Examples for Improving Compliance, Second Edition
Developed for hospital medical staff, medical staff executive
committees, and governing boards, Credentialing and Privileging Your
Hospital Medical Staff: Examples for Improving Compliance, Second
Edition, identifies key responsibilities of the hospital, the organized
medical staff member, and the medical staff executive committee and
governing board in granting and reviewing clinical care credentials
and privileges. It also provides an assortment of examples for
improving or sustaining Joint Commission compliance and
thoroughly explains Joint Commission requirements for granting
and reviewing credentials and clinical privileges.
The following Joint Commission compliance strategies are featured:
• Developing the medical staff bylaws
• Applying for medical staff membership and privileges
• Verifying current licenses, education, training, and experience
• Assessing competency, appointments, and privileges
• Conducting the focused professional practice evaluation and
ongoing professional practice evaluation
• Addressing other credentialing and privileging requirements,
such as disaster privileging, temporary privileging, and
telemedicine issues
About Joint Commission Resources
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Commission. JCR provides consulting services independently from The Joint Commission and in a fully confidential manner.
Please visit our Web site at http://www.jcrinc.com.
Free online extras for Credentialing and Privileging Your Hospital Medical Staff:
Examples for Improving Compliance, Second Edition, are available on Joint
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The online extras feature examples used by organizations to ensure
compliance with Joint Commission credentialing and privileging requirements.
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Credentialing and Privileging Your Hospital Medical Staff, Second Edition
Credentialing and Privileging Your Hospital Medical Staff:
Credentialing and Privileging
Your Hospital Medical Staff:
Examples for Improving Compliance
Second Edition
Credentialing and Privileging
Your Hospital Medical Staff:
Examples for Improving Compliance
Second Edition
Senior Editor: Ilese J. Chatman
Project Manager: Andrew Bernotas
Manager, Publications: Diane Bell
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Executive Director: Catherine Chopp Hinckley, Ph.D.
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Victoria Maripolsky, Derick Pasternak, Paul vanOstenberg
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Table of Contents
Introduction ..................................................................................................vii
Overview of This Book ................................................................................................................vii
Acknowledgments ......................................................................................................................viii
Chapter 1: Medical Staff Bylaws and Credentialing and Privileging ........1
The Importance of Credentialing and Privileging ..........................................................................1
Legal Issues ....................................................................................................................................1
Legal Exposures ............................................................................................................................1
Confidentiality of Peer Evaluations................................................................................................2
Protection from Legal Exposure......................................................................................................3
Legal Challenge Alternatives..........................................................................................................3
Deemed Status Authority from the Centers for Medicare & Medicaid Services ............................4
Developing the Medical Staff Bylaws ............................................................................................4
Introduction to Standard MS.01.01.01 ........................................................................................4
The Organized Medical Staff ......................................................................................................16
The Organized Medical Staff Structure........................................................................................16
The Medical Staff Executive Committee......................................................................................17
Patient Outcomes ........................................................................................................................17
Professional Performance Experience and Competency................................................................18
Credentials Requirements ............................................................................................................18
Hospital Medical Staff Credentialing and Privileging ..................................................................19
The Credentialing Process ..........................................................................................................19
Verification of Current Licensure ................................................................................................22
Verification of Education and Training........................................................................................22
Applying for Medical Staff Membership and Privileges................................................................22
Presenting Evidence ....................................................................................................................23
Consenting to Inspection ............................................................................................................25
The Privileging Process ................................................................................................................38
Criteria......................................................................................................................................46
Approval Process ........................................................................................................................47
Evaluation ................................................................................................................................48
Required Peer Recommendation ..................................................................................................49
Other Evaluation Methods ..........................................................................................................49
Nonphysician Providers ..............................................................................................................51
Recredentialing ............................................................................................................................51
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Credentialing and Privileging Your Hospital Medical Staff: Examples for Improving Compliance, Second Edition
Temporary Clinical Privileges ......................................................................................................53
Granting Temporary Privileges ....................................................................................................57
Important Patient Care Needs for Temporary Clinical Privileges....................................................57
Awaiting Review and Approval for New Applicants......................................................................57
Streamlining the Processes for Credentialing and Privileging ......................................................62
Criteria......................................................................................................................................63
Approval Process ........................................................................................................................63
Ineligibility ................................................................................................................................63
Conclusion ..................................................................................................................................64
Chapter 2: Focused and Ongoing Professional Practice Evaluation
Processes..................................................................................................65
Benefits........................................................................................................................................65
Focused Professional Practice Evaluation Process ........................................................................65
The Organized Medical Staff Responsibilities ..............................................................................72
Performance-Monitoring Process ..................................................................................................73
