical staff membership and voluntary or
involuntary limitation reduction, or loss of clinical privileges at another healthcare
organization;
previous or pending successful challenges to any licensure or narcotics
registration or involuntary relinquishment of licensure or registration;
past and current professional liability insurance carriers, including policy
numbers, amounts and dates of coverage;
Credentialing, Recredentialing & Privileging Basics
1





past or pending professional liability action, including information about final
judgments or settlements involving the applicant;
misdemeanor or felony convictions;
denial of participation, suspended from, denied renewal from the Medicare or
Medicaid program, or participation status modified;
illegal use of drugs; and
ability to safely exercise the privileges requested with or without reasonable
accommodation.
Professional Practice Questions
Before granting privileges, the medical staff should evaluate:





challenges to any licensure or registration;
voluntary and involuntary relinquishment of any license or registration;
voluntary and involuntary termination of medical staff membership;
voluntary and involuntary limitation, reduction, or loss of clinical privileges; and
any evidence of an unusual pattern or an excessive number of professional liability
actions resulting in a final judgment against the applicant.
Attachments to Application
In addition to the application itself, organization may require attachments to be included.
These attachments are considered a part of the application and the application is not
considered complete until they are submitted.
Sample attachments may include:








copies of licensure;
professional liability insurance face sheet;
curriculum vitae;
application fee;
photograph;
CME;
application fee; and
clinical privileges request.
Credentialing, Recredentialing & Privileging Basics
2
Review for Completeness
The application should contain a chronological history starting with
graduate education, and continuing through the date of the application.
There should be not be any unaccounted for gaps.
The application is not considered complete until all required information
has been provided. All questions must be answered, the information
provided must be legible, all required attachments are present, and the application is
signed and dated. If any information is incomplete or missing, the application should be
returned to the applicant for completion.
EXERCISE: APPLYING CRITERIA FOR MEDICAL STAFF
APPOINTMENT
Using the Sample Medical Staff Bylaws Language for Medical Staff Appointment and
Sample application (following pages) determine whether the applicant should be sent an
application based on bylaws requirements.
Credentialing, Recredentialing & Privileging Basics
3
Sample Medical Staff Bylaws Language
Criteria for Medical Staff Appointment
Section 1.
General Qualifications
Every practitioner who seeks or enjoys Medical Staff appointment must, at the time of
application and initial appointment must demonstrate, to the satisfaction of the
appropriate authorities of the Medical Staff and of the Board, the following qualifications:
A.



B.
Licensure: The following are required:
A currently valid M.D., D.O., DDS, DMD, DPM license issued by the State of
Louisiana;
Current valid Federal DEA Certificate; and
Current Illinois Controlled Substance License
Professional Education and Training:
Graduate of an approved medical or dental school or school of osteopathy or
podiatry, or certified by the Educational Council for Foreign Medical Graduates,
or have a Fifth Pathway Certificate and have passed the foreign Medical
Graduate Examination in the Medical Sciences; and, if a physician, satisfactory
completion of at least three years in an approved postgraduate training program;
if a dentist, satisfactory completion of at least two years in an approved
postgraduate training program; if a podiatrist, satisfactory completion of at least
two years in an approved post graduate training program. An "approved"
postgraduate training program is one fully accredited throughout the time of the
practitioner's training by the Accreditation Council for Graduate Medical
Education, by the Commission on Dental Accreditation, or by the Council on
Podiatric Medical Education.
C.
Board certification by the appropriate specialty Board (American Board of
Medical Specialties, American Osteopathic Association, American Dental
Association, Council on Podiatric Medical Education, or one of their subspecialty
boards); or proof of admissibility for examination for certification by the
appropriate specialty Board, and thereafter certified within (5) years of
completion of residency training.
D.
Residence and office location sufficiently close to the hospital to fulfill medical
staff responsibilities and to provide timely and continuous care for patients.
E.
Disability:
To be free of or have under adequate control any significant physical or mental
health impairment and to be free from abuse of any type of substance or
chemical that affects cognitive, motor or communication ability in a manner that
interferes with, or presents a reasonable probability of interfering with, the ability
to perform privileges requested or carrying out the responsibilities of medical staff
membership.
Credentialing, Recredentialing & Privileging Basics
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F.
Verbal and Written Communication Skills:
Ability to read and understand the English language, to communicate in writing
and verbally in the English language in an intelligible manner, and to prepare
medical record entries and other required documentation in a legible manner.
G.
Professional Liability Insurance:
Professional liability insurance of $1 million per occurrence and $5 million annual
aggregate.
H.
Alternate Coverage:
Each practitioner must assure timely, adequate professional care for his/her
patients in the Hospital by being available or designating a qualified alternate
practitioner with whom prior arrangements have been made and who has the
requisite clinical privileges at this Hospital to care for the patient. The name of
such alternate must be provided on application to the medical staff.
I.
Hospital and Community Need, and Ability to Accommodate:
In acting on new applications for Medical Staff appointment and clinical
privileges, and on applications for changes in clinical privileges, in Medical Staff
appointment status, or in principal Department affiliation, the Board may also
consider any policies, plans and objectives formulated by it concerning:
1.
2.
the Hospital's current and projected patient care, teaching and
research needs; and
the Hospital's ability to provide the physical, personnel and financial
resources that will be required if the application is acted upon favorably.
Credentialing, Recredentialing & Privileging Basics
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SAMPLE APPLICATION FOR APPOINTMENT TO MEDICAL STAFF
LAST NAME
FIRST NAME
MIDDLE NAME
DEGREE
Smith
Josiah
Thomas
MD
Other Name Used/Maiden Name __________________________________________________
Specialty: General and Vascular Surgery
BOARD CERTIFICATION
List the certifying board, the specialty, the date of certification/recertification & expiration.
Name of Board
Specialty
Certification/Recertification Date(s)
Expiration Date
Am Board Surgery
General Surgery
1/1/83, 6/30/03, 6/30/2013
12/31/2020
Name of Board
Specialty
Certification/Recertification Date(s)
Expiration Date
Not planning to take boards
Not eligible to take boards
Board certification in process. Date scheduled or taken ___/___/___ Specialty___________
GENERAL INFORMATION
Citizenship (If foreign national – USA Status)
USA
PRIMARY OFFICE ADDRESS:
Date of
Medicare UPIN
birth
A2194
12/13/49
Approximate distance from hospital: 30 miles
Street and Suite Number
1110 N. 9th Street
City
O’Fallon
Telephone Number
FAX
Exchange Number
Name of Office Manager
Jennifer Johnston
( 618) 223-8998
( 618) 223-8990
(
) Pending
Social Security Number
321-897-3876
State
IL
SECONDARY OFFICE ADDRESS:
Approximate distance from hospital:
Street and Suite Number
City
Telephone Number
FAX
(
(
)
)
State
Zip
62269
Zip
Name of Office Manager
HOME ADDRESS:
Approximate distance from hospital: 40 miles
Street Address
43 Green Acres
City
Godfrey
Home Phone
State
IL
Zip
62035
( 618) 224-8726
Cell Phone Number
(618 ) 222-7262
LICENSES AND REGISTRATION
State
IL
License Number
036-4598874
Date Granted
3/30/99
Expiration Date
6/30/15
State
LA
License Number
MD 413679
Date Granted
7/5/75
Expiration Date
12/31/99
State
IL Cont Sub
License Number
031-036-4598874
Date Granted
3/30/99
Expiration Date
6/30/15
Federal DEA
Number
AS 1234567
Date Granted
7/30/75
Expiration Date
7/30/15
Credentialing, Recredentialing & Privileging Basics
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EDUCATION/TRAINING
MEDICAL SCHOOL
Name
U of Illinois
Address, City, State, Zip
Chicago, IL
Dates of Attendance
From:
5/71
To: 5/75
If Foreign Medical Graduate:
ECFMG #
RESIDENCY #1
Degree Granted/Date
MD
Date Issued:
Name
Earl Long Medical Center
Address, City, State, Zip
Shreveport, LA
Dates of Attendance
From:
7/75
To: 6/77
Specialty
General Surgery
Name of Program Director
RESIDENCY #2
Name
LA State University
Address, City, State, Zip
Shreveport, LA
Dates of attendance
From:
7/77
To: 6/81
Specialty
General Surgery
Name of Program Director
FELLOWSHIP
Name
Address, City, State, Zip
Dates of attendance
From:
Specialty
To:
Name of Program Director
ALTERNATE(S) - List the name of the Medical Staff appointee(s) who will serve as your
alternates and/or proctors.
ALTERNATES:
Don’t have one at this time. Am discussing with several surgeons on your staff.
Credentialing, Recredentialing & Privileging Basics
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WORK HISTORY/HOSPITAL AFFILIATIONS, PAST AND PRESENT
List work history, starting with the present. Include office practice, teaching
appointments, employers, current and past hospital affiliations. If additional
space is needed, provide details on separate sheet and attach.
Name of Organization, Hospital, or Office Practice
St. Jude Memorial Hospital
Address, City, State, Zip
4501 St. Jude Place, Shreveport, LA
From:
Position
Surgeon
7/81
To: 12/98
Name of Organization, Hospital, or Office Practice
St. Stephen Catholic Hospital
Address, City, State, Zip
12 Main Street, Scoville, Il, 63421
From:
Position
Surgeon
4/99
To: Present
Name of Organization, Hospital, or Office Practice
Address, City, State, Zip
From:
Position
To:
Name of Organization, Hospital, or Office Practice
Address, City, State, Zip
From:
Position
To:
Name of Organization, Hospital, or Office Practice
Address, City, State, Zip
From:
Position
To:
PERSONAL REFERENCES
List three peer references - NOT RELATED TO YOU OR A PROSPECTIVE PARTNER - who have personal knowledge of
your current clinical ability, ethical character, and ability to work cooperatively with others. These references should have
acquired their knowledge through recent observation of your professional performance and, at least one must have had
organizational responsibility for supervision of your performance. (e.g. department chair, service chief, training
program director).
Name
Adam West, MD
Relationship
Colleague
Name
Tina Graham, M.D.
Relationship
Colleague
Name
Address
11 Brown
City, State, Zip
St. Louis, MO 63108
Address
University Hospital Emergency Department
City, State, Zip
St. Louis, MO, 63106
Address
Relationship
City, State, Zip
Credentialing, Recredentialing & Privileging Basics
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PROFESSIONAL LIABILITY INSURANCE INFORMATION
NAME OF CURRENT CARRIER:
Lloyds of London
ADDRESS:
Lloyd's America Inc.
6340 Sugarloaf Parkway
Suite 200
Duluth
GA 30097
POLICY LIMITS
_500 K_________ per occurrence
aggregate
_1 mil annual
DATE UNDERWRITTEN:
6/1/13
POLICY NUMBER:
MR 4437
DATE OF EXPIRATION:
12/31/15
NAME(s), ADDRESS(s), AND POLICY NUMBERS FOR ADDITIONAL PROFESSIONAL LIABILITY INSURANCE CARRIERS YOU
HAVE HAD OVER THE PAST FIVE YEARS:
PROFESSIONAL BACKGROUND
Please answer the following questions regarding your professional background. If the answer
to any question is "yes", please provide the nature and specific details on a separate sheet and attach.
1.
a.
b.
c.
d.
e.
f.
3.
4.
5.
6.
Have you ever voluntarily or involuntarily surrendered, or had any pending or
completed action involving the denial, revocation, suspension, reduction, limitation,
probation, reprimand, or non-renewal of,
a license or certificate to practice medicine or any profession in any state
or country
Drug Enforcement Agency or other controlled substance license or registration
membership or fellowship in any local, state, or national professional organization
specialty or subspecialty board certification or eligibility
faculty membership at any medical or other professional school
staff membership or clinical privileges at any hospital, clinic, or healthcare institution
YES NO
Has any hospital, health plan, or government sponsored program ever restricted,
suspended, invoked probation, or rejected or terminated your contract?
Have you ever been named as a defendant in a case alleging medical negligence,
or has a suit for any alleged malpractice ever been brought against you?
Do you have any physical or mental health condition, treated or untreated,
which in any way impairs your ability in terms of skill, attitude, or judgment
to practice to the fullest extent of your license and qualifications or in any way
poses a risk of harm to your patients?
Have you ever been convicted of a felony, or currently have felony charges
pending?
Credentialing, Recredentialing & Privileging Basics
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APPLICANT'S CONSENT AND RELEASE
I hereby apply for appointment to the Medical Staff of State Hospital. In making application for appointment to the
Medical Staff of State Hospital, I certify that I have received, read, and agree to be bound by the Medical Staff
Bylaws, Rules and Regulations and related manuals, and the current hospital policies that apply to my activities as a
Medical Staff appointee and that are consistent with the Medical Staff Bylaws, Rules and Regulations and related
manuals. Moreover, I specifically pledge that I will maintain an ethical practice, provide for continuous care of all my
patients, refrain from fee-splitting or other inducements relating to patient referral, and refrain from providing "ghost"
surgical or medical services.
I certify that there has not been any unsuccessful or currently pending challenges to licensure or registration, no loss
of medical or dental organization membership, nor loss of medical staff membership or privileges at another hospital,
except as noted herein. I understand that my competence and general functioning and performance with regard to my
patients and my duties and obligations as a Medical Staff appointee of State Hospital, will be reviewed from time to
time by my peers working within the structure of the Medical Staff in accordance with the Bylaws thereof. I hereby
give my permission for, and in fact request, such review pursuant to my appointment and reappointment to the
Medical Staff of State Hospital, that I will not bring legal action to prevent such review or to recover damages from
those participating in such review.
(a)
(b)
(c)
By applying for Medical Staff appointment, I accept the following conditions below during the processing and
consideration of my application and for the duration of my medical staff appointment regardless of whether or not I
am granted Medical Staff appointment and clinical privileges:
I extend absolute immunity to and release from any and all liability, State Hospital, its authorized representatives, and
any third parties, as defined in subsection (c) below, for any acts, communications, reports, statements, documents,
recommendations or disclosures involving me, performed, made, requested or received by any third party, including
otherwise privileged or confidential information.
The foregoing shall be privileged to the fullest extent permitted by law; such privilege shall extend to the hospital and
its authorized representatives, and to any third parties.
I specifically authorize the hospital and its authorized representatives to consult with any third party who may have
information, including otherwise privileged information, bearing on my professional qualifications, credentials, clinical
competence, character, mental or emotional stability, physical condition, ethics, behavior or any other matter bearing
on my satisfaction of the criteria for Medical Staff appointment as well as to inspect any and all communications,
reports, statements, documents, recommendations, or disclosures of said third parties relating to such questions. I
also specifically authorize said third parties to release such information, including any and all peer review material
from any and all hospitals wherein I have held appointments, to the hospital and its authorized representatives upon
request.
The term "hospital and its authorized representatives" means State Hospital and any of the following individuals who
have any responsibility for acting upon my application for Medical Staff appointment: the members of the hospital's
Board and their appointed representatives, the Chief Executive Officer or his designees, other hospital employees,
consultants to the hospital, the hospital's attorney(s) and his/her partners, associates or designees, and all
appointees to the Medical Staff. The term "third parties" means all individuals, including appointees to the medical
staffs of other hospitals or physicians or health practitioners, nurses or other government agencies, organizations,
associations, insurance companies, managed care organizations, credentials verification organizations, partnerships
and corporations, whether hospitals, health care facilities or not, from whom information has been requested by the
hospital or its authorized representatives or who have requested such information from the hospital and its authorized
representatives.
I also agree to provide any additional information as may be requested by the hospital or its authorized
representatives. Failure to produce this information will prevent my application from being evaluated and acted upon.
A copy of this consent and release is a binding as the original. In submitting this application for the purpose of
securing appointment to the Medical Staff of State Hospital, I hereby voluntarily state that all of the information above
is complete and truthful. I also voluntarily state that I have made no effort to evade telling the complete truth
regarding my professional career. I understand that any incomplete or false statement will lead to automatic
withdrawal of this application for appointment. Should I be appointed to the Medical Staff of State Hospital and it is
subsequently found that any statement above is false I understand that my Medical Staff appointment and privileges
will be automatically terminated.
SIGNATURE______________________________________DATE___________________________
PRINTED OR TYPED NAME_______Josiah Smith, M.D.___________________________________
Credentialing, Recredentialing & Privileging Basics
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Review the application on the previous pages and list any “red flags”.
Credentialing, Recredentialing & Privileging Basics
11
VERIFICATION OF APPLICATION INFORMATION
The healthcare organization is obligated to assure that only competent practitioners
provide treatment and services to its patients. This is accomplished through verification
of the information provided by the practitioner and assuring that the practitioner meets
the requirements for membership and privileges.
Primary Source
A primary source is the original source that can verify the accuracy of a credential,
qualification, or other information reported by the practitioner. For instance, when
seeking to verify completion of a residency program, the organization contacts the
residency program and asks for this verification.
Primary source verification can be performed via letter, fax, approved official website, or
well-documented telephone call. If verifying by phone, include the name of the
organization called, the date, the person contacted, the questions asked, the response,
the name of the person receiving the response.
EDUCATION AND TRAINING
Undergraduate education (school, year of graduation) is not typically verified unless
privileges requested correspond with the training received. Hospitals should verify
accredited medical school completion. In the managed care setting, the MCO must
verify the highest of the following three levels of education and training obtained by the
practitioner: (1) graduation from medical or professional school, (2) residency, or (3)
board certification. Medical school completion is typically verified through direct contact
with the school or by AMA or AOA profile for US graduates and ECFMG for foreign
medical graduates.
Postgraduate training including internship, residency, and fellowship should be verified.
In addition to completion of this training, a hospital will request information about the
quality of an applicant’s work and clinical competence from an internship, residency, or
fellowship program in order to verify competency and ability to perform privileges. Any
specialized training outside the residency or fellowship that reflects on the applicant’s
privileges should be verified.
Options for Verification of Education and Training
Relevant training or experience is defined by the specific circumstances of the
applicant. This may vary among specialties. The hospital must believe there is
sufficient information on which to base a reasoned decision. Verification can come
from:

