Hospital Credentialing and Privileging FAQs

What is credentialing?

Credentialing is the process of verifying qualifications to ensure current competence to grant privileges. The term credentialing involves verification of education, training, experience, and licensure to provide services.

What is privileging?

Privileging is the process of authorizing a specific scope of practice for patient care based on credentials and performance.

Which comes first, credentialing or privileging?

Credentialing is the first step to vet a physician for hospital practice. Privileging authorizes a physician’s scope of practice.

What is a hospital governing board?

A set of individual(s) or a group that has ultimate authority and responsibility for establishing policy, quality of care, treatment, or service, and provides the organizational management and planning.

What are medical staff bylaws?

Medical staff bylaws are documents created by medical staff and approved by the hospital governing board describing the rights, responsibilities, and accountability of the medical staff. The bylaws describe a hospital’s organization, structure, and rules for its self-governance.

Who can be on the medical staff?

Medical staff must include medical doctors (MDs and DOs). In accordance with state laws, including scope-of-practice laws, medical staff may include other categories of physicians, as well as non-physician practitioners privileged through a medical staff process.

What is the relationship between the medical staff and the hospital governing board?

The medical staff is self-governing and accountable to the hospital governing board.

What is my first step to obtain privileges?

Check the medical staff bylaws to make sure you meet the eligibility criteria before applying for privileges.

What is a delineation form?

A delineation form is a form that assists the credentialing/executive committee in determining which privileges the applicant is qualified to obtain.

Are delineation forms standard for all hospitals?

No. The selection of a delineation form is a local decision.

If I meet eligibility criteria, what are the steps for credentialing?

Contact the medical staff credentialing office to obtain a list of the required documents with the method of submission. This information typically includes the following:

  • Provide documentation of education, training, experience, current competence, board certification, state licensure, and malpractice liability certificate. Providing a curriculum vitae (CV) will help distinguish you as an individual.
  • Collect letters of recommendation from past instructors, preceptors, those who have monitored your clinical work, and colleagues who have worked with you.
  • Assemble case reports, including data about the number and types of cases, treatment outcomes, etc., and documentation records maintained during your family medicine residency.

Your complete documentation, case reports, and letters of recommendation should be in order at the time you fill out your applications for privileges. Include all contact information from previous facilities. The hospital may only require that you submit a list of references. However, these additional materials should be readily available upon request.

It is important that you make a copy of each document you submit if the original documents are lost or misplaced. Keep track of dates of submission. Ongoing documentation of your clinical experiences should be maintained.

How is competence measured?

The framework to measure a physician’s competency is modeled after the Accreditation Council for Graduate Medical Education (ACGME)(www.acgme.org) and American Board of Medical Specialties (ABMS). The six areas of general competency are:

  • Patient care
  • Medical clinical knowledge
  • Practice-based learning and improvement
  • Interpersonal and communication skills
  • Professionalism
  • System-based practice

What is the next step in the credentialing process?

The process requires verification of information provided, along with the initiation of a background check of the applicant.

When the credentialing process is complete, do I have hospital privileges?

No. The next step is a review by the medical staff. The decision to grant or deny privilege(s) is an objective evidence-based process.

Is there recourse if I do not meet eligibility criteria?

If you do not meet the criteria, you will rarely qualify for the appeal and due process remedies of your hospital medical staff bylaws. Your best option may be to work within your local medical staff structure to change the eligibility criteria.

When can I expect notification of privileges?

Decision to grant, limit, or deny requested privileges are communicated to the physician within the time frame specified by the medical bylaws.

Once privileging is obtained, is there anything else I need to know?

Periodically (no less frequently than every 24 months in the absence of state law), requires conduct appraisals of individual physicians for continued or revised hospital privileges.

Are conduct appraisals only for physicians who have newly granted privileges?

No. The focused professional practice evaluation (FPPE) is the process to confirm a physician’s current competence at the time new privileges are granted. FPPE is more frequent with more intense monitoring than ongoing professional practice performance (OPPE). The OPPE begins when competency is established. This process includes the ongoing assessment of existing medical staff performance.  

Do I really need to review the medical staff bylaws?

Yes. Pay close attention to this information, as any item within the bylaws may directly impact you now or in the future. Often, you may be required to sign and date that you have read, understand, and will comply with the medical staff bylaws.

Does the AAFP have any policies on privileging?

Yes. Several policies are available for members. The information may be found here by searching for a policy or select the links at the bottom of this page.