Common Triggers........................................................................................................................74
Challenges with the System..........................................................................................................74
Ongoing Professional Practice Evaluation ....................................................................................75
Ongoing Professional Practice Trends That Impact Patient Safety ..................................................75
What Process to Use? ..................................................................................................................76
What Data to Collect? ................................................................................................................76
Conflicting Recommendations......................................................................................................76
Adverse Privileging Decisions ......................................................................................................77
Use of Information ....................................................................................................................77
Fair Hearing and Appeal ............................................................................................................77
Conclusion ..................................................................................................................................78
Chapter 3: Continuing Education and Practitioner Health
Compliance ..............................................................................................81
Monitoring Data ........................................................................................................................81
Hospital-Sponsored Classes..........................................................................................................82
Making Arrangements for Staff Education ..................................................................................83
Digital Technology ......................................................................................................................84
Electronic Performance Support Systems ......................................................................................84
Education and Performance Improvement Data ..........................................................................84
Documenting Continuing Education ..........................................................................................85
Practitioner Health ......................................................................................................................85
Providing Health Education........................................................................................................87
Identifying Health Issues Through Referral and Self-Referral ........................................................87
Confidentiality ..........................................................................................................................87
Process/Policies for Helping Practitioners ......................................................................................88
Monitoring and Reporting to the Medical Staff ............................................................................88
Conclusion ..................................................................................................................................89
iv
Table of Contents
Chapter 4: Additional Credentialing and Privileging Compliance
Responsibilities ........................................................................................91
Emergency Management Disaster Privileges ................................................................................91
Hospital Responsibilities ..............................................................................................................92
Medical Staff Responsibilities ......................................................................................................92
Granting Privileges ....................................................................................................................97
Identification ............................................................................................................................97
Oversight ................................................................................................................................105
Human Resource Requirement..................................................................................................105
Verification and Documentation................................................................................................105
Credentials Verification Organization........................................................................................106
Criminal Background Check ....................................................................................................106
Health Screening ......................................................................................................................106
Challenges with Contractual Agreements ..................................................................................106
Telemedicine Link ....................................................................................................................106
Interpretive Services via Telemedicine Link ................................................................................110
Off-Site Services ......................................................................................................................110
Contracted Services Requirements ............................................................................................110
Recommendations ....................................................................................................................111
Nature and Scope of Services ....................................................................................................111
Monitoring and Evaluating Contracted Services ........................................................................112
Conclusion ................................................................................................................................113
Appendix ....................................................................................................115
Glossary ......................................................................................................141
Index ............................................................................................................151
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Credentialing and Privileging Your Hospital Medical Staff: Examples for Improving Compliance, Second Edition
vi
Introduction
T
he Joint Commission’s medical staff credentialing and privileging requirements continue to be
challenging standards for hospitals. This updated edition of Credentialing and Privileging Your
Hospital Medical Staff: Examples for Improving Compliance provides a thorough discussion of The
Joint Commission standards and requirements as they relate to credentialing, privileging, and
competency. It also includes discussions on hospital medical staff credentialing and privileging issues
and topics.
In addition, this book includes examples of how hospitals have successfully implemented their
policies and procedures. Some of the forms in the book may apply to your hospital; others may not.
All hospitals must create their own processes, policies, and forms that are suitable to their
organizations’ specific needs. The examples in this book are intended to serve ony as a reference
point.
Overview of This Book
Chapter 1, “Medical Staff Bylaws and Credentialing and Privileging,” discusses the application
process for medical staff membership and the credentialing and privileging processes. It reviews the
relevant Joint Commission requirements and provides detailed discussions of how hospitals can
manage compliance strategies. In addition, a thorough discussion of the new Standard MS.01.01.01
is also provided.
Chapter 2, “Focused and Ongoing Professional Practice Evaluation Processes,” details the benefits of
professional practice evaluations and includes approaches to overcoming common pitfalls to conducting
effective evaluations. Managing adverse privileging decisions and compliance issues is also discussed.
Chapter 3, “Continuing Education and Practitioner Health Compliance,” provides guidance on how
education activities should be considered when making decisions about reappointing medical staff,
recredentialing, and renewing clinical privileges. This chapter also outlines requirements for the
development of physician health policies.
Chapter 4, “Additional Credentialing and Privileging Compliance Responsibilities,” focuses on other
hospital requirements associated with the credentialing and privileging process. This chapter includes
compliance information about emergency management disaster privileges, human resources
requirements, and contracted services requirements associated with credentialing and privileging.