the school;
Credentialing, Recredentialing & Privileging Basics
12






American Medical Association (AMA) Physician Masterfile (for physician);
A credentials verification organization;
Educational Commission for Foreign Medical Graduates (ECFMG) for verification
of graduation from a foreign medical school;
American Osteopathic Association (AOA) Physician Database for predoctoral
education accredited by the AOA Bureau of Professional Education.
American Medical Association (AMA) Physician Masterfile; and
(AOA) Physician Database for postdoctoral education approved by the AOA
Council on Postdoctoral Training
Medicare CoP Regarding Verification of Education and Training
The governing body ensures that the criteria for selection of both new medical staff
members and selection of current medical staff members for continued membership
must be based on individual character, competence, training, experience, and
judgment.
Credentialing, Recredentialing & Privileging Basics
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Sample Letter for Verification of Training
[Date]
Re: [Applicant’s full name, Title]
Training: [Residency/fellowship]
Specialty: [Specialty]
Dates: [From/to]
Dear [Program Director name]:
We have received an application from the above-named provider for medical staff
appointment and/or privileges. A copy of the privileges requested is attached. The
applicant noted that the above-specified training took place at your institution. In order
to process the application we require verification of completion of training and
documentation of experience, ability, and current competence on the six areas of
“General Competencies” adopted from the Accreditation Council for Graduate Medical
Education (ACGME) and the American Board of Medical Specialties (ABMS) joint
initiative.
Our policies require completion of the enclosed form. Failure to receive this form
will delay consideration of the applicant’s request for privileges. Also, our
policies require the physician to document competency in performing specific
procedures by allowing our organization to obtain a copy of his/her procedure list
from your program and the outcomes for those procedures (if outcomes are
available). The applicant has authorized you to provide this information to our
organization via signature on the attached Authorization and Release Form.
Enclosed is a copy of a release and immunity statement signed by the applicant
consenting to this inquiry and your response. The immunity statement releases from
liability any individual who provides the requested information.
Thank you for your assistance. We look forward to hearing from you.
Sincerely,
Director
Enclosures
Credentialing, Recredentialing & Privileging Basics
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Residency Program Director’s Evaluation and Recommendation
Page 1
Re: [Applicant’s full name]
Training: [Residency/fellowship]
Specialty: [Specialty]
Dates: [From/to]
Area of Evaluation
YES
NO
Please use comment section below to provide additional information noting
question number for which information is provided.
1
2
3
4
5
6
7
8
9
10
11
12
Unable
to
Evaluate
Were you the director of the program at the time of this applicant’s training?
Was the applicant at your institution in the above program for the stated period of time?
Was the program fully accredited throughout the applicant’s participation in it?
Did the applicant successfully complete the program?
Did the applicant receive satisfactory ratings for all aspects of his/her training in the program?
Was the applicant ever subject to or considered for disciplinary action?
Did the applicant ever attempt procedures beyond his/her assigned training protocols?
Was the applicant’s status and/or authority to provide services ever revoked, suspended,
reduced, restricted, not renewed, or was he/she placed on probationary status or reprimanded
at any time or were proceedings ever initiated that could have led to any of the actions?
Did the applicant ever voluntarily terminate his/her status in the program or restrict his/her
activities in the program in lieu of formal action or to avoid an investigation?
In reviewing the attached request for privileges, do you feel that the applicant’s training and
experience included these procedures?
In reviewing the attached request for privileges, do you feel that the applicant is currently
competent to carry out these procedures?
Are you aware of any physical or mental condition that could affect this practitioner’s ability to
exercise clinical privileges in his/her specialty area, or would require an accommodation to
exercise those privileges safely and competently?
Comments:
Question
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Comment
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
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Residency Program Director’s Evaluation and Recommendation
Page 2
Re: [Applicant’s full name]
Training: [Residency/fellowship]
Specialty: [Specialty]
Dates: [From/to]
Please rate the applicant in each of the following areas:
Excellent
Good
Fair
Poor
Unable to
evaluate
Patient care
Medical knowledge
Practice-based learning and
improvement
Interpersonal and
communication skills
Professionalism
Systems-based practice
This evaluation is based upon:
Personal knowledge of the applicant.
Review of file.
Other _____________________________________________________________________________
Overall Recommendation (check ONE):
I recommend privileges as requested without reservation.
I recommend privileges as requested with the following reservation(s) (use back of form, if necessary
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I do not recommend this applicant for the following reason(s)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_______________________________________
Signature
_____________________________
Date
_______________________________________
Name, Position/Title (Please Print)
_____________________________
Phone Number
Please return this form within 2 weeks. Failure to receive the form will delay consideration of the applicant’s request for
privileges.
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PEER RECOMMENDATIONS
A peer recommendation is a statement provided in support of an applicant’s request for
appointment/ reappointment and/or privileges by a practitioner in the same professional
discipline as the applicant. Peer recommendations are typically obtained from prior
training program directors, department chairs, chiefs of staff, or others familiar with the
applicant’s professional history and current clinical competence. Friends, neighbors,
and relatives are not appropriate sources for peer recommendations. Peer
recommendations should include reference to the applicant’s competence and ability to
perform the privileges requested.
Peer recommendations should address the practitioner’s relevant training and
experience, current competence, and any effects of health status on privileges being
requested.
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Sample Peer Recommendation Letter
Date
Facility Name
Facility Address
Regarding applicant: John Doe, M.D.
Specialty: General Surgery
Dear ______________:
We have received an application from the above-named provider for medical staff
appointment and privileges. A copy of the privileges requested is attached. The
applicant has listed you as a peer who will be willing to provide a recommendation. In
order to process the application we require your evaluation of the applicant’s
experience, ability, and current competence in the areas of medical/clinical knowledge,
technical and clinical skills, clinical judgment, interpersonal skills, communication skills,
and professionalism.
Our policies require completion of the enclosed form. Failure to receive this form
will delay consideration of the applicant’s request for privileges. You may
supplement the form with additional information, if you so desire. The applicant
has authorized you to provide this information to our organization via signature
on the attached Authorization and Release Form.
Sincerely,
Medical Staff Coordinator
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Sample Peer Recommendation Form
CONFIDENTIAL Professional Peer Reference & Competency Validation
Page 1 of 2
Name of Applicant:________________________________________________________________________________
Name of Evaluator:____________________________________ Relationship to Applicant:________________________
How well do you know the applicant?
not well
Do you refer your patients to the applicant?
yes
casual personal acquaintance
professional acquaintance
very well
no. If no, list reason(s) why not ___________________________________
_________________________________________________________________________________________________________
PLEASE RATE THE PRACTITIONER IN THE FOLLOWING AREAS
Excellent
Good
Fair
Medical knowledge - Practitioner should have a good knowledge of
established and evolving biomedical, clinical, and cognate sciences, and
how to apply this knowledge to patient care. This is evidenced by
completion of educational and training requirements as well as on-the-job
experience, inservice training, and continuing education.
Technical and clinical skills - Skill involves the capacity to perform specific
privileges/procedures. It is based on both knowledge and the ability to apply
the knowledge.
Clinical judgment - Clinical judgment refers to the observations,
perceptions, impressions, recollections, intuitions, beliefs, feelings,
inferences of providers. These clinical judgments are used to reach
decisions, individually and/or collectively with other providers, about a
patient’s diagnosis and treatment.
Communication skills - The provider should create and sustain a
therapeutic and ethically sound relationship with other care givers, patients,
and their families. He/she should be able to communicate effectively and
demonstrates caring, compassionate, and respectful behavior. This also
includes effective listening skills, effective nonverbal communication,
eliciting/providing information, and good writing skills
Interpersonal skills - Areas of evaluation include how the provider works
effectively with other professional associates, including those from other
disciplines, to provide patient-focused care as a member of a healthcare
team.
Professionalism - Professionalism is demonstrated by respect,
compassion, and integrity. It means being responsive and accountable to
the needs of the patient, society, and the profession. It means being
committed to providing high-quality patient care and continuous professional
development as well as being ethical in issues related to clinical care,
patient confidentiality, informed consent, and business practices.
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19
Poor
Unable
to
evaluate
CONFIDENTIAL Professional Peer Reference & Competency Validation
Page 2 of 2
Name of Applicant:__________________________________________________________________________
Name of Evaluator:________________________________________________________________________________
Relevant training and experience – In reviewing the attached request for privileges, do you feel that the applicant’s training and experience are
adequate to carry out these procedures?
No - If no, please provide an explanation_______________________________________________________________
Yes
Unable to evaluate
Current competence – In reviewing the attached request for privileges, do you feel that the applicant is currently competent to carry out these
procedures?
No - If no, please provide an explanation_______________________________________________________________
Yes
Unable to evaluate
Health Status - Are you aware of any physical or mental condition that could affect this practitioner’s ability to exercise clinical privileges in his/her
specialty area, or would require an accommodation to exercise those privileges safely and competently?
No
Yes - If yes, please provide an explanation_______________________________________________________________
Unable to evaluate
_________________________________________________________________________________________________
Overall Recommendation (check ONE):
I recommend privileges as requested without reservation.
I recommend privileges as requested with the following reservation(s) (use back of form, if necessary
_______________________________________________________________________________________________
_________________________________________________________________________________________________
I do not recommend this applicant for the following reason(s) ___________________________________________
_______________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________
Signature
_____________________________
Date
_______________________________________
Name, Position/Title (Please Print)
_____________________________
Phone Number
Please return this form within 2 weeks. Failure to receive the form will delay consideration of the applicant’s request for privileges.
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20
WORK HISTORY AND AFFILIATIONS
Some organizations verify all current and past hospital affiliations, while some verify only the past 5 10 years. There are several reasons for performing this verification.
One reason is to make sure there are no unexplained gaps. Many hospitals feel it is important to
document the provider’s whereabouts and clinical activity for the period from medical school to the
date of application. This is done to make sure that there are no unaccounted for periods of time. For
example, a provider who spent time in prison or in a drug/alcohol rehabilitation facility may attempt to
hide this by stating he/she was on staff at a hospital during this time. Verification of the dates on staff
may turn up the discrepancy.
Another reason work history and affiliations are verified is to ascertain current clinical competence.
This is particularly important in the hospital. Typically, such requests will include dates on staff,
current staff status or category, disciplinary actions, and whether the privileges requested are
consistent with those held at the facility being queried.
Some managed care plans require a provider to have medical staff appointment at a hospital that
contracts with the managed care plan. The MCO will verify this appointment. Some MCOs will ask
the hospital to provide a list of providers on a routine basis in lieu of individual verification letters.
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Sample Letter: Facility Privileges and Competency Validation
Date
Facility Name
Facility Address
Regarding applicant: John Doe, M.D.
Specialty: General Surgery
Dear Medical Services Professional:
We have received an application from the above-named provider for medical staff appointment and
privileges. A copy of the privileges requested is attached. The applicant noted that s/he currently, or
has in the past, held privileges at your facility. In order to process the application we require
documentation experience, ability, and current competence on the six areas of “General
Competencies” adopted from the Accreditation Council for Graduate Medical Education (ACGME)
and the American Board of Medical Specialties (ABMS) joint initiative. These competencies include
assessment of patient care, interpersonal and communication skills, professionalism, medical
knowledge, practice-based learning and improvement, and systems-based practice.
Our policies require completion of the enclosed form. Failure to receive this form will delay
consideration of the applicant’s request for privileges. Also, our policies require the physician
to document competency in performing specific procedures by allowing our organization to
obtain a copy of his/her privilege form from your hospital as well as a list of the actual
procedures performed in the past 12 months and the outcomes for those procedures. The
applicant has authorized you to provide this information to our organization via signature on
the attached Authorization and Release Form.
Sincerely,
Medical Staff Coordinator
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22
CONFIDENTIAL Evaluation of Privileges and Competency Validation
Name of Facility Providing Information:___________________________________________________________
Name of Practitioner for which Information is Provided:_______________________________________________
Dates on Staff: From ________________________________ To ____________________________________
Has the practitioner been subject to any disciplinary action, restrictions, modifications, or loss of
privileges or medical staff appointment either voluntary or involuntary at your facility?
Yes
No
Are you aware of any restrictions, modifications, or loss of privileges or medical staff appointment,
either voluntary or involuntary, at any another facility?
Yes
No
Are you aware of any physical or mental condition that could affect this practitioner’s
ability to exercise clinical privileges as requested, or would require accommodation to perform
privileges safely and competently?
Yes
No
If the answer to any of the above questions is “YES”, please explain:
_________________________________________________________________________
_________________________________________________________________________
Evaluation:






Please rate the practitioner in the following areas.
Patient Care is compassionate, appropriate, and effective for the treatment of health problems and promotion of health
Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and
the application of this knowledge to patient care
Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of
scientific evidence, and improvements in patient care
Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other
health professionals
Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and
sensitivity to a diverse patient population
Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of
health care and the ability to effectively call on system resources to provide care that is of optimal value.

