Credentialing and Privileging Your Hospital Medical Staff:

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Credentialing and Privileging


our Hospit

al Medical S

taff, Second Edition

Order Code: CPMS10

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

Joint Commission Resources (JCR) is an expert resource for health care organizations, providing consulting services, educational services, and publications to assist in improving quality and safety and to help in meeting the accreditation standards of The Joint Commission. JCR provides consulting services independently from The Joint Commission and in a fully confidential manner. Please visit our Web site at

Second Edition

Credentialing and Privileging

Your Hospital Medical Staff:

Examples for Improving Compliance

Joint Commission Resources (JCR), an affiliate of The Joint Commission, is the official publisher and educator of The Joint Commission.

1515 West 22nd Street, Suite 1300W Oak Brook, IL 60523-2082 U.S.A.

Credentialing and Privileging Your Hospital Medical Staff:

Examples for Improving Compliance, Second Edition

Free online extras for Credentialing and Privileging Your Hospital Medical Staff:

Examples for Improving Compliance,Second Edition, are available on Joint

Commission Resources Web site at The online extras feature examples used by organizations to ensure compliance with Joint Commission credentialing and privileging requirements.


Second Edition

Credentialing and Privileging

Your Hospital Medical Staff:


Senior Editor:Ilese J. Chatman

Project Manager: Andrew Bernotas

Manager, Publications:Diane Bell

Associate Director, Production: Johanna Harris

Executive Director:Catherine Chopp Hinckley, Ph.D.

The Joint Commission/Joint Commission Resources Reviewers:Diane Bell, Lynn Berry, Harold Bressler, John Herringer, Catherine Chopp Hinckley, Victoria Maripolsky, Derick Pasternak, Paul vanOstenberg

Joint Commission Resources Mission

The mission of Joint Commission Resources is to continuously improve the safety and quality of health care in the United States and in the international community through the provision of education, publications, consultation, and evaluation services.

Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process.

The inclusion of an organization name, product, or service in a Joint Commission Resources publication should not be construed as an endorsement of such organization, product, or service, nor is failure to include an organization name, product, or service to be construed as disapproval. The information presented in this publication should not be construed as providing legal advice with regard to any specific circumstances.

This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. Every attempt has been made to ensure accuracy at the time of publication; however, please note that laws, regulations, and standards are subject to change. Please also note that some of the examples in this publication are specific to the laws and regulations of the locality of the facility. The information and examples in this publication are provided with the understanding that the publisher is not engaged in providing medical, legal, or other professional advice. If any such assistance is desired, the services of a competent professional person should be sought.

© 2010 The Joint Commission

Joint Commission Resources, a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. Joint Commission Resources reproduces and distributes these materials under license from The Joint Commission. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Printed in the U.S.A. 5 4 3 2 1

Requests for permission to make copies of any part of this work should be mailed to Permissions Editor

Department of Publications Joint Commission Resources One Renaissance Boulevard Oakbrook Terrace, Illinois 60181 ISBN: 978-1-59940-390-8

Library of Congress Control Number: 2010921925


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


Approval Process ...47

Evaluation ...48

Required Peer Recommendation...49

Other Evaluation Methods...49

Nonphysician Providers ...51

Recredentialing ...51


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


Approval Process ...63


Conclusion ...64

Chapter 2: Focused and Ongoing Professional Practice Evaluation



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



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





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 Complianceprovides 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.



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 When the 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.


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.


Chapter 1


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.1As 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

Medical Staff Bylaws and


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



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