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Credentialing and Privileging Your Hospital Medical Staff: Examples for Improving Compliance, Second Edition
In addition, Online Extras are available on Joint Commission Resources’ Web site at
http://www.jcrinc.com/CPMS10/Extras/. When the nline extras symbol is found with an
example, the example can also be found on the Web site for free access.
For current standards, requirements, and scoring guidelines check the current edition of the
Comprehensive Accreditation Manual for Hospitals: The Office Handbook. This book reflects
requirements effective as of its publication in August 2010.
Acknowledgments
The Joint Commission and Joint Commission Resources gratefully acknowledge the following
organizations for contributing examples for this book:
• Carson-Tahoe Hospital, Carson City, Nevada
• Department of the Navy, Portsmouth, Virginia
• Holland Hospital, Holland, Michigan
• Methodist Healthcare, Memphis
• Migrant Clinicians Network, Austin, Texas
• Saint Francis Health System, Greenville, South Carolina
• Silver Cross Hospital, Joliet, Illinois
• Stanford Hospital and Clinics Lucille Packard Children’s Hospital, Palo Alto, California
• University of California, San Diego
• Washington State Department of Health, Tumwater, Washington
• Wisconsin Hospital Association, Madison, Wisconsin
• Yale-New Haven Hospital, New Haven, Connecticut
We also thank the following reviewers for their valuable input in making this book possible: Diane
Bell, Lynn Berry, Harold Bressler, John Herringer, Catherine Chopp Hinckley, Victoria Maripolsky,
Derick Pasternak, and Paul vanOstenberg.
Special thanks to Julie Henry for her patience and diligence in updating this book.
viii
Chapter 1
Medical Staff Bylaws and
Credentialing and Privileging
P
ractitioners all share one common goal—to provide safe, high-quality patient care. To achieve
that goal, any medical staff or governing body must make evaluating and assessing practitioner
competency a top priority. This chapter discusses current issues and processes in credentialing and
privileging.
The Importance of Credentialing and Privileging
The importance of credentials review and privileging cannot be overstated. When a patient enters a
hospital, he or she has the right to receive care from competent practitioners.1 As hospitals seek to
provide high-quality care and to ensure patient safety in a rapidly changing environment, the medical
staff credentials review and privileging functions become increasingly important.
The credentialing and privileging process involves a series of activities that are designed to collect, to
verify, and to evaluate data (and/or events) that are relevant to a practitioner’s professional
performance and serves as the foundation to providing care, treatment, or services to a patient.
The following section is not intended and should not be construed as providing legal advice with
regard to any specific circumstances. Legal issues surrounding credentialing and privileging are
presented here for consideration.
Legal Issues
Credentialing and privileging activities are interwoven into consideration of certain important legal
issues. These legal issues center on the following four concerns:
1. Legal exposure for a hospital that negligently conducts credentialing and privileging activities
2. Protection of confidentiality of peer review activities involved in credentialing and privileging
3. Protection from legal exposure for those who engage in the credentialing and privileging process
4. The legal challenge alternatives available to those who believe they have been unfairly treated in
the credentialing and privileging processes
Legal Exposures
An understanding of the legal concept of negligent credentialing, a relatively recent concept that arose in
the 1960s, requires an understanding of the legal exposures to patients of hospitals and individual
practitioners who are not employees of the hospital. Hospitals are responsible for the mistakes in patient
care made by their employees. However, with regard to individual practitioners who are not employees, a
hospital is not responsible for the mistakes of such practitioners to which its employees did not
contribute. Notes Harold J. Bressler, General Counsel for The Joint Commission, “Even if the hospital’s
employees did contribute to the mistake, there is now a widely accepted concept of contributory
negligence. This means the hospital could be legally responsible only for that portion of the damages
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Credentialing and Privileging Your Hospital Medical Staff: Examples for Improving Compliance, Second Edition
represented by the significance of its contribution to the mistake. In other words, a physician stands
alone for his or her mistake, unless the hospital contributed to the mistake.”
Beginning in the 1960s, a legal doctrine was developed that, as a practical matter, made an exception
to this rule. The doctrine is known as negligent credentialing, and it refers to the possibility of a
hospital negligently placing a physician in the position to engage in an activity made defective by the
mistake. In other words, through the credentialing and privileging processes, the hospital determines
what a physician can do in treating patients within its organization. Negligence in making
credentialing and privileging decisions is directly related to placing the physician in the position to
make an injurious mistake and has been recognized as a separate ground for liability of the hospital.
