CREDENTIALICREDENTIALING Where does NG Where does the Board fit in?the Board fit in?

Robert P. RedwineRobert P. RedwinePresident, Board of DirectorsPresident, Board of Directors

Blount Memorial HospitalBlount Memorial HospitalMaryville, TennesseeMaryville, Tennessee

At the top of a hospital’s At the top of a hospital’s organization is a governing organization is a governing board. The legal status of the board. The legal status of the board of any American board of any American corporation is relatively clear corporation is relatively clear in that the board functions as in that the board functions as the owner of the entity. So the the owner of the entity. So the board functions as the owner board functions as the owner and is accountable to the and is accountable to the community and/or the patients community and/or the patients that are treated at the that are treated at the hospital.hospital.

Joint Commission Joint Commission Leadership Standard Leadership Standard

LD.01.03.01LD.01.03.01

The governing body is ultimately The governing body is ultimately accountable for the safety and accountable for the safety and quality of care, treatment, and quality of care, treatment, and services.services.

The governing board The governing board delegates credentialing of delegates credentialing of the physicians and allied the physicians and allied health professionals to the health professionals to the Medical Staff. Medical Staff.

What is credentialing?What is credentialing?

Credentialing makes sure that the Credentialing makes sure that the healthcare provider is who they healthcare provider is who they say they are, they have been say they are, they have been trained to do the privileges they trained to do the privileges they are requesting, and they are are requesting, and they are physically able and competent to physically able and competent to do those privileges.do those privileges.

BOTTOM LINE:BOTTOM LINE:

Primary reason for Primary reason for credentialing—Patient credentialing—Patient

SafetySafety

MS.4.10 Credentialing MS.4.10 Credentialing ProcessProcess

Designed to ensure that patients receive Designed to ensure that patients receive care, treatment, and services from care, treatment, and services from qualified providersqualified providers

Follows the steps outlined in the bylaws or Follows the steps outlined in the bylaws or other documents as previously approved other documents as previously approved by the governing bodyby the governing body

Includes a mechanism to ensure that the Includes a mechanism to ensure that the individual requesting approval is the same individual requesting approval is the same individual identified in the credentialing individual identified in the credentialing documents by viewing current picture documents by viewing current picture hospital ID, valid state or federal IDhospital ID, valid state or federal ID

MS.4.10 Credentialing MS.4.10 Credentialing Process (Cont.)Process (Cont.)

Requires that the hospital verifies Requires that the hospital verifies in writing from the primary in writing from the primary source whenever feasiblesource whenever feasible Current licensure at the time of Current licensure at the time of

granting and renewal of privileges, granting and renewal of privileges, and at the time of and at the time of expiration/renewalexpiration/renewal

Relevant trainingRelevant training Current competenceCurrent competence

MS.4.15 Clinical PrivilegesMS.4.15 Clinical Privileges Privileges: “Authorization granted by the Privileges: “Authorization granted by the

appropriate authority (for example, the appropriate authority (for example, the governing body) to a practitioner to provide governing body) to a practitioner to provide specific care, treatment, and services in an specific care, treatment, and services in an organization within well-defined limits, organization within well-defined limits, based on the following factors, as based on the following factors, as applicable: license, education, training, applicable: license, education, training, experience, competence, health status, and experience, competence, health status, and judgment.”judgment.”

The decision to grant or deny a privilege(s), The decision to grant or deny a privilege(s), and/or renew an existing privilege(s), is an and/or renew an existing privilege(s), is an objective evidenced-based processobjective evidenced-based process

MS.4.15 Clinical Privileges MS.4.15 Clinical Privileges (Cont.)(Cont.)

The process for granting privileges The process for granting privileges includes:includes: Clearly defined procedure approved by Clearly defined procedure approved by

the organized medical staff for the the organized medical staff for the processing of applications for granting, processing of applications for granting, renewal, or revision of privilegesrenewal, or revision of privileges

The procedure is approved by the The procedure is approved by the organized medical stafforganized medical staff

Applicant submits information that no Applicant submits information that no health problems exist that could affect his health problems exist that could affect his or her ability to perform the privileges or her ability to perform the privileges requestedrequested

MS.4.15 Clinical Privileges MS.4.15 Clinical Privileges (Cont.)(Cont.)