Excellent
Good
Fair
Poor
Unable to
evaluate
Patient care
Medical knowledge
Practice-based learning and
improvement
Interpersonal and
communication skills
Professionalism
Systems-based practice
_______________________________________
Signature
_____________________________
Date
_______________________________________
Name, Position/Title (Please Print)
_____________________________
Phone Number
Please return this form within 2 weeks along with a copy of the applicant’s privilege list for your hospital and a
list of the actual procedures performed in the past 12 months and the outcomes for those procedures.
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23
LICENSURE
A license is the authority a government agency grants an individual to practice a profession.
Regulation of medical and other professional practice is a state function. States exercise the
regulation of medical practice through licensing laws. Some states issue a controlled substance
license in addition to the license to practice medicine. If so, this license should also be verified.
State licensing boards also take disciplinary action against professional licenses. This may include
revocation, suspension, probation or reprimand. Although basic information is available via the
Internet or telephone, many state licensing boards will not provide specific information on disciplinary
actions unless requested in writing. The extent of the information provided differs depending on the
laws of the state.
It is essential to verify licensure status for all licensed providers in the state the practitioner will be
practicing. It is up to the individual facility or MCO whether or not to check licensure in each state the
applicant is or was ever licensed. Some states use reciprocity, which refers to agreements between
jurisdictions in which states are willing to recognize each other's licensees based on comparable
requirements for licensure. In many cases, not only do they accept the licensure of that state, they
also accept disciplinary action from the other state.
Definitions of Licensure/Certification/Registration
Some professions are not licensed, but rather are regulated through registration or certification.
Although individual states may have their own definitions, below are general definitions:
Licensure: The most restrictive form of professional and occupational regulation. Under licensure
laws, it is illegal for a person to practice a profession without first meeting state or provincial
standards.
Certification: Under certification, the state grants title protection (right-to-title) to persons meeting
predetermined standards. Those without certification may perform the duties of the occupation, but
may not use the title.
Registration: The least restrictive form of regulation. Usually takes the form of requiring individuals to
file their names, addresses and qualifications with a government agency before practicing the
occupation. This may include posting a bond or filing a fee.
Medicare CoPs Requirements for Verification of Licensure
The hospital must assure that personnel are licensed or meet other applicable standards that are
required by State or local laws. All staff required by the State to be licensed must possess a current
license. The hospital must assure that these personnel are in compliance with the State’s licensure
laws. The laws requiring licensure vary from state to state. Examples of healthcare professionals that
a state may require to be licensed could include: nurses, MD/DOs, physician assistants, dieticians, xray technologists, dentists, physical therapists, occupational therapists, respiratory therapists, and
hospital administrators.
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SAMPLE POLICIES AND PROCEDURES FOR CREDENTIALING
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25
Verification of Current Licensure and Licensure Sanctions
POLICY AND PROCEDURES
[Facility Name]
Policy:
It is the policy of the Facility and Medical Staff to require verification of all relevant information
provided on applications for Medical Staff appointment and/or clinical privileges. The verification of
current licensure informs the facility that the applicant is appropriately licensed to practice as a health
care provider as required by state and/or federal law. Practitioners currently licensed in the state of
[add state name] are eligible to request Medical Staff Appointment and clinical privileges. AHPs
holding a license, certificate or other official credential as provided under state law, are eligible to
provide specified services in the Facility as delineated by the Medical Staff Executive Committee and
Governing Body. In addition, Applications must include information as to previously successful or
currently pending challenges to, or the voluntary relinquishment of a license to practice any
profession in any jurisdiction.
It is the policy of the facility to verify current licensure in the state in which the facility provides
services with the state licensure board or that board’s designated agent at the time of appointment
and initial granting of privileges, at reappointment, renewal, or revision of clinical privileges, and at the
time of expiration by a letter or computer printout obtained from the appropriate licensing board,
through the primary source internet site, or by telephone.
It is the policy of this Facility to verify whether or not the applicant has been subject to licensure
sanctions in each state in which the practitioner currently or has ever held a license or certificate.
This is accomplished by either (1) querying the medical board of each state in which the provider has
held or currently holds licensure, or (2) querying the Federation of State Medical Boards (FSMB).
Note: Each facility should customize the paragraph above to reflect current practices.
Note: If the Facility contracts with a Credentials Verification Organization (CVO), these licensure and
sanction verifications may be provided by the CVO.
Procedure
Procedure for verification of current licensure and licensure disciplinary actions via internet site:
1. Access the state licensure board web page for each state in which the license is held or has been
held in the past. Each licensure board maintains a data base that can be used to verify licensure.
Some states include all licensed and certified providers in one database, and some maintain
separate data bases for nursing and other non-physician providers.
Note: The website of the Administrators in Medicine (AIM) Association of State Medical Board
Executive Directors has a page with links to each licensure board’s web site. You can access
this site at http://www.docboard.org/docfinder.html. The data in the AIM DocFinder database is
intended for public use, not for commercial verification, and it requires a contractual agreement
for the facility to use the database for verification of licensure. There are some state licensure
boards that use AIM as their only source of internet verification and when you attempt verify
licensure at the State’s website, it opens a link to AIM DocFinder. In this case, the AIM
Credentialing, Recredentialing & Privileging Basics
26
website is considered a primary source for the licensure board data for that state and you do
not have to pay for this verification.
2. Using the search mechanism on the state licensure board’s website, enter the required provider
information and search. If you are searching on name only, the search results may contain more
than one name. Examine each resulting name to determine the correct provider. In some cases,
the search results may only provide a summary and you may have to click on an additional link(s)
to bring up detailed information. Print all available information.
3. If the results of the verification show that there was disciplinary action taken against the license,
but this information is not available on the website, write to the licensing board and request the
additional information. You can find the address on the licensing board’s website. Include a copy
of the Applicant’s consent and release form with the request. Place a copy of the letter in the
applicant’s credentials file.
Note: A listing of names and mailing addresses for all state licensure boards is also available
at http://www.docboard.org/aim/brd_exec_dir.htm.
4. Check the printed document(s) to make sure the current date is printed. If the verification does not
have the date on it, write the date on the verification using permanent ink.
5. Place the verification in the credentials file.
6. Include the verification date in the [software name] credentialing software database.
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27
Notification of Internal and External Parties Regarding Practitioner Privileges
Policy:
Key external and internal persons and organizations must be notified whenever a change occurs in a
practitioner’s privileges or when a new practitioner is granted privileges or appointment. Some
internal sources require information regarding clinical privileges granted, while others require only a
general notification.
Procedure:
Internal Sources:
General Notification of New Practitioner:
When a new practitioner is granted medical staff appointment or clinical privileges, a general
notification should be distributed via email or memo to all hospital departments. The following
information should be included:
Full name, credential, address, phone, fax, pager/paging service number, partners, alternates,
effective date, picture, sponsoring physician (if AHP).
General Notification Practitioner Leaving Staff:
When a practitioner leaves the staff, a general notification should be distributed via email or memo to
all hospital departments. The following information should be included:
Full name, credential, forwarding address (if applicable), and effective date.
Notification of Privileges
When new privileges are granted either to a new applicant or an existing medical staff member or
allied health professional; or when there is a modification (addition, deletion, termination, proctorship,
etc.) to current privileges; the following internal personnel should be notified via email or memo and a
copy of the privileges (or modification to privileges) should be included with the notification. (Note:
Will need to modify this language to reference privileges that are posted via intranet or other
electronic means).
[Name]
[Name]
[Name]
[Name]
[Name]
[Name]
[Name]
[Name]
Admitting Department
Operating Room
Nursing Administration (for distribution to all nursing units)
Administration
Emergency Department
Outpatient/Ambulatory Clinic(s)
Quality Management
(Include others, as appropriate)
External Sources
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28
National Practitioner Data Bank and State Licensing Boards
The Health Care Quality Improvement Act of 1986 includes a requirement for reporting of certain
adverse actions to the National Practitioner Data Bank.
Hospitals must report:
(1)
a professional review action which adversely affects a physician’s or dentist’s clinical privileges
for more than 30 days and is based upon the physician’s or dentist’s professional competence or
professional conduct; and
(2)
the voluntary surrender of clinical privileges by a physician or dentist who is under investigation
relating to questions of professional competence or conduct, or in return for no investigation or
professional review action being conducted.
A professional review action includes denying, reducing, restricting, revoking and suspending
privileges, and also includes a decision not to renew clinical privileges if that action is based on the
physician’s or dentist’s professional competence or conduct.
Hospitals must submit adverse action reports to the appropriate state licensing board within 15 days
of final Board action in the case of an adverse action or within 15 days of the date the physician
surrenders his or her clinical privileges. These reports must be submitted electronically to the
National Practitioner Data Bank as an Adverse Action Report. Within 15 days, a printed copy of the
electronic report must be forwarded to the state medical licensing board.
Revisions to previously reported adverse actions must also be reported. For example, if a physician’s
clinical privileges are reinstated after a 45 day suspension, both the suspension and the
reinstatement must be reported.
Note: All reports to state licensing boards and the NPDB should be coordinated with the Legal
Department.
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NPDB Query
POLICY AND PROCEDURES
[Facility Name]
Policy
It is the facility’s policy to comply with the requirements of the Healthcare Quality Improvement Act by
performing a query of the National Practitioner Data Bank (NPDB) at each of the following times:




A physician, dentist, or other health care practitioner applies for medical staff appointment or
for clinical privileges at the facility
At least every 2 years (biennially) on all physicians, dentists, and other health care
practitioners who are on the medical staff or have clinical privileges.
When a practitioner wishes to add to or expand existing privileges
When a practitioner submits an application for temporary privileges
In addition, the facility may, in its discretion, query the NPDB as necessary for professional review
activities.
Procedure:
The following information is required to perform a query:
Entity Data Bank Identification Number: [insert DBID Number]
User ID Number: [insert ID number]
Password: [insert password]
Note: Each facility should add information here regarding the password and entity ID number.
If the facility uses the Data Bank’s Querying and Reporting XML Service (QRXS) to store and
manage their subject and report data within their own information or credentialing systems, this
process should be included on this procedure.
For more information, see www.npdb-hipdb.hrsa.gov.
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Identification of Excluded Providers
POLICY AND PROCEDURE
[Facility Name]
Policy:
It is the policy of the facility to verify that providers are not currently excluded from participation in
Medicare, Medicaid, or other Federal health care programs.
The Office of Inspector General's (OIG) List of Excluded Individuals/Entities (LEIE) database provides
information regarding individuals and entities currently excluded from participation in Medicare,
Medicaid and all Federal health care programs.
System for Award Management (SAM) identifies those parties excluded throughout the U.S.
Government (unless otherwise noted) from receiving Federal contracts or certain subcontracts and
from certain types of Federal financial and nonfinancial assistance and benefits.
The System for Award Management (SAM) includes the following systems:




Central Contractor Registry (CCR)
Federal Agency Registration (Fedreg)
Online Representations and Certifications Application
Excluded Parties List System (EPLS)
Procedure for accessing the OIG’s LEIE:
1.
2.
3a.
3b.
4.
5.
6.
Access the exclusion database at http://exclusions.oig.hhs.gov/
Enter the last name and first name of the provider.
If no results are found, print the search results.
If results are found, click on the name field and this will bring up a page in a printable format
along with a place to enter the social security number. Enter the social security number and
click Verify.
Print out the page
Place report in the credentials file.
If results show that an action was taken, notify [include appropriate name].
Procedure for accessing the System for Award Management:
1.
2.
3.
4.
5.
Access database at www.sam.gov and click Search Records tab.
Enter name of the provider and click the Search button (a new page will open with results)
Click on the Printer Friendly link. A new page will open. Print the search results.
If no records, print out the page and place report in the credentials file.
If results show that an action was taken, click on View Details button, print the page and place
report in the credentials file. Notify [include appropriate name].
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Criminal Background Checks
POLICY AND PROCEDURES
[Facility Name]
Policy:
It is the policy of the facility and Medical Staff to require verification of all relevant information
provided on applications for Medical Staff appointment and/or clinical privileges (“Application(s)”.
Criminal background checks are provided for in the Medical Staff Bylaws and by the Facility’s policy
on employee criminal history background checks for employed physicians or other employed
privilege-holders. Medical Staff Bylaws require applicants to include with their application, any current
criminal charges pending against the applicant and any past convictions or pleas. In addition, Bylaws
require that a practitioner shall notify the CEO and the Chief of Staff within seven (7) days of receiving
notice of the initiation of any criminal charges, and shall acknowledge the Facility’s right to perform a
background check at appointment, reappointment and any interim time when reasonable suspicion
has been shown.
Procedure:
1.
Each applicant for clinical privileges or appointment to the Medical Staff (“Applicants”) shall be
required to sign an authorization to allow the Facility to conduct a criminal background check
on the Applicant (“Authorization”) as part of his/her Application.
2.
Failure to sign the Authorization or withdrawal of the Authorization by the professional shall
constitute a material omission from the Application which shall result in the Application being
incomplete, and the Facility may decline to process the Application further. A material
omission shall also be grounds for automatic and immediate rejection of the Application
resulting in denial of appointment and/or privileges.
3.
With respect to Facility employees (or prospective employees) who are also Applicants, such
individuals shall also be required to comply with the Employee Background Checks policy of
the Facility. The Human Resources Department may share results of Employee Background
Checks of such individual with the Medical Staff Office and the others involved in the
credentialing process in the same manner as if it were a Medical Staff Background Check.
The Medical Staff Office may share reports on employee Applicants with the Facility’s HR
Department.
4.
Denial of appointment and/or privileges based solely on failure to provide or revocation of the
Authorization shall not entitle the Applicant to the procedural rights of hearing and appellate
review provided in the Medical Staff Bylaws, and it shall not be deemed to be an adverse
action or professional review action for purposes of reporting to the National Practitioner Data
Bank.
5.
The Medical Staff Office shall include the results of the Background Check in the Applicant’s
credentialing file.
6.
If an Applicant makes a misrepresentation or omission on his/her Application concerning
his/her criminal history which is revealed as a result of further investigation, including, but not
limited to, the Medical Staff Background Check (or the Employee Background Check, if
applicable), such action shall be grounds for automatic and immediate rejection of the
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32
Application, resulting in denial of appointment and/or clinical privileges. Denial of appointment
and/or privileges based solely on such misrepresentation or omission shall not entitle the
Applicant to the procedural rights of hearing and appellate review provided in the Medical Staff
Bylaws, and it shall not be deemed to be an adverse action or professional review action for
purposes of reporting to the National Practitioner Data Bank.
7.
The Applicant may refute the information in the report with the CRA pursuant to the
requirements of the CRA.
8.
If the report (or Employee Background Check, if applicable) reveals that the Applicant has a
criminal history, the Medical Staff Office shall and share the reports with the Chief of Staff
(COS), the Chief Executive Officer (CEO), and the applicable Department Chair or Service
Chief.
9.
The Facility shall investigate any adverse information in such report(s) by inquiring with the
Applicant to provide clarification or more information, among other means. In all cases, the
Applicant should be given an opportunity to explain the circumstances of the arrest through a
written submission or through a meeting with the COS and CEO. The facility may also request
additional information including, contacting the arresting officer and/or obtaining a copy of the
arrest record.
10.
The COS and CEO shall consider the criminal history information and make recommendations
to the Credentialing Committee.
11.
The Credentialing Committee shall consider criminal history information in light of how the
conduct relates to the Applicant’s qualification for appointment to the medical staff including,
but not limited to, the applicant’s practice, maintaining patient safety and protecting the
reputation of the Facility and Medical Staff. The committee should take into consideration
whether the crime has a relationship to the treatment of patients, and whether or not it may be
a reflection of poor moral conduct or unethical character.
12.
A disqualifying offense may be a felony conviction, guilty plea or plea of no contest to a felony
possession or sale of narcotics or controlled substances, murder, manslaughter, armed
robbery, rape, sexual battery, sex offenses listed in state codes, child abuse, arson, grand
larceny, burglary, gratification of lust, or aggravated assault, or felonious abuse and/or battery
of a vulnerable adult which has not been reversed on appeal or for which a pardon has not
been granted.
13.
Mitigating circumstances which may be considered include, but are not limited to, age at which
the crime was committed; nature and gravity of the crime; circumstances surrounding the
crime; length of time since the arrest, conviction or prison time; criminal history since the
conviction; work history; current membership and character references; and other evidence
demonstrating the individual’s ability to perform their privileges competently and that the
person poses no threat to the health and safety of patients. In any such instance,
documentation will be produced and maintained outlining any mitigating circumstances and
recommendations as to whether or not the Applicant’s membership and/or privileges shall be
granted.
Credentialing, Recredentialing & Privileging Basics
33
Using The AMA Physician and AAPA Physician Assistant Masterfile Query
POLICY AND PROCEDURE
[Facility Name]
Policy:
It is the policy of [Facility Name] to require verification of all relevant information provided on
applications for Medical Staff appointment and/or clinical privileges.
The American Medical Association’s Physician Masterfile and the American Academy of Physician
Assistants Masterfiles contains primary source verification of a number of credentialing elements.
It is the policy of [Facility Name] to use the AMA Physician Masterfile for verification of the following
elements for physicians who hold an M.D:



U.S. or Puerto Rican medical school graduation
Residency completion
Board certification
Note: While completion of residency can be verified with the AMA Masterfile, the residency program
should also be contacted to verify that the physician has been trained to perform the privileges
requested. (See policy and procedure on Verification of Postgraduate Training.)
It is the policy of [Facility Name] to use the AMA Physician Assistant Masterfile for verification of the
following elements for physician’s assistants:


Education of physician assistant’s medical school
Certification by the National Commission for the Certification of Physician Assistants
Note: If the Facility contracts with a Credentials Verification Organization (CVO), as the hospital’s
agent, the Masterfiles may be requested by the CVO, or the CVO may query directly to the primary
source in lieu of using the AMA/AAPA Masterfiles.
.
Credentialing, Recredentialing & Privileging Basics
34
LIABILITY HISTORY/PROOF OF INSURANCE
Malpractice insurance is provided by per occurrence and by an aggregate value. For instance, the
policy may provide $1 million per each occurrence with a maximum yearly aggregate amount of $3
million. Most hospitals require proof of liability insurance with a specified minimum face value.
Most hospitals and MCOs require the applicant to provide, at minimum, information concerning
current professional liability coverage and any final judgments and settlements. The applicant may be
required to provide information regarding current past insurers, whether insurance has ever been
canceled by carrier and reasons why, and claims filed and disposition. Often, a letter, such as the
one below, is included in the application packet.
It is important for the organization to understand that just because a provider has a malpractice suit, it
does not necessarily mean that the provider is incompetent or is a problem provider. The organization
must evaluate the liability history of each individual provider to determine whether or not it is
significant in relation to the privileges requested. In some physician specialties, for instance
orthopedics and neurosurgery, there is a higher rate of malpractice suits filed. In addition, liability
insurance providers may settle some lawsuits just because it's cheaper to do so then to go through
the litigation. Oftentimes, the provider has no control over these settlements.
Date]
[Insurance Company name and address]
RE: [Practitioner name]
[Policy number]
Dear Sir or Madam:
I have applied for Medical Staff membership at [hospital name]. As a requirement for this
membership, proof of ongoing liability insurance is required. Please add [hospital name] as a
certificate holder to my policy and provide a copy of my certificate of coverage to [hospital name]
including the limits of the insurance coverage and any additional insured.
Additionally, please provide ongoing notice of cancellation, nonrenewal, or any material limitations in
coverage within 30 days in advance for any statutorily permitted reason including nonpayment of
premium.
Please also provide [hospital name] with a record of my claims history/loss run including date of the
loss, date the claim was reported, name of the claimant, synopsis of what happened, amount paid to
date, and whether the claim is closed or open.
Sincerely,
[practitioner name]
Credentialing, Recredentialing & Privileging Basics
35
HEALTH STATUS/ABILITY TO PERFORM
Applicants should be asked to document their ability to safely exercise the privileges requested with
or without reasonable accommodation. The Americans with Disabilities Act (ADA) is a federal civil
rights law that prohibits discrimination based on disability and bars discrimination against a qualified
individual due to the disability. State and local court opinions vary regarding whether ADA applies
only to employees only or includes medical staff members. It is up to individual hospitals to
determine how the ADA applies to its privileging and credentialing processes. When discussing the
issue of the aging provider, it is essential to maintain compliance with state and federal law related to
age discrimination. Joint Commission standards require that the hospital evaluate the health status of
physicians who exercise, or seek to exercise clinical privileges or other health care services. When
the organization employs the physician the ADA applies. If not employed, most hospital medical staffs
do not abide by the ADA.
The question that needs to be addressed is whether the physician is currently competent and
qualified to safely exercise the privileges granted. Some believe that age is irrelevant. Bylaws and
policies should be designed to effectively monitor, review, audit and evaluate how providers perform.
This is essential in making a determination as to whether they are meeting expected standards.
Of course, there may come a time when the skills of a provider begin to diminish. If so, steps need to
be taken in order to assure that the interests of patient care are seen to while also respecting the
rights and privileges of physicians. This may involve a process to review and investigate possible
causes. The review should be accomplished in a supportive, collegial manner consistent with bylaws,
rules and regulations and applicable policies.
Some medical staffs set a certain age, for instance age 65, at which physicians are required to submit
to an annual physical exam.
BOARD CERTIFICATION
The ABMS coordinates the activities of its 24 Member Boards in the United States and provides
information to the public, government, medical profession and its Members concerning issues
involving specialization and certification in medicine. According to the ABMS, the fundamental
objective of its member boards is to act in the public interest by contributing to the improvement of
medical care by establishing qualifications for candidates and by evaluating those who apply for
certification.
The 24 ABMS member boards offer general and sub-specialty certificates. Each specialty board acts
as an independent body determining its own requirements and policies for certification. The board
accepts candidates for certification from persons who fulfill its requirements, administers certification
exams, and issues certificates to those who pass. All member boards require a written exam and
most also require an oral exam. Obstetrics and gynecology, neurological surgery orthopedic surgery,
pathology, physical medicine & rehab, radiology, and urology boards have an additional requirement
for one to two years of clinical experience.
At one time, boards issued lifetime certificates meaning once you were certified, you were certified for
life. All ABMS member boards now have time-limited certificates and require recertification. Most
boards now require recertification after 10 years with the exception of Family Practice (7 years),
OB/GYN (7 years), and Pediatrics (7 years). If you query an ABMS member board and ask about
“board eligibility”, it will respond by stating an individual's precise position in the certifying process.
Credentialing, Recredentialing & Privileging Basics
36
The American Osteopathic Association does continue use the term “board eligible”. AOA Board
eligibility status terminates on December 31 of the sixth year after completing the training program.
AOA has 18 certifying boards.
Hospital requirements for board certification vary, often based on physician availability. Those
hospitals located in a geographic area with an abundance of physicians often require board
certification, while those in underserved areas often do not. It is not unusual for each medical staff
department to set its own criteria for privileges which may include board certification. Some managed
care organizations require board certification to participate in provider panels.
If certification is required, it is necessary to keep track of all certifications and expiration dates.
Bylaws should define any requirements for board certification/eligibility and a process should be in
place to verify board certification. If the medical staff requires board certification on appointment or
within a certain timeframe, follow-up should occur to assure these requirements are met. Reminder
letters should be sent to physicians prior to the expiration of their boards or eligibility. Include in this
letter the bylaws language that requires board certification. Whatever your requirements, make sure
that they are consistently applied.
Board certification is usually verified by obtaining confirmation from the board. Board certification for
ABMS boards can be verified via the ABMS CertiFacts online, the ABMS Certifax service, ABMS
products administered through Choice Point Services, Inc. and the online subscription service,
www.boardcertifieddocs.com. AOA certification can be verified via the AOA Official Osteopathic
Physician Profile Report or AOA Physician Master File.
The American Board of Medical Specialties (ABMS) has replaced its recertification program with a
Maintenance of Certification (MOC) program that reflects the concept of physician practice
assessment based on performance rather than solely on success on a written exam. This includes
assessment of six “general competencies” - patient care, interpersonal and communication skills,
professionalism, medical knowledge, practice-based learning and improvement, and systems-based
practice. The MOC has four basic components requiring evidence of professional training, lifelong
learning with involvement in a periodic self-assessment process, cognitive expertise, and evaluation
of performance in practice.
What About Those “Other Boards”
There are many self-designated medical boards in the U.S. that are not members of the ABMS or the
AOA. While hospitals and medical staffs set their own criteria for appointment, careful consideration
should be given to specifying which certifying boards are considered acceptable.
Medicare CoPs Regarding Board Certification
§482.12(a)(7) [The governing body must] Ensure that under no circumstances is the accordance of
staff membership or professional privileges in the hospital dependent solely upon certification,
fellowship or membership in a specialty body or society.
“A hospital is not prohibited from requiring board certification when considering a MD/DO for medical
staff membership. Rather, the regulation provides that a hospital may not rely solely on the fact that a
MD/DO is or is not board certified in making a judgment on medical staff membership. In addition to
matters of board certification, a hospital must also consider other criteria such as training, character,
Credentialing, Recredentialing & Privileging Basics
37
competence and judgment. After analysis of all of the criteria, if all criteria are met except for board
certification, the hospital has the discretion to decide not to select that individual to the medical staff.”
(Source: CMS Interpretive Guidelines)
VERIFICATION OF IDENTITY
Joint Commission standards require the organization to verify the identity of the practitioner
requesting by viewing a current picture hospital ID card or a valid picture ID issued by a state or
federal agency (e.g., driver's license or passport). It is expected that this be done prior to the
practitioner providing patient care, treatment, or services.
Credentialing, Recredentialing & Privileging Basics
38
Sample Policy and Procedure for Verification of Identity
Policy:
It is the policy of ___________ Hospital to verify the identity of all licensed independent practitioners (LIPs)
who apply for medical staff appointment and privileges prior to the practitioner providing any patient care,
treatment, or services. This is done to determine that these practitioners are the same practitioners identified in
the credentialing documents.
Verification of identity can be accomplished by viewing any of the following:
Military ID, State ID, Customs Passport, State Drivers License
Procedure:
Verification can be done during any of the following processes:



During provider orientation
During the process of obtaining hospital picture ID
Any time the practitioner presents in person to the Medical Staff Office
After presentation of a valid Military ID, state drivers license/ID, or customs passport that includes a
picture, the person verifying completes the Verification of Identity Documentation Form (Attachment A). The
completed form is forwarded to the Medical Staff Office for inclusion in the practitioner’s credentials file.
Reference: Joint Commission Hospital Standard MS.06.01.03
Attachment A
Verification of Identity Documentation Form
Practitioner Name: ____________________________________________________
I have reviewed the following identification for the above-named practitioner:
Military ID
Passport
State Driver’s license or ID ______________________________________
[list issuing state]
_______________________________
Signature of person verifying
____________________
Date
_______________________________
Printed name of person verifying
Credentialing, Recredentialing & Privileging Basics
39
PRIVILEGES RESOURCES
Credentialing, Recredentialing & Privileging Basics
40
“Laundry List” Example
Family Practice Privileges
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amniocentesis
androscopy
anoscopy
arterial puncture
arthrocentesis
aspiration of bladder: suprapubic
bartholin’s cyst: drainage
biopsy skin and subcutaneous
biopsy: vulva or vagina
bladder catheterization
breast: needle aspiration of cyst
burns: partial; full thickness
casting, splinting, and bracing
cervix: biopsy and polypectomy
cervix: cryosurgery
chemotherapy, adult and child
colonoscopy w /biopsy
colonoscopy w/o biopsy
colposcopy and biopsy
culdocentesis
dilatation and curettage
dilatation and curettage
dislocations: simple/closed
reduction
ECG interpretation
ectopic pregnancy: medical
management
EGD w/ biopsy
EGD w/o biopsy
endometrial bx/aspiration
curettage
endoscopy: w/ foreign body
removal
epistaxis: anterior
extensor tendon repair:
simple/primary
fine needle biopsy: superficial
lymph node or thyroid
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foreign body removal, eye, ear,
nose, throat
fracture care closed reduction
fracture care non-operative/nondisplaced
frenulum release
ganglion: aspiration/drainage
hemorrhoidectomy: banding or
infrared
hemorrhoidectomy: external
surgical
history and physical exam
holter monitoring
hymenotomy
hysterosalpingogram
I & D abscess
injection: joint, tendon, or bursa
intrauterine demis management
IU insertion/removal
laceration: simple repair
laceration: intermediate repair
laryngoscopy: direct
laryngoscopy: indirect
LEEP biopsy or cone
lumbar puncture
lymph node superficial biopsy or
excision
lymph node excision or biopsy
meatotomy
morton’s neurom injection
nail matrix destruction
nail plate removal
nasal fractur undisplaced
neoplasia of skin: thermal or
surgical treatment
NG tube placement
non-stress testing
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oral lesions: biopsy and excision;
simple
osteopathic manipulative therapy
paracervical block
pilonidal cyst I & D or excision
proctosigmoidoscopy: flexible w/
biopsy
proctosigmoidoscopy: flexible
w/o biopsy
proctosigmoidoscopy: rigid w/
biopsy
proctosigmoidoscopy: rigid w/o
biopsy
pudendal block
pulmonary function testing
removal of cerumen impaction
rhinolaryngoscopy: fiberoptic
sebaceous cyst excision
skin biopsy: shave, punch,
incisional or excisional
slit lamp exam
stress testin exercise treadmill
sub-cutaneous contraceptive
devic insertion/removal
thoracentesis: needle/catheter
thoracentesis: needle/catheter
tonometry
ultrasound
urethra dilation of female
urethra dilation of male
vacuum curette incomplete
abortion
vasectomy
venereal warts: treatment
venereal warts: treatment
venipuncture
Signature___________________________________________
Date________________________________________________
Credentialing, Recredentialing & Privileging Basics
41
Sample Core Privileges form American Academy of Family Practice
AAFP Core Privileges Example
CLINICAL PRIVILEGE REQUEST
FOR FAMILY MEDICINE WITH MATERNITY CARE SOURCE: AMERICAN ACADEMY OF FAMILY PHYSICIANS
CLINICAL PRIVILEGE REQUEST
FOR FAMILY MEDICINE WITH MATERNITY CARE
Name:
Effective from __/__/__ to __/__/__
INTRODUCTION OF CORE PRIVILEGES
Family medicine is the medical specialty which provides continuing, comprehensive health care for the
individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences.
The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity.
Core privileges within the department of family medicine should reflect the core curriculum and training
offered in accredited family medicine residency programs. The categories and core privileges listed are based
on the “Program Requirements for Graduate Medical Education in Family Medicine,” a publication by The
Accreditation
Council
for
Graduate
Medical
Education
(ACGME)
(http://www.acgme.org/acWebsite/downloads/RRC_progReq/120pr706.pdf),
and
the
“Recommended
Curriculum Guidelines for Family Medicine Residents” endorsed by the American Academy of Family
Physicians (http://www.aafp.org/x16524.xml). Resources for family physicians and hospitals for special noncore privileges can be found at the AAFP website at aafp.org, including the AAFP position paper on
colonoscopy found at http://www.aafp.org/online/en/home/policy/policies/c/colonoscopypositionpaper.html.
ELIGIBILITY
To be eligible to apply for core privileges in family medicine, the applicant must meet the following criteria:

Current certification or active participation in the examination process leading to certification in family
medicine by the American Board of Family Medicine or the American Osteopathic Board of Family
Physicians
And/or
 Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or
American Osteopathic Association (AOA) accredited post-graduate training program in family
medicine.
FAMILY MEDICINE CORE PRIVILEGES
☐Requested Admission, evaluation, diagnosis, treatment and management of infants and children, adolescents
and adults for most illnesses, disorders and injuries. Core privileges include but are not limited
to:
 The care of neonates and infants, including both well-baby and ill newborns.
 Illnesses, disorders and injuries of childhood, such as pneumonia, asthma, gastrointestinal
infections, dehydration and urinary tract infections.
 Illnesses, disorders and injuries of adolescence.
 Illnesses, disorders and injuries of the adult, including but not limited to conditions of the
heart, kidney, lung, musculoskeletal system, skin, eye, and nervous system, and including
multi-system diseases such as diabetes mellitus, HIV/AIDS and cancer, and including the
care of patients requiring admission to intensive care.
Credentialing, Recredentialing & Privileging Basics
42
Sample Core Privileges form American Academy of Family Practice
 Women’s health, including illnesses, disorders and injuries of the female reproductive
and genitourinary systems.
 Pre- and post-operative evaluation and care.
 Acute and chronic diseases of the elderly, including dementias, as well as functional
assessment, physiologic and psychologic aspects of senescence and end-of-life care.
 Psychiatric disorders in children and adults, emotional aspects of non-psychiatric
disorders, psychopharmacology, alcoholism and other substance abuse.
 The care for patients of all ages with acute illnesses, disorders and injuries in an
emergency care setting.
 Community issues, such as child abuse and neglect, domestic violence, elder abuse and
neglect, disease prevention and disaster preparedness.
 Procedures such as suturing lacerations, removal of non-penetrating corneal foreign
bodies, simple skin biopsies or excisions, incision and drainage of abscesses, burn care,
the management of uncomplicated minor closed fractures and uncomplicated
dislocations, and such other procedures that are extensions of the same techniques and
skills.
Exclusions: Though considered core privileges for Family Medicine, the following privileges will be
excluded for this applicant at their request.
__________________________________________________________________________________________
__________________________________________________________________________________________
MATERNITY CORE PRIVILEGES
☐Requested Admit, evaluate and manage pregnancy, labor and delivery, post-partum care, and other
procedures related to maternity care, including medical diseases that are complicating factors in
pregnancy (with consultation as appropriate). Applicant must provide documentation of at least 2
months obstetrical rotation during family practice residency with 40 patients delivered.
SPECIAL NON-CORE PRIVILEGES
To be eligible to apply for special non-core privileges, the applicant must have documented training and/or
experience and current competence in performing the requested procedure(s) consistent with criteria set forth in
medical staff policies governing the exercise of specific privileges. This may be accomplished by providing
documentation of acceptable supervised training and experience during residency and/or fellowship training, or
successful completion of an approved, recognized course when such exists.
C-Section

