The hospital credentialing and privileging process is complicated, and you likely have many questions. This FAQ guide provides a brief summary of the basics, including your role in the process and the hospital’s role. Note that details and individual requirements likely differ across hospitals, so be sure to secure and reference a copy of the hospital’s medical staff bylaws.
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.
Privileging is the process of authorizing a specific scope of practice for patient care based on credentials and performance.
Credentialing is the first step to vet a physician for hospital practice. Privileging authorizes a physician’s scope of practice.
Yes. Review the medical staff bylaws for a statement of duties and privileges in each category of medical staff (active or courtesy).
You may see the term active or admitting privileges. Applying for this type of hospital privilege signifies you will be eligible for appointment as medical staff. As part of the medical staff, you may admit to that hospital or medical center. Review medical staff bylaws for obligations in call etc.
The term courtesy privilege means you may either admit patients occasionally or may act as consultant. You will be ineligible to participate in medical staff activities. Review medical staff bylaws for obligations.
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.
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.
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.
The medical staff is self-governing and accountable to the hospital governing board.
Check the medical staff bylaws to make sure you meet the eligibility criteria before applying for privileges.
A delineation form is a form that assists the credentialing/executive committee in determining which privileges the applicant is qualified to obtain.
No. The selection of a delineation form is a local decision.
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:
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.
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:
The process requires verification of information provided, along with the initiation of a background check of the applicant.
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.
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.
Decision to grant, limit, or deny requested privileges are communicated to the physician within the time frame specified by the medical bylaws.
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.
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.
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.
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.