The courts in dealing with a negligent credentialing claim will not engage in a complete second-guessing
of the judgments made by the hospital. “The courts understand that the experts in the credentialing and
privileging process are the health care professionals. However, a court will look to see whether a hospital
acted in good faith and followed appropriate procedures,” states Bressler. “It should be clear that for
purposes of this potential legal exposure, the courts do not make any distinction between a hospital and
its medical staff. The hospital as a whole incurs the legal exposure, albeit, there has been discussion of the
possibility of separate exposure for the medical staff if the applicable state law recognizes the medical staff
as a separate legal entity,” notes Bressler. Therefore, this legal doctrine supports the approach of law,
regulation, and accreditation standards that the medical staff must be accountable to the governing body
for properly conducting the credentialing and privileging processes and that the governing body has an
oversight responsibility for the activities of its medical staff. This does not mean the governing body has
the responsibility to review all the details of individual credentialing and privileging recommendations;
but, rather, the responsibility to take the action necessary to provide it with confidence that the
recommendations made by the medical staff reflect the exercise of reasonable judgment being made in
good faith and based on appropriate information. Hospitals working with their counsel need to think
through whether their credentialing and privileging activities support this conclusion and how those
activities should be documented.
Confidentiality of Peer Evaluations
The next legal issue of substantial importance to the credentialing and privileging processes is the
issue of the confidentiality of the peer review evaluations made in connection with those processes.
Particularly, the issue arises as to whether the peer review activity is exempt from discovery in
litigation. Discovery, of course, means the right of parties to litigation to obtain relevant documents
and testimony from their opposing parties or by subpoena from others not parties to the litigation.
Currently, there is no federal-specific protection, or what is known as privilege, for such peer review
information. However, throughout the United States, state law provides for such protection with very
few exceptions. There is recognition that the most effective peer review can be discouraged if the
evaluation activity does not remain confidential, particularly with regard to attempts to discover such
information in connection with malpractice or liability actions claiming negligent treatment. The
theory of the protection is that plaintiffs in such cases can obtain their own experts and make their
own evaluations to present to a judge or jury and do not need to invade the peer review processes
that take place within the hospital. “A hospital should obtain counsel from an expert attorney in this
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Chapter 1: Medical Staff Bylaws and Credentialing and Privileging
area to make sure that its credentialing and privileging processes meet the requirements set forth in
the applicable state law for peer review protection,” notes Bressler.
Protection from Legal Exposure
A different question is whether, without regard to the confidentiality of peer review activities, such
activities can be utilized as evidence in litigation or be the basis of claims against individual
participants in the peer review process and organizations conducting those processes. There is a
federal law dealing with this issue, and that law, the Health Care Quality Improvement Act of 1986,
provides that if a hospital acts in good faith and follows fair procedures, as spelled out in the statute,
the hospital and the participants in the peer review process obtain immunity from litigation both in
federal courts and in state courts. This Act has been applied very effectively to protect good faith peer
review activity. There is also relevant state law throughout the United States dealing with this issue.
Legal Challenge Alternatives
Finally, this leads to the issue of what rights to challenge, if any, are available to a physician or other
practitioner who believes he or she has been unfairly treated in the credentialing and privileging process.
Much of what is discussed previously with respect to the first three issues is also relevant here. As
discussed later in this book, there is some controversy as to how often any such abuse occurs, and
whether this is a significant problem. As also suggested previously, the potential for successful legal
challenges to peer review activity is very limited. Again, courts will not retry the medical staff’s quality
and safety judgments. A challenger argument, as a practical matter, is essentially limited to attempts to
prove bad faith or a failure to follow hospital procedures as established by medical staff bylaws.
What does all this mean? Historical tradition, professional responsibility, and applicable law,
regulation, and accreditation standards all call for engaging in effective credentialing and privileging,
and there is potential legal exposure for failing to do so. But asking professionals to participate
effectively and as best they can in such evaluations of others is to ask them to accept a burden that
can become personally unpleasant.
Practitioners may also find uncompelling fully logical explanations of the remoteness of any possible legal
issue and demand that which cannot be given an ironclad guarantee of no legal issues arising. They may
also, as legal laymen, make the mistake of “practicing law” and develop their own legal analysis without
the benefit of counsel. Therefore, it is important for hospitals to be sensitive to those concerns and think
about potential mechanisms to deal with them. At the same time, it is essential that legal thinkers and
the legal system, including academics, practicing lawyers, legislatures, and judges, think about the need
for rules and approaches to applicable law that encourage effective credentialing and privileging to the
benefit of the public. All of these professionals, however, should also consider whether there is anything
appropriate to do beyond what exists today, that is not inconsistent with encouraging effective
credentialing and privileging, to deal with any possible cases of credentialing and privileging abuse.
Finally, it should be clear that medical staff bylaws and their development are critical to the legal
issues discussed previously. Thus, the following discussion is particularly relevant to the legal analysis
presented previously.
3