Requested Application Criteria: Successful completion of an ACGME or AOA accredited residency training
program in family medicine or obstetrics and gynecology.
Required Previous Experience: A minimum of 30 Cesarean births as primary operator.
Credentialing, Recredentialing & Privileging Basics
43
Sample Core Privileges form American Academy of Family Practice
Acknowledgement of Practitioner
I acknowledge that I have requested only those privileges for which by current competence, training and/or
experience, I am qualified to perform and for which I wish to exercise at the Hospital. I understand that I am
bound by the applicable bylaws or policies of the Hospital.
Signed:
Date:
Typed or printed name:
Department Chair’s Recommendation
I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant
and make the following recommendation(s):
☐Recommend all requested privileges
☐Recommend privileges with the following conditions/modifications:
☐Do not recommend the following requested privileges:
Privilege
Condition/Modification/Explanation
1.
2.
3.
4.
Notes:
Department Chair Signature:
Credentialing, Recredentialing & Privileging Basics
Date:
44
Sample Core Privileges form American Academy of Family Practice
FAMILY MEDICINE CORE: APPENDIX A
CORE PROCEDURES
The following are a few examples of procedures from the Family Medicine CORE, illustrating the depth of
Family Medicine training. As with other specialties, not every applicant for privileges will choose to do all
procedures within the core, and may elect to exclude those procedures from their privilege request. It remains
the responsibility of the Family Medicine department chair to forward credentialing/privileging applications to
the credentials committee that have been appropriately vetted at the department level.
General
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Arthrocentesis
Incision and drainage (I & D) abscess
Incision and drainage (I & D) hemorrhoids
Breast cyst aspiration
Burn care
Excision of skin and subcutaneous lesions
Excision of cutaneous and subcutaneous tumors and nodules
Local anesthetic techniques
Lumbar puncture
Management of uncomplicated closed fractures and dislocations
Needle biopsies
Placement of anterior and posterior nasal hemostatic packing
Perform skin biopsy or excision
Peripheral nerve blocks
Interpretation of electrocardiograms
Management of non-penetrating corneal foreign body, nasal foreign body
Repair of lacerations, including those requiring layer closure
Suprapubic bladder aspiration
Exercise Treadmill testing
Vascular access and intubation of newborns
Management of abnormal Pap, including colposcopy, cryotherapy and LEEP
Insertion and removal of intrauterine devices
Tracheal Intubation
Circumcision
Central venous line placement
Paracentesis/Thoracentesis
Credentialing, Recredentialing & Privileging Basics
45
Sample Core Privileges form American Academy of Family Practice
Maternity Care
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Amniotomy
Normal spontaneous vaginal delivery of a term vertex presentation, including ante- and postpartum care
Dilation and curettage (D&C), including suction and postpartum
Excision of vulvar lesions at delivery
External and internal fetal monitoring
Augmentation of labor
Induction of labor
Management of uncomplicated labor
Manual removal of placenta, post delivery
Operative or assisted vaginal delivery
Oxytocin challenge test
Post partum hemorrhage (PPH)
Post partum endometritis
Pudendal anesthesia
Repair of episiotomy, including lacerations/extensions
Repair of vaginal and cervical lacerations
Dilation and Curettage for Incomplete Abortion
Note: Appendix A is NOT incorporated by reference into the Core document but instead is to be used by an
applicant when seeking privileges when they determine it would be to their benefit. There is no expectation that
every physician graduating from a Family Medicine program will have been trained/be competent in all listed
procedures. It is the responsibility of the Family Medicine department chair to forward only those requests for
privileges that have been appropriately reviewed and vetted at the department level. Alternatively, Appendix A
does not represent the entire scope of family medicine. Utilizing Appendix A as a mechanism to restrict
privileges for family physicians by interpreting the appendix as a comprehensive delineation of services offered
by family physicians would be incorrect.
Credentialing, Recredentialing & Privileging Basics
46
[HOSPITAL NAME]
[Hospital Address]
Family Medicine Clinical Privileges Source: Core Privileges for Physicians: A Practical Approach to
Developing and Implementing Criteria-based Privileges, Fifth Edition published by HCPro.
Name:
Effective from: ____/____/______ to ____/____/______
HCPro Core Privileges Example
☐Initial appointment
☐Reappointment
All new applicants must meet the following requirements as approved by the governing body effective
____/____/______.
If any privileges are covered by an exclusive contract or an employment contract, practitioners who are
not a party to the contract are not eligible to request the privilege(s), regardless of education, training, and
experience. Exclusive or employment contracts are indicated by [EC].
Applicant: Check off the “Requested” box for each privilege requested. Applicants have the burden of
producing information deemed adequate by the Hospital for a proper evaluation of current competence,
current clinical activity, and other qualifications and for resolving any doubts related to qualifications for
requested privileges.
[Department Chair/Chief]: Check the appropriate box for recommendation on the last page of this form.
If recommended with conditions or not recommended, provide condition or explanation on the last page of
this form.
Other Requirements
Note that privileges granted may only be exercised at the site(s) and setting(s) that have the appropriate
equipment, license, beds, staff, and other support required to provide the services defined in this
document. Site-specific services may be defined in hospital or department policy.
This document is focused on defining qualifications related to competency to exercise clinical privileges.
The applicant must also adhere to any additional organizational, regulatory, or accreditation
requirements that the organization is obligated to meet.
Qualifications for Family Medicine
 To be eligible to apply for core privileges in family medicine, the initial applicant must meet
the following criteria:
Successful completion of an Accreditation Council for Graduate Medical Education (ACGME)– or
American Osteopathic Association (AOA)–accredited residency in family medicine.
AND/OR
Current certification or active participation in the examination process [with achievement of certification
within [n] years] leading to certification in family medicine by the American Board of Family Medicine or
the American Osteopathic Board of Family Physicians.
Required previous experience: Applicants for initial appointment must be able to demonstrate provision
of care, reflective of the scope of privileges requested, for at least 24 inpatients as the attending physician
during the past 12 months or demonstrate successful completion of an ACGME- or AOA-accredited
residency, clinical fellowship, or research in a clinical setting within the past 12 months.
Credentialing, Recredentialing & Privileging Basics
47
[HOSPITAL NAME]
[Hospital Address]
Family Medicine Clinical Privileges Source: Core Privileges for Physicians: A Practical Approach to
Developing and Implementing Criteria-based Privileges, Fifth Edition published by HCPro.
Name:
Effective from: ____/____/______ to ____/____/______
Reappointment requirements: To be eligible to renew core privileges in family medicine, the applicant
must meet the following maintenance of privilege criteria:
Current demonstrated competence and an adequate volume of experience ([n] inpatients) with
acceptable results, reflective of the scope of privileges requested, for the past 24 months based on
results of ongoing professional practice evaluation and outcomes. Evidence of current ability to perform
privileges requested is required of all applicants for renewal of privileges.
Core Privileges
FAMILY MEDICINE CORE PRIVILEGES
☐Requested
Admit, evaluate, diagnose, treat, and provide consultation to adolescent and adult
patients with illnesses, diseases, and functional disorders of the circulatory, respiratory,
endocrine, metabolic, musculoskeletal, hematopoietic, gastroenteric, and genitourinary
systems. [May provide care to patients in the intensive care setting in conformance with
unit policies.] Assess, stabilize, and determine disposition of patients with emergent
conditions consistent with medical staff policy regarding emergency and consultative call
services. The core privileges in this specialty include the procedures on the attached
procedure list and such other procedures that are extensions of the same techniques and
skills.
REFER AND FOLLOW PRIVILEGES
Criteria: Education and training as for family medicine core privileges.
☐Requested
Perform outpatient preadmission and history and physical, order noninvasive outpatient
diagnostic tests and services, visit patient in hospital, review medical records, consult
with attending physician, and observe diagnostic or surgical procedures with the approval
of the attending physician or surgeon.
PEDIATRIC CORE PRIVILEGES
Criteria: As for family medicine core plus:
Required previous experience: Demonstrated current competence and evidence of the provision of
care, reflective of the scope of privileges requested, to at least 10 pediatric inpatients in the past 12
months.
Maintenance of privilege: Demonstrated current competence and evidence of the provision of care to at
least [n] pediatric inpatients in the past 24 months based on results of ongoing professional practice
evaluation and outcomes.
☐Requested
Admit, evaluate, diagnose, and treat pediatric patients up to the age of 18 with common
illnesses, injuries, or disorders. This includes the care of the normal newborn as well as
the uncomplicated premature infant equal to or greater than 36 weeks gestation. Assess,
stabilize, and determine disposition of patients with emergent conditions consistent with
medical staff policy regarding emergency and consultative call services. The core
privileges in this specialty include the procedures on the attached procedure list and such
other procedures that are extensions of the same techniques and skills.
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[HOSPITAL NAME]
[Hospital Address]
Family Medicine Clinical Privileges Source: Core Privileges for Physicians: A Practical Approach to
Developing and Implementing Criteria-based Privileges, Fifth Edition published by HCPro.
Name:
Effective from: ____/____/______ to ____/____/______
GYNECOLOGY CORE PRIVILEGES
Criteria: Must qualify for and be granted privileges in family medicine plus:
Required previous experience: Demonstrated current competence and evidence of provision of care,
reflective of the scope of privileges requested, to at least 10 gynecologic inpatients in the past 12 months.
Maintenance of privilege: Demonstrated current competence and evidence of provision of care to at
least [n] gynecologic inpatients in the past 24 months based on results of ongoing professional practice
evaluation and outcomes.
☐Requested
Admit, evaluate, diagnose, treat, and provide consultation to postpubescent female
patients with injuries and disorders of the female reproductive system and the
genitourinary system. [May provide care to patients in the intensive care setting in
conformance with unit policies.] Assess, stabilize, and determine disposition of patients
with emergent conditions consistent with medical staff policy regarding emergency and
consultative call services. The core privileges in this specialty include the procedures on
the attached procedure list and such other procedures that are extensions of the same
techniques and skills.
OBSTETRICAL CORE PRIVILEGES
Criteria: Must qualify for and be granted privileges in family medicine. Plus, applicant must provide
documentation of three to four months’ obstetrical rotation during family medicine residency with [n]
patients delivered. Current NALS certification.
Required previous experience: Demonstrated current competence and evidence of the performance of
at least 10 deliveries in the past 12 months.
Maintenance of privilege: Demonstrated current competence and evidence of the performance of at
least [n] deliveries in the past 24 months based on ongoing professional practice evaluation and
outcomes.
☐Requested
Admit, evaluate, and manage female patients with normal term pregnancy with an
expectation of uncomplicated vaginal delivery, management of labor and delivery, and
procedures related to normal delivery, including medical diseases that are complicating
factors in pregnancy (with consultation). [May provide care to patients in the intensive
care setting in conformance with unit policies.] Assess, stabilize, and determine
disposition of patients with emergent conditions consistent with medical staff policy
regarding emergency and consultative call services. The core privileges in this specialty
include the procedures on the attached procedure list and such other procedures that are
extensions of the same techniques and skills.
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[HOSPITAL NAME]
[Hospital Address]
Family Medicine Clinical Privileges Source: Core Privileges for Physicians: A Practical Approach to
Developing and Implementing Criteria-based Privileges, Fifth Edition published by HCPro.
Name:
Effective from: ____/____/______ to ____/____/______
Qualifications for Geriatric Medicine (Applicable when a family medicine physician treats
geriatric patients only, has completed a fellowship and/or holds subspecialty
certification.)
 To be eligible to apply for core privileges in geriatric medicine, the initial applicant must meet
the following criteria:
Successful completion of an Accreditation Council for Graduate Medical Education (ACGME)– or
American Osteopathic Association (AOA)–accredited residency in either family medicine or internal
medicine followed by an ACGME- or AOA-accredited fellowship in geriatric medicine.
AND/OR
Current subspecialty certification or active participation in the examination process [with achievement of
certification within [n] years] leading to subspecialty certification in geriatric medicine by the American
Board of Internal Medicine, or the American Board of Family Medicine, or a Certificate of Added
Qualifications in Geriatric Medicine by the American Osteopathic Board of Family Physicians.
Required previous experience: Applicants for initial appointment must be able to demonstrate provision
of inpatient care, reflective of the scope of privileges requested, for at least 24 patients as the attending
practitioner during the past 12 months or demonstrate successful completion of an ACGME- or AOAaccredited residency, clinical fellowship, or research in a clinical setting within the past 12 months.
Reappointment requirements: To be eligible to renew core privileges in geriatric medicine, the applicant
must meet the following maintenance of privilege criteria:
Current demonstrated competence and an adequate volume of experience ([n] inpatients) with
acceptable results, reflective of the scope of privileges requested, for the past 24 months based on
results of ongoing professional practice evaluation and outcomes. Evidence of current ability to perform
privileges requested is required of all applicants for renewal of privileges.
Core Privileges
GERIATRIC MEDICINE CORE PRIVILEGES
☐Requested
Admit, evaluate, diagnose, treat, and provide consultation to older adult patients with
illnesses and disorders that are especially prominent in the elderly or have different
characteristics in the elderly, including neoplastic, cardiovascular, neurologic,
musculoskeletal, metabolic, and infectious disorders. [May provide care to patients in the
intensive care setting in conformance with unit policies.] Assess, stabilize, and determine
disposition of patients with emergent conditions consistent with medical staff policy
regarding emergency and consultative call services. The core privileges in this specialty
include the procedures on the attached procedure list and such other procedures that are
extensions of the same techniques and skills.
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[HOSPITAL NAME]
[Hospital Address]
Family Medicine Clinical Privileges Source: Core Privileges for Physicians: A Practical Approach to
Developing and Implementing Criteria-based Privileges, Fifth Edition published by HCPro.
Name:
Effective from: ____/____/______ to ____/____/______
Special Noncore Privileges (See Specific Criteria)
If desired, noncore privileges are requested individually in addition to requesting the core. Each individual
requesting noncore privileges must meet the specific threshold criteria governing the exercise of the
privilege requested including training, required previous experience, and maintenance of clinical
competence.
CESAREAN SECTION
Criteria: Must qualify for and receive family medicine obstetrics privileges.
Required previous experience: Demonstrated current competence and the successful completion of an
accredited one- to two-year family medicine obstetric fellowship in the past 12 months or [n] cesarean
births as primary operator during the past 12 months.
Maintenance of privilege: Demonstrated current competence and evidence of [n] cesarean births as the
primary operator in the past 24 months.
☐Requested
ATTENDANCE AT DELIVERY TO ASSUME CARE OF NORMAL NEWBORNS
Criteria: Successful completion of an accredited residency which included training in this procedure, or
the applicant must have completed hands-on training in this procedure under the supervision of a
qualified physician preceptor. Current NALS certification.
Required previous experience: Demonstrated current competence and evidence of attendance at [n]
deliveries in the past 12 months.
Maintenance of privilege: Demonstrated current competence and evidence of attendance at [n]
deliveries in the past 24 months based on results of quality assessment/improvement activities and
outcomes.
☐Requested
CIRCUMCISION
Criteria: Successful completion of formal training in this procedure or the applicant must have completed
hands-on training in this procedure under the supervision of a qualified physician preceptor. Evidence of
having performed [n] proctored procedures during training.
Required previous experience: Demonstrated current competence and evidence of the performance of
at least [n] procedures in the past 12 months.
Maintenance of privilege: Demonstrated current competence and evidence of the performance of at
least [n] procedures in the past 24 months based on results of quality assessment/improvement activities
and outcomes.
☐Requested
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[HOSPITAL NAME]
[Hospital Address]
Family Medicine Clinical Privileges Source: Core Privileges for Physicians: A Practical Approach to
Developing and Implementing Criteria-based Privileges, Fifth Edition published by HCPro.
Name:
Effective from: ____/____/______ to ____/____/______
FLEXIBLE SIGMOIDOSCOPY
Criteria: Successful completion of an ACGME- or AOA-accredited residency in family medicine that
included training in flexible sigmoidoscopy or evidence of prior training and experience.
Required previous experience: Demonstrated current competence and evidence of at least 30
procedures in the past 12 months.
Maintenance of privilege: Demonstrated current competence and evidence of the performance of at
least [n] procedures in the past 24 months based on results of ongoing professional practice evaluation
and outcomes.
☐Requested
LUMBAR PUNCTURE
Criteria: Successful completion of an ACGME- or AOA-accredited residency in family medicine that
included training in lumbar puncture, or evidence of active clinical practice in the procedure.
Required previous experience: Demonstrated current competence and evidence of the performance of
at least [n] lumbar punctures in the past 12 months.
Maintenance of privilege: Demonstrated current competence and evidence of the performance of at
least [n] lumbar punctures in the past 24 months based on results of ongoing professional practice
evaluation and outcomes.
☐Requested
VENTILATOR MANAGEMENT
Criteria: For ventilator cases not categorized as complex (up to 36 hours), successful completion of an
ACGME- or AOA-accredited postgraduate training program that provided the necessary cognitive and
technical skills for ventilator management not categorized as complex.
For complex ventilation cases, the applicant must demonstrate successful completion of an accredited
fellowship that provided the necessary cognitive and technical skills for complex ventilator management.
Required previous experience: Demonstrated current competence and evidence of the management of
at least [n] mechanical ventilator cases in the past 12 months.
Maintenance of privilege: Demonstrated current competence and evidence of the management of at
least [n] mechanical ventilator cases in the past 24 months based on results of ongoing professional
practice evaluation and outcomes.
Source: California Thoracic Society Position Paper—Clinical Privileges for Mechanical Ventilator
Management 05/25/06
☐Requested