The process for granting The process for granting privileges includes:privileges includes:

National Practitioner Data Bank National Practitioner Data Bank (NPDB) query (initially granted, (NPDB) query (initially granted, renewal of privileges, and when a renewal of privileges, and when a new privilege is requested)new privilege is requested)

Peer recommendationsPeer recommendations

MS.4.15 Clinical Privileges MS.4.15 Clinical Privileges (Cont.)(Cont.)

Before recommending to the Before recommending to the governing board that privileges be governing board that privileges be

granted, the Medical Staff Evaluates:granted, the Medical Staff Evaluates: Challenges to any licensure or regulationChallenges to any licensure or regulation Voluntary and involuntary relinquishment Voluntary and involuntary relinquishment

of any license or registrationof any license or registration Voluntary and involuntary limitation, Voluntary and involuntary limitation,

reduction, or loss of clinical privilegesreduction, or loss of clinical privileges Any evidence of an unusual pattern or an Any evidence of an unusual pattern or an

excessive number of professional liability excessive number of professional liability actions resulting in a final judgment actions resulting in a final judgment against the applicantagainst the applicant

MS.4.15 Clinical Privileges MS.4.15 Clinical Privileges (Cont.)(Cont.)

Before recommending to the Before recommending to the governing board that privileges be governing board that privileges be

granted, the Medical Staff evaluates:granted, the Medical Staff evaluates:

Documentation as to the applicant’s Documentation as to the applicant’s health statushealth status

Relevant practitioner-specific data as Relevant practitioner-specific data as compared to aggregate data, when compared to aggregate data, when availableavailable

MS.4.70 Peer MS.4.70 Peer RecommendationsRecommendations

Obtained from a practitioner in the same Obtained from a practitioner in the same professional discipline as the applicant with professional discipline as the applicant with personal knowledge of the applicant’s ability to personal knowledge of the applicant’s ability to practicepractice

Obtained/evaluated for all new applicants for Obtained/evaluated for all new applicants for privilegesprivileges

On renewal of privileges, when insufficient On renewal of privileges, when insufficient practitioner-specific data are available must be practitioner-specific data are available must be able to comment on:able to comment on: Medical/clinical knowledgeMedical/clinical knowledge Technical and clinical skillsTechnical and clinical skills Clinical judgmentClinical judgment Interpersonal skillsInterpersonal skills Communication skillsCommunication skills ProfessionalismProfessionalism

The governing board needs:The governing board needs:a Medical Executive a Medical Executive

Committee that is dedicated to Committee that is dedicated to quality patient carequality patient care

A Credentials Committee A Credentials Committee that is dedicated to quality that is dedicated to quality

patient carepatient care

Medical Staff Services Medical Staff Services personnel that are personnel that are

dedicated to quality patient dedicated to quality patient carecare

BECAUSE:BECAUSE:

Blount Memorial’s Blount Memorial’s Credentialing ProcessCredentialing Process

Pre-application to the Medical Staff Pre-application to the Medical Staff Services OfficeServices Office

Full application packet to the Medical Full application packet to the Medical Staff Services OfficeStaff Services Office

Verifications and competency Verifications and competency reviewed by Medical Staff Services reviewed by Medical Staff Services personnelpersonnel

Review of the complete file and Review of the complete file and signature by the Department Chairsignature by the Department Chair

Blount Memorial’s Blount Memorial’s Credentialing Process Credentialing Process

(Continued)(Continued) Review of the complete file and Review of the complete file and

signature by the Credentials signature by the Credentials CommitteeCommittee

Review of a summary of the Review of a summary of the complete file and signature by the complete file and signature by the Medical Executive CommitteeMedical Executive Committee

Review of a summary of the Review of a summary of the complete file and signature by the complete file and signature by the Board of DirectorsBoard of Directors

Blount Memorial’s Blount Memorial’s Credentialing Process Credentialing Process

(Continued)(Continued)Temporary Privileges may be granted if Temporary Privileges may be granted if

the file is complete, it fulfills the criteria the file is complete, it fulfills the criteria set forth in the Bylaws, and the chair of set forth in the Bylaws, and the chair of the Department and the chairs of the the Department and the chairs of the above Committees and the President of above Committees and the President of the Board reviews and gives their the Board reviews and gives their signatures for approval. The file must signatures for approval. The file must still go thru the above process, but the still go thru the above process, but the applicant will have temporary privileges applicant will have temporary privileges until the Board grants the applicant until the Board grants the applicant membership and privileges.membership and privileges.