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Keys To Navigating The Hospital Credentialing And Privileging Process

Podiatric physicians can reap valuable benefits from an association with a hospital although attaining privileges can be a daunting process. This author explains how credentialing and privileging at hospitals work, detailing what is expected of physicians throughout the process to make for a smooth transition.

The thought of joining a new hospital system as a podiatric physician ought to be exciting and exhilarating, especially since the benefits are numerous. These may include an increase in the referral base, additional patient volume, professional networking and so on. Instead, what most clinicians initially experience is irritation with the lengthy credentialing process. This certainly does not have to be the case.

You can easily avoid long delays and unnecessary frustration with the hospital credentialing process with a clearer understanding of the process in addition to adequate planning and preparation.

The Joint Commission on the Accreditation of Hospitals, which was later renamed the Joint Commission, was established in 1951 to provide independent oversight of hospitals and ultimately to further enhance the overall quality in hospitals. In 1953, the Joint Commission created the first accreditation standards manual, which required hospitals to establish credentialing committees to review physician competence.1

Once the Joint Commission has reviewed and accepted a physician’s credentials, he or she receives clinical privileges to work in the hospital. Current credentialing standards include a review of practitioner licensure, relevant training or experience and competence as determined by the individual institutions no less frequently than every 24 months.2  

Whether you are a seasoned physician who is relocating or a new physician who recently completed residency or fellowship, the same rule applies: you cannot be on staff at any hospital without successfully completing the credentialing process. Often, we erroneously use the words “credentialing” and “privileging” interchangeably. They are not the same. Credentialing refers to a hospital’s due diligence with regard to primary source verification, which includes education, training, work experience, etc.3 Alternatively, privileging relates to granting approval to practice in a hospital and perform a specific set of competencies or procedures that are typically based on documented competency.

How The Credentialing Process Works

Though all hospitals must follow their own specific bylaws in regard to credentialing, the process is relatively similar at most institutions. After receiving an application, the medical staff office begins the primary source verification. Essentially, the staff’s job is to confirm that you are who you say you are in regard to education, training and work experience. Once the verification is complete, the application and file go to the Department Chair or Section Chief for review. Depending on the hospital, this part of the process may involve a face-to-face meeting or telephone call with the Department Chair or Section Chief.

Once the application and file are approved by the Department Chair or Section Chief, a Credentialing and Privileging Committee completes the file review process while taking the clinician’s requested privilege into account. When all those steps are complete, the Medical Staff Executive Committee typically grants temporary privileges and subsequently full privileges.

With all those steps involved with hospital credentialing, it should come as no surprise that strategic planning and timing are of great importance. Additionally, hospital bylaws typically mandate the frequency of committee meetings. Some committees meet once a month while others may meet once a quarter and so on. Knowing this information can prove to be vital when submitting your credentialing application in a timely fashion for consideration. For instance, if the hospital credentialing committee meets on the first Monday of every other month and you happen to miss this deadline by one day, then your application will essentially sit and wait until the next meeting. This translates into an easily avoidable delay in your application. When obtaining your initial appointment application