Ventilator Management (not complex including CPAP—up to 36 hours)
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[HOSPITAL NAME]
[Hospital Address]
Family Medicine Clinical Privileges Source: Core Privileges for Physicians: A Practical Approach to
Developing and Implementing Criteria-based Privileges, Fifth Edition published by HCPro.
Name:
Effective from: ____/____/______ to ____/____/______
☐Requested
Complex, including BiPAP. *More than 36–48 hours, or for patients defined as those
having any of the following ongoing characteristics or any other of similar complexity:
PEEP requirement  10 cm of water; FI02 requirement  0.6; static plateau pressure  30
cm of water; presence of significant preexisting pulmonary disease; multisystem organ
failure; chronic ventilator dependence; patient not meeting previous criteria, but clinical
condition deteriorating.
ADMINISTRATION OF SEDATION AND ANALGESIA
☐Requested
See Hospital Policy for Sedation and Analgesia by Non-Anesthesiologists
Core Procedure List
This list is a sampling of procedures included in the core. This is not intended to be an all-encompassing
list but rather reflective of the categories/types of procedures included in the core.
To the applicant: If you wish to exclude any procedures, please strike through those procedures that you
do not wish to request, initial, and date.
General
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Arthrocentesis and joint injection
Burns, superficial and partial thickness
Chronic ventilator management
I & D abscess
Local anesthetic techniques
Manage uncomplicated minor closed fractures and uncomplicated dislocations
Perform history and physical exam
Perform simple skin biopsy or excision
Peripheral nerve blocks
Placement of anterior and posterior nasal hemostatic packing
Remove nonpenetrating foreign body from the eye, nose, or ear
Suture uncomplicated lacerations
Pediatrics
1.
2.
3.
4.
5.
6.
I & D abscess
Manage uncomplicated minor closed fractures and uncomplicated dislocations
Perform history and physical exam
Perform simple skin biopsy or excision
Remove nonpenetrating corneal foreign body
Suture uncomplicated lacerations
Gynecology
1.
2.
3.
4.
5.
6.
Biopsy of cervix, endometrium
Colposcopy
Cryosurgery/cautery for benign disease
Diagnostic cervical dilation and uterine curettage
Excision/biopsy of vulvar lesions
Incision and drainage of Bartholin duct cyst or marsupialization
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[HOSPITAL NAME]
[Hospital Address]
Family Medicine Clinical Privileges Source: Core Privileges for Physicians: A Practical Approach to
Developing and Implementing Criteria-based Privileges, Fifth Edition published by HCPro.
Name:
Effective from: ____/____/______ to ____/____/______
7.
8.
9.
10.
11.
Insertion of intrauterine devices
Perform history and physical exam
Removal of foreign body from vagina
Suturing of uncomplicated lacerations
Uterine curettage following incomplete abortion
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[HOSPITAL NAME]
[Hospital Address]
Family Medicine Clinical Privileges Source: Core Privileges for Physicians: A Practical Approach to
Developing and Implementing Criteria-based Privileges, Fifth Edition published by HCPro.
Name:
Effective from: ____/____/______ to ____/____/______
Obstetrics
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Amniotomy
Augmentation of labor
D&C including suction and postpartum
Excision of vulvar lesions at delivery
External and internal fetal monitoring
Induction of labor with consultation and pitocin management
Initial management of post partum hemorrhage (PPH)
Investigative OB ultrasound for presentation only
Management of prenatal and postpartum care
Management of uncomplicated labor including normal spontaneous vaginal delivery or a term vertex
presentation
Manual removal of placenta, post delivery
Normal spontaneous vaginal delivery
Oxytocin challenge test
Perform history and physical exam
Post partum endometritis
Pudendal anesthesia
Repair of episiotomy—first, second, and third degree
Repair of vaginal lacerations
Vacuum assisted delivery
Geriatric Medicine
1. Apply the general principles of geriatric rehabilitation, including those applicable to patients with
orthopedic, rheumatologic, cardiac, and neurologic impairments
2. Assess patient to includes medical, affective, cognitive, functional status, social support, economic,
and environmental aspects related to health
3. Manage areas of special concern such as falls and incontinence
4. Manage aspects of preventive medicine, including nutrition, oral health, exercise, screening,
immunization, and chemoprophylaxis against disease
5. Manage the appropriate interdisciplinary coordination of the actions of multiple health professionals,
including physicians, nurses, social workers, dieticians, and rehabilitation experts, in the assessment
and implementation of treatment
6. Perform history and physical exam
7. Recognize and evaluate cognitive impairment
8. Treat and prevent iatrogenic disorders
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[HOSPITAL NAME]
[Hospital Address]
Family Medicine Clinical Privileges Source: Core Privileges for Physicians: A Practical Approach to
Developing and Implementing Criteria-based Privileges, Fifth Edition published by HCPro.
Name:
Effective from: ____/____/______ to ____/____/______
ACKNOWLEDGEMENT OF PRACTITIONER
I have requested only those privileges for which by education, training, current experience, and
demonstrated performance I am qualified to perform and that I wish to exercise at Hospital, and I
understand that:
a. In exercising any clinical privileges granted, I am constrained by Hospital and Medical Staff policies
and rules applicable generally and any applicable to the particular situation.
b. Any restriction on the clinical privileges granted to me is waived in an emergency situation and in
such situation my actions are governed by the applicable section of the Medical Staff Bylaws or
related documents.
Signature:
Date:
[DEPARTMENT CHAIR/CHIEF]'S RECOMMENDATION
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and make the following recommendation(s):
Recommend all requested privileges.
Recommend privileges with the following conditions/modifications:
Do not recommend the following requested privileges:
Privilege
1.
2.
3.
4.
Condition/Modification/Explanation
Notes
[Department Chair/Chief] Signature:
Date:
FOR MEDICAL STAFF OFFICE USE ONLY
Credentials Committee action
Medical Executive Committee action
Board of Trustee action
Credentialing, Recredentialing & Privileging Basics
Date:
Date:
Date:
56
Modified Core Example Family Medicine
Qualifications
To be eligible to apply for privileges in family medicine, the applicant must meet the following
criteria:
Training:
MD or DO with successful completion of an Accreditation Council for Graduate Medical
Education (ACGME) or American Osteopathic Association (AOA) accredited residency in family
medicine. (Does not apply to current medical staff appointees.)
Board Certification
One of the following requirements must be met:
1.
Current certification in family medicine by the American Board of Family Medicine or the
American Osteopathic Board of Family Physicians; or
2.
Actively seeking Board certification with achievement of certification within 1 year of
appointment.
Board certification requirements do not apply to any practitioner already a member of the
Medical Staff as of _____________________.
Required previous experience
Applicants for initial appointment or initial privileges must be able to demonstrate adequate
experience reflective of the scope of privileges requested in order for the medical staff to make
a reasoned decision regarding the competency of the practitioner.
Reappointment requirements
To be eligible to renew privileges in family medicine, the applicant must demonstrate current
demonstrated competence and an adequate volume of experience with acceptable results,
reflective of the scope of privileges requested, for the past 24 months based on results of
ongoing professional practice evaluation, monitoring through the Medical Staff Quality
Improvement Program, and patient care outcomes.
Privileges Requested
Applicant Instructions: Check off the “Requested” box for each privilege requested. Applicants
have the burden of producing information deemed adequate by the Hospital for a proper
evaluation of current competence, current clinical activity, and other qualifications and for
resolving any doubts related to qualifications for requested privileges. Your ability to perform
each procedure/privilege will be assessed. Requests for privileges not included on this form
should be made in writing and include documentation of training and experience. Please check
only the boxes reflective of your practice specific to this hospital. The procedures and
privileges listed on this form reflect what most physicians with specified training and
experience can request & the hospital can support.
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Referring Staff Category Privileges - Refer patients to the Hospital for outpatient
testing and/or procedures and refer patients to Active Staff members or Hospitalists for
inpatient treatment. (Referring Staff may visit their referred patients in the Hospital,
review patients’ medical records and receive information concerning patients’ medical
condition and treatment, but may not participate in any inpatient treatment or make any
entries in the medical record.)
Applicants for Refer and Follow category are not eligible to request additional privileges. Stop
here and review and sign the Acknowledgment section of this form.
Active Staff Privileges - > 2 patient admissions per month or > 24 per year
Courtesy Staff Privileges - < 2 patient admissions per month or < 24 per year
Consulting Staff Privileges - Evaluate, diagnose, treat, and provide consultation to
adolescent and adult patients on request of an Active or Courtesy Staff member.
Adult Medicine Privileges/Procedures - The privileges below include the specific procedure
requested and such other procedures that are extensions of the same techniques and skills.
Admit, evaluate, diagnose, treat, and provide consultation to adolescent and adult
patients; assess, stabilize, and determine disposition of patients with emergent
conditions consistent with medical staff policy regarding emergency and consultative call
services; provide care to patients in the intensive care setting; performance of history
and physical exam; care of the normal newborn and uncomplicated premature infant
equal to or greater than 36 weeks gestation.
Arthrocentesis and joint injection
Bone marrow aspiration/biopsy
Burns, superficial and partial thickness
I & D abscess
Local anesthetic techniques
Lumbar puncture
Manage uncomplicated minor closed fractures and uncomplicated dislocations
Osteopathic manipulative treatment using isotonic, isometric forces
Perform simple skin biopsy or excision
Peripheral nerve blocks
Placement of anterior and posterior nasal hemostatic packing
Remove nonpenetrating foreign body from the eye, nose, or ear
Suture uncomplicated lacerations
Vasectomy
Administration of Conscious Sedation and Analgesia
Additional Qualifications for Conscious Sedation and Analgesia:
 Initial applicants must complete Qualifying Examination for Sedation/Analgesia
 For recredentialing, must have performed a minimum of ten (10) cases per year
within the two (2) year reappointment period (total of 20 cases) OR must retake and
successfully pass the Qualifying Examination for Sedation/Anesthesia.
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Pediatric Privileges/Procedures - The privileges below include the specific procedure requested
and such other procedures that are extensions of the same techniques and skills.
Newborn Circumcision
I & D abscess
Lumbar puncture
Manage uncomplicated minor closed fractures and uncomplicated dislocations
Perform simple skin biopsy or excision
Remove nonpenetrating corneal foreign body
Suture uncomplicated lacerations
Administration of Conscious Sedation and Analgesia
Additional Qualifications for Conscious Sedation and Analgesia:
 Initial applicants must complete Qualifying Examination for Sedation/Analgesia
 For recredentialing, must have performed a minimum of ten (10) cases per year
within the two (2) year reappointment period (total of 20 cases) OR must retake and
successfully past the Qualifying Examination for Sedation/Anesthesia.
Gynecology Privileges/Procedures - The privileges below include the specific procedure
requested and such other procedures that are extensions of the same techniques and skills.
Biopsy of cervix, endometrium
Colposcopy
Cryosurgery/cautery for benign disease
Diagnostic cervical dilation and uterine curettage
Excision/biopsy of vulvar lesions
Incision and drainage of Bartholin duct cyst or marsupialization
Insertion and removal of intrauterine devices
Removal of foreign body from vagina
Suturing of uncomplicated lacerations
Uterine curettage following incomplete abortion
Obstetrical Privileges/Procedures- The privileges below include the specific procedure
requested and such other procedures that are extensions of the same techniques and skills.
Amniotomy
Attendance at delivery to assume care of normal newborns
Augmentation of labor
Cesarean section
D&C including suction and postpartum
Excision of vulvar lesions at delivery
External and internal fetal monitoring
Induction of labor, medical
Induction of labor, rupture of membranes
Initial management of post partum hemorrhage (PPH)
Investigative OB ultrasound for presentation only
Management of prenatal and postpartum care
Management of uncomplicated labor including normal spontaneous vaginal delivery or a
term vertex presentation
Manual removal of placenta, post delivery
Normal spontaneous vaginal delivery
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Oxytocin challenge test
Post partum endometritis
Pudendal anesthesia
Repair of episiotomy—first, second, and third degree
Repair of vaginal lacerations
Vacuum assisted delivery
Acknowledgement of Practitioner
I have requested only those privileges for which by education, training, current experience, and
demonstrated performance I am qualified to perform, for which my professional liability
insurance will cover, and that I wish to exercise at [Hospital Name]. I understand that:
a. In exercising any clinical privileges granted, I am constrained by Hospital and Medical Staff
policies and rules applicable generally and any applicable to the particular situation.
b. Any restriction on the clinical privileges granted to me is waived in an emergency situation
and in such situation my actions are governed by the applicable section of the Medical Staff
Bylaws or related documents.
c. If any privileges are covered by an exclusive contract or an employment contract,
practitioners who are not a party to the contract are not eligible to request the privilege(s),
regardless of education, training, and experience.
Signature:
_______________________________
Date: _________________
Department Chair's Recommendation
I have reviewed the requested clinical privileges and supporting documentation for the abovenamed applicant and make the following recommendation(s):
I recommend all requested privileges.
I recommend privileges with the following conditions/modifications (include explanation):
Privilege
Condition(s)/Modification(s)/Explanation
I do not recommend the following requested privileges (include explanation):
Privilege
Condition(s)/Modification(s)/Explanation
_______________________________________
Department Chair Signature
Credentialing, Recredentialing & Privileging Basics
___________________
Date
60
Work Sheet For Consideration of New Privilege
Name of procedure/privilege_________________________________________
Education required to request privilege (check all that apply)
MD - Medical Doctor
DO - Osteopathic Physician)
DDS - Oral and Maxillofacial Surgeon
DMD - Dentist
DPM - Podiatrist
APN – Advance Practice Nurse (specify specialty)______________________________
PA – Physician Assistant (specify specialty) ___________________________________
DC – Chiropractic
Other (specify) __________________________________________________________
Training Required:
Experience required
Additional Requirements:
CME
Manufacturer’s Training Course/Certificate
Board Certification
Peer Recommendations
Is monitoring or proctoring required?
No
Yes.
If yes, specify the following:
Number of procedures ___________
Length of time __________________
In order to complete proctorship/monitoring requirements, the applicant must perform
_______ (number) procedures within _____________(time frame).
What type of review or follow up will be conducted?
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STRUCTURED INTERVIEW QUESTIONS
Education, Training, Experience, and Current Work Practice and Experience
1.
2.
3.
Briefly explain your educational background and training.
Do you have any specific areas of interest or expertise? If so, explain.
Are there any areas of your practice for which you anticipate the hospital would need to purchase
additional equipment or would require additional training of staff should the hospital choose to provide
these services?
Systems-Based Practice
1.
2.
3.
4.
5.
Please describe the various health care delivery settings and systems in which you will be participating.
(i.e. outpatient surgical centers, other hospitals, etc.).
Describe how membership on the medical staff of [Hospital name] will develop or build your practice.
What percentage of your patient practice do you anticipate will be performed at [Hospital name]?
Describe your anticipated use of consultants.
Would you be available to provide patient education by participating in educational presentations,
development of educational materials, etc?
Understanding of Bylaws Requirements
(List key issues the medical staff or hospital feel need to be reinforced.)
1.
2.
3.
4.
Do you understand that the bylaws require you to provide for alternate coverage? Please describe the
arrangements you have made for alternate coverage.
Do you understand that the bylaws require continuous professional liability coverage of at least $1
million per claim and $3 million annual aggregate and if claims made insurance is purchased, you must
provide for the purchase of "tail coverage" or "nose coverage"?
Do you understand your responsibility for participating in the call rotation for providing care to
unassigned patients who present through the emergency department?
Do you understand the requirements for completion of medical records including automatic suspension
provision for incomplete records over ___ days old?
Follow-up of Information Received in Application Process
(List any issues identified in the application process that require clarification or discussion.)
1.
2.
3.
4.
Please discuss the details of any malpractice claims that have been filed against you.
A letter received from one of the hospitals you practiced at it the past documents that you experienced
a chronic problem with timely completion of medical records. Please describe the steps you are taking
to assure this does not happen at [Hospital name].
You noted in your application that you are not board certified. Have you applied to take the exam?
Have you taken the exam and failed?
You seem to have changed practice locations a number of times; can you explain the reason for these
moves
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DOCUMENTING RECOMMENDATIONS
Minutes Language
Sample language for medical staff minutes:
“Committee members reviewed the applications, the supporting documentation, the Department
Chairmen’s recommendations, and information received during the credentialing and privileging
processes [or insert OPPE/FPPE etc., as appropriate]. Based on this review, it is the committee’s
opinion that the following applicants meet the requirements for Medical Staff appointment and have
documented appropriate education, training, experience, current competency, clinical judgment,
professionalism, and health status to perform the privileges requested. It was moved, seconded, and
carried to recommend to the [fill in Credentials Committee or MEC as appropriate] approval of the
following appointments and clinical privileges [or insert cessation of FPPE, etc]:”
Sample language for Board minutes:
“Board members reviewed the applications, the supporting documentation, the Department
Chairmen’s recommendations, Medical Executive Committee’s recommendations, and information
received during the credentialing and privileging processes [insert OPPE/FPPE etc., as appropriate].
Based on this review, it is the Board’s opinion that the following applicants meet the requirements for
Medical Staff appointment and clinical privileges [insert cessation of FPPE etc., as appropriate] as
recommended and it was moved, seconded, and carried to approve of the following appointments
and clinical privileges [insert cessation of FPPE, etc]:”
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Recommendation and Approval Form for Medical Staff Appointment and Clinical
Privileges
Practitioner Name:____________________________________________________________________
Staff Status:__________________ Department:_____________________ Specialty:_________________________
Departmental Recommendation
Based on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant the
following recommendations are made:




