• Factors that Impact Hospital Credentialing and Privileging Decisions

    Medicare legislation specifies that hospitals participating in the Medicare program must meet certain requirements. Conditions of Participation (CoP) and Conditions for Coverage (CfCs) were developed by the Centers for Medicare & Medicaid Services (CMS) for health care organizations to participate in Medicare and Medicaid programs and receive reimbursement. Among the CoP are standards related to compliance with federal, state, and local laws, the governing body, and the medical staff.
    Within the CoP, is the requirement of an effective hospital governing body. The governing body is legally responsible for the conduct of the hospital. Functions of the governing body include standards for the medical staff. Within these standards are the medical staff composition, organization, accountability, and bylaws, including the following:  

    • Determine, in accordance with state law, which categories of an individual credentialed within a recognized health care discipline, and are involved in providing the services of that discipline to patients.
    • Appoint members to the medical staff, after consideration of the recommendations from the existing medical staff membership.
    • Ensure the medical staff has bylaws.
    • Medical staff bylaws and other medical staff rules and regulations are approved by the medical staff.
    • Medical staff are accountable to the hospital governing body for the quality of care provided to patients.
    • Medical staff are self-governed.
    • Confirm the criteria for selection includes individual character, competence, training, experience, and judgment.
    • Under no circumstance is the accordance of staff membership or professional privileges in the hospital solely dependent upon certification, fellowship, or membership in a specialty body or society.  

    Medical Staff Composition

    The hospital must have an organized medical staff composed of doctors of medicine or osteopathy, and within state law may include other categories of non-physician practitioners who are determined to be eligible for appointment by the governing body. The process for appointment of medical staff must be in accordance with state laws and include scope-of-practice laws.

    Medical Staff Eligibility

    The medical staff must examine the credentials of all eligible candidates for medical staff membership. Recommendations are made to the governing body on the appointment of these candidates. Any candidate recommended by the medical staff who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations. Periodically, the medical staff must conduct appraisals of its members. Objective, evidence-based criteria, and decisions are used to grant or deny a privilege or renew existing privileges.

    Medical Staff Organization and Accountability

    The medical staff must be organized in a manner endorsed by the governing body for the quality of care provided to patients. If the medical staff has an executive committee, a majority of this committee must be doctors of medicine or osteopathy. The responsibility or organization and conduct of the medical staff must be assigned to one of the following:

    • An individual doctor of medicine or osteopathy;
    • A doctor of dental surgery or medicine, when permitted by state law of the state in which the hospital is located; or
    • A doctor of podiatry when permitted by state law of the state in which the hospital is located.  

    Medical Staff Bylaws

    The bylaws describe the medical staff‘s organizational responsibility, and how the medical staff and governing body will work together. Medical staff bylaws and criteria include:

    • Approval by the governing body
    • Statement of duties and privileges of each category of medical staff
    • Description of the medical staff organization
    • Description of the qualifications met by a candidate, in order for the medical staff to recommend the candidate be appointed by the governing body
    • Criteria for determining privileges granted to an individual practitioner, and a procedure for applying criteria to individual requesting privileges