Privileges be granted/renewed
Medical staff membership be granted/renewed
Additional privileges requested be granted
Privileges be modified as follows: _________________________________________________________________________
_____________________________________________________________________________________________________
 Privileges not be granted/renewed
 Medical staff membership not be granted/renewed (comment below)
 Additional privileges requested be denied (comment below)
Comments:
Department Chairman
Date
Credentials Committee Recommendation
Based on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant
and on the evaluations and recommendations of the Department Chairman the following recommendations are made:
 Concur with recommendation(s) of the Department Chairman and forward these recommendations to the Medical
Executive Committee
 Do not concur with the recommendations of the Department Chairman, and instead make the following recommendations:
___________________________________________________________________________________________________________
Credentials Committee Representative
Date
Medical Staff Executive Committee Recommendation
Based on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant,
and on the evaluations and recommendations of the Department Chairman and Credentials Committee, the following recommendations
are made:
 Concur with recommendation(s) of the Department Chairman and Credentials Committee and forward these
recommendations to the governing body for consideration.
 Do not agree with the recommendations of the Department Chairman, and Credentials Committee and instead make the
following recommendations: _________________________________________________________________________
Medical Staff Executive Committee Representative
Date
Governing Body Approvals/Action Taken
Based on the evaluation of the education, training, current competence, health status, skill, character, and judgment data and
information, and on the recommendations of the Medical Staff, the following action is taken:
 Concur with and approve the recommendation(s) of the Medical Staff.
 Do not concur with the recommendations of the Medical Staff. Action taken is documented in Board minutes of ________________.
(date)
Board of Trustees Representative
Credentialing, Recredentialing & Privileging Basics
Date
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UNDERSTANDING NEGLIGENCE IN CREDENTIALING
What is Negligence?
Negligence is defined as conduct that is culpable because it falls short of what a reasonable person
would do to protect another individual from a foreseeable risk of harm.
If the organization knew or should have known that a practitioner is not qualified and the practitioner
injures a patient through an act of negligence, the organization can be found separately liable for the
negligent credentialing of this practitioner.
Healthcare organizations have legal responsibility under a number of theories. Some have been held
liable for “negligent credentialing” or, the failure to adequately screen a practitioner through the
credentialing and privileging processes. There are at least 28 states which recognize the claim of
negligent credentialing.
But there are some other theories under which Health Care organizations are held liable.
Theories of Liability
In some states, negligent credentialing falls under the corporate liability or corporate negligence
doctrine. The premise of this theory is that a patient who enters a hospital does so with the
reasonable expectation that the hospital will attempt to cure him. The hospital has the duty to make a
reasonable effort to monitor and oversee the care and treatment prescribed and administered by the
physicians practicing in its property. A hospital’s responsibility also includes extending privileges only
to competent practitioners.
The governing body is given authority to make final decisions in credentialing matters. Although the
board may delegate an activity, such as oversight of those with independent privileges to the medical
staff, it maintains the ultimate responsibility for these decisions.
Respondeat Superior is a common-law doctrine that makes an employer liable for the actions of an
employee when those actions take place within the scope of employment. This doctrine is often
applied to contracted or employed practitioners.
Apparent or Ostensible Agency is a legal doctrine that is used to hold someone liable for the acts of a
third party because the third party looks like the agent of that person. This theory is frequently applied
to facility-based providers such as anesthesiologists and emergency physicians. The basis of this
theory is, the patient has no choice in choosing these practitioners therefore, they are felt to be an
agent of the hospital.
Elements of Negligence
The fact that someone did not credential someone adequately, in itself, does not mean that the
organization was negligent. For example, if an organization fails to verify a medical license for a
qualified and competent practitioner within the prescribed requirements of the accreditation
standards, this in itself is not negligence.
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Specific elements need to be present in order to establish negligence. There has to be a duty to
exercise due care, and that duty has to be breached. There has to be an injury, and the breach of
duty has to be the reason or “proximate cause” of the injury. Finally, the person bringing the charges
must establish that the injury resulted in compensable damages.
An easy way to remember elements of negligence are by remembering the “4 D’s”:
Deviation from Duty Directly causes Damages
Using the earlier example, suppose a Physician injured a patient, and it was found that this injury was
a result of negligence on the Physicians behalf. If it was found that the organization failed to verify
the license on initial appointment, and if it had done so, it would have found that the license was
suspended, then it can be reasonably assumed that, had the organization credentialed the Physician
appropriately, it would not have granted the Physician privileges. In this case it’s pretty easy to
connect the dots and see that the breach of the hospital’s duty to appropriately credential the
Physician could have resulted in the injury to the patient.
Duty to Exercise Due Care
Within the healthcare organization, the duty to exercise due care is defined in a number of ways.
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State licensing regulations may include requirements for adopting criteria and for granting medical
staff appointment and privileges.
Accreditation standards specify what kind of primary-source verification must be completed and
specify requirements for credentialing and privileging policies and procedures
Medical staff and facility bylaws, R&R, policies may include additional requirements above and
beyond regulations and accreditation standards.
Finally, case law may address due care in credentialing and privileging.
Examples of Breach of Duty
In many cases in which organizations are found to be negligent in credentialing, the facility has the
appropriate bylaws, policies and procedures, but fails to consistently apply the requirements. This
emphasizes the importance of knowing the requirements of your facility’s bylaws, rules and
regulations and policies.
Another potential for breach of duty is the failure to address concerns identified in the
credentialing/recredentialing process. Documentation in the credentials file should address all issues
or concerns identified in the credentialing or recredentialing process. For example, if a verification
letter comes back with a response that is different than the information provided on the application,
such as different affiliation dates, there should be documentation in the credentials file of how you
resolved this issue. In addition, medical staff and governing body minutes should document how
these bodies addressed concerns. For example, suppose you are recredentialing an applicant a find
that he was named in three medical malpractice suits since his last application. When your medical
staff reviews this, they determine that none of these cases have settled or been tried, so they feel that
there is no reason to not grant medical staff appointment and privileges based on outstanding cases.
There should be some documentation that this issue was discussed and addressed by the medical
staff.
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Finally, adopting credentialing policies and procedures or privileging criteria that do not reflect what a
reasonable hospital would do to protect a patient from a foreseeable risk of harm may also be
considered a breach of duty. For example, most hospitals verify all past medical staff appointments
for all initial applicants. This is not required by Joint Commission accreditation standards. The fact
that it is something that most hospitals do, means that it is the standard of care that all hospitals will
be held to. It’s essential that your policies meet the requirements of your organization’s accreditation
standards as well as state and federal regulations. If there is a difference between accreditation
standards and a state and Federal requirements, you always have to follow the strictest requirement.
When developing privileging criteria, the organization should take into consideration any guidelines
that have been published by professional organizations.
Setting a Precedent
A precedent-setting case is one which establishes a new legal principle. This principle is based on the
court coming to a certain conclusion based on a certain set of facts. This finding is thereafter
authoritative, meaning it is to be followed from that point on when similar or identical facts are before
a court.
Let’s take a look at some precedent-setting cases as well as some recent negligent credentialing
cases. These will give you a better idea of how the courts apply the duty to exercise due care in the
credentialing process.
Darling v. Charleston Community Memorial Hospital
This 1965 case is the very first case in which a hospital was found to be negligent in allowing a doctor
to practice at the hospital. Prior to this case, hospitals were looked upon as charitable organizations
and were immune from being sued under the Charitable Immunity Doctrine. This case set aside this
doctrine.
Darling was a football player who broke his leg during a game. He had his leg placed in a cast by the
on-call doctor, subsequently developed gangrene, and had to have his leg amputated below the
knee. The plaintiff claimed—and the court agreed—that the hospital was negligent for two reasons: it
failed to properly review the work of an independent doctor, and its nurses failed to administer
necessary tests. Darling held that the hospital bylaws, licensing regulations, and standards for
hospital accreditation were sufficient evidence to establish the standard of care. Therefore, a lay jury
was able to conclude from the evidence that the hospital had breached its duty to act as a reasonably
careful hospital.
Johnson v. Misericordia
In another negligent credentialing case – Johnson v. Misericordia Community Hospital, the hospital
was found to be liable to a patient injured by physician who had failed to disclose pending malpractice
cases and who lied about his privileges at other hospitals.
This action arose out of a surgical procedure performed at Misericordia by a Dr. Salinsky. Salinsky
unsuccessfully attempted to remove a pin fragment from Johnson’s right hip, and during surgery,
damaged the common femoral nerve and artery. This caused permanent paralysis of Johnson’s right
thigh muscles, atrophy, weakness, and loss of function.
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Johnson settled his claim against Salinsky for medical malpractice, and then sued the hospital
alleging negligence in hospital’s appointment of Salinsky to its medical staff and in granting him
orthopedic surgical privileges.
When completing his application, Salinsky stated that his privileges at other hospitals had never
“been suspended, diminished, revoked, or not renewed.” He also failed to answer any of the
questions pertaining to his malpractice insurance and stated that he had requested privileges only for
those surgical procedures in which he was qualified by certification.
The hospital did not verify the information on the application. Had they done so, they would have
found that Salinsky had experienced denial and restriction of his privileges, as well as never having
been granted privileges at the hospitals he listed in his application.
This information was readily available to Misericordia and if the hospital had credentialed Salinsky
appropriately, it would have been revealed that these hospitals had a concern regarding his
competency. In addition, if the hospital would have verified medical malpractice information, they
would have found that seven malpractice suits had been filed against Salinsky prior to his
appointment date.
The court in this case instructed the jury that “a hospital is under a duty to exercise reasonable care
to permit only competent medical doctors the privilege of using their facilities”. The court also stated
that reasonable care “meant that degree of care, skill, and judgment usually exercised under like or
similar circumstances by the average hospital”. Evidence in this case supported a finding that, had
the hospital exercised ordinary care, it would not have appointed Salinsky to its medical staff.
Recent cases
Now that we’ve discussed some precedent-setting cases let’s look at some recent cases.
Frigo v. Silver Cross Hospital
This in an Illinois case from 2007. In this case, the patient alleged that podiatrist Dr. Kirchner’s
negligence in performing a bunionectomy on an ulcerated foot resulted in osteomyelitis and
subsequent amputation of the foot.
When Dr. Kirchner applied for membership and Level II surgical privileges at the Hospital in 1992, a
podiatrist was required to have either completion of an approved surgical residency training program
or board eligibility or certification by the American Board of Podiatric Surgery. Dr. Kirchner did not
meet these criteria.
To complicate matters, in 1993, the hospital’s credentialing criteria was changed to require successful
completion of a 12-month podiatric surgical residency training program, passage of at least the
written portion of the board certification exam, and documentation of having performed a specific
number of procedures. For Level II surgical privileges, which included bunionectomies, a podiatrist
needed to document performing at least 30 procedures.
For every reappointment thereafter and at the time Dr. Kirchner performed the bunionectomy on Jean
Frigo, he had not satisfied these requirements. He had only performed six Level II procedures, none
of them at Silver Cross.
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Based on these facts, Frigo argued that Dr. Kirchner never should have been given Level II privileges
in the first place and certainly not in 1998, when he performed her surgery. Additionally, she
maintained that the granting of privileges to an unqualified practitioner who was never appropriately
grandfathered was a violation of the Hospital’s duty to ensure that only those podiatrists who met the
required criteria were granted Level II privileges.
Frigo claimed that the Hospital's breach of this duty caused her amputation because of Dr. Kirchner’s
negligence. The jury agreed and awarded her almost eight million dollars.
Larson v. Wasemiller
In August 2007, the Minnesota Supreme Court recognized, for the first time, that a cause of action
exists against a hospital for the manner in which a hospital credentials a physician to see patients
within that facility. The Larson case stemmed from a medical malpractice claim initially asserted
against two physicians who performed a gastric bypass surgery on the plaintiff, Mary Larson. Larson
experienced a number of complications and remained hospitalized for approximately three months.
After initially suing only the physicians, the Larsons amended their Complaint to include a claim that
St. Francis was negligent in credentialing Dr. James Wasemiller to perform surgery or see patients at
the hospital. They base this upon the fact that Dr. James Wasemiller had been the subject of ten
prior malpractice claims or lawsuits and had struggled to find malpractice insurance. He also had
been disciplined by the Minnesota Board of Medical Practice and had failed his board certification
examination three times before passing. Interestingly, they also claimed that the Physician should not
have been credentialed for reasons apart from his professional experience – namely, that he was
behind in his child support and income taxes. After a series of findings and appeals, the case
eventually made it to the Minnesota supreme court. The supreme court compared the tort of negligent
credentialing to one of negligent hiring and it concluded that negligent credentialing is “more directly
related” to the negligent selection of an independent contractor. The supreme court concluded in
favor of recognizing a negligent credentialing claim because “negligence could be shown on the basis
of what was actually known or what should have been known at the time of the credentialing
decision”.
Other Related Issues
There are couple other things that need to be considered when credentialing providers and those are
being sure not to give wrong information when answering verification requests and omitting key
information when answering verification requests.
One way this can be avoided it is by maintaining all information in the credentials file. If there is
important information that is not included in the credentials file, there should be some kind of cross
reference in the credentials file so that the people who respond to verification requests will know
where to find information. For example, I know of a case in which a Medical Services professional
provided information to another hospital that said that a Physician had resigned in lieu of termination.
Unknown to the Medical Services professional, the hospital had worked out a written agreement with
the Physician which stated that the hospital would reply to any verification letters with a statement
that the Physician had resigned in good standing. Unfortunately this information was not included in
the credentials file. When the Medical Services professional researched medical staff minutes to find
out what happened with the Physician, she only found reference to a recommendation for termination.
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The case of Kadlec Medical Center v. Lakeview Anesthesia Associates also is an example of what
can happen when wrong information is provided or pertinent information is omitted.
Kadlec v. Lakeview Anesthesia Assoc. and Lakeview Medical Center
According to court documents, Dr. Lee Berry was fired by Lakeview Anesthesia Associates for
reporting to work in an “impaired” condition in March of 2001. Here is a copy of the termination letter
which was signed four physicians, including Drs. Mark Dennis and William Preau, III.
The termination letter stated that Berry was being terminated “with cause” due to having “reported to
work in an impaired physical, mental, and emotional state” that prevented Berry from properly
performing his duties and put patients “at significant risk”.
After Berry was terminated by Lakeview Anesthesia Associates, he sought work as a locum tenens
physician which eventually landed him at Kadlec Medical Center in Richland, WA.
Kadlec had credentialed Dr. Berry, but the letters they received failed to disclose his impairments.
The letter from Dr. Dennis stated, “I have worked closely with Dr. Berry for the past four years. He is
an excellent clinician with a pleasant personality. I am sure he will be an asset to your anesthesia
service.” The letter from Dr. William Preau stated, “This is a letter of recommendation for Dr. Lee
Berry. I have worked with him here at Lakeview Regional Medical Center for four years. He is an
excellent anesthesiologist. He is capable and all fields of the anesthesia including obstetrics,
pediatrics, cardiovascular, and all regional blocks. I recommend him highly.”
The Kadlec hospital had also written to Lakeview medical center to confirm Dr. Berry’s appointment
there. They received a letter back that just gave the dates on staff. It was one of those letters that
said “due to the volume of requests that we receive, we are responding with this form letter.”
Dr. Berry was granted privileges at Kadlec Medical Center where, after a routine tubal ligation
procedure, he removed a patient’s breathing tube too early and she suffered a heart attack and
massive brain damage. This resulted in a multimillion-dollar lawsuit against the hospital. During the
course of discovery, these letters that you’ve seen here were provided to the plaintiff on order of the
court. Kadlec first learned that Dr. Berry had been terminated by his anesthesia group during
discovery for this case.
Kadlec sued Lakeview Anesthesia Associates and Lakeview Medical Center for failing to disclose
Berry’s known impairments. The hospital won its cases against both, but the appeals court reversed
the decision against Lakeview Medical Center.
Although the court found that the reference letters from Berry’s former partners were false and
patently misleading, it felt that Lakeview Medical Center’s letter was not materially misleading. The
court also found that, because Lakeview hospital did not have a legal duty to disclose its investigation
of Dr. Berry and its knowledge of his drug problems, the judgment against Lakeview Medical must be
reversed.
Decreasing the Chance
Making sure that Medical Services professionals and medical staff leaders are adequately trained is
very important. It is helpful for Medical Services professionals to be involved in their state and local
NAMSS chapters or to attend the NAMSS National conference. Medical staff leaders need to know
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what they’re getting themselves into when they say yes to taking on a job as a department chair,
credentials committee member, or medical executive committee member. They need to be trained in
their responsibilities in reviewing the qualifications of their peers. This can be something as simple as
sitting down with a department chairman and going over how to read a credentials file to something
more complicated, and costly, such as, bringing someone into the hospital to train medical staff
leaders or sending them to educational programs where they can receive intensive training about
their roles and responsibilities.
Be sure to get the Medical Staff involved in all phases of credentialing and privileging. It is essential
that your medical staff leaders review all information in the credentials file and, that they have
sufficient information on which to base a reasoned decision regarding the competency of the
practitioner.
Follow all policies, procedures, and bylaws. Many times, bylaws and procedures mirror language
contained in accreditation standards. Over time the accreditation standards change, and so we
change our practices to reflect the new accreditation standards. Sometimes, we neglect to make
appropriate changes to our bylaws and policies to reflect the changes resulting in a failure to follow
our own policies.
It is a good idea to audit bylaws, rules and regulations and policies to make sure they comply with
state regulations and accreditation standards. If you find that, in practice, you are doing something
that is not in compliance with bylaws, determine the basis for this bylaws requirement. If it is not
required by a corporate policy, accreditation standards, or state or Federal regulations, confer with
your legal counsel as to whether to change the bylaws to reflect your current practice. A good
example of this is many hospitals have a requirement for all physicians to be board certified or
actively participating in the board certification process. This is not required by state or Federal
regulations, or accreditation standards. But if the hospital has such a bylaws requirement, it must
follow and apply this requirement. If it finds it is making exceptions to this rule then it should consider
changing the requirement.
When making an effort to see that that only qualified, competent practitioners are providing patient
care services, the first line of defense is a thorough credentialing and privileging process that is
consistently applied. If the process is circumvented, the very safeguards which are put in place to
assure patient safety can be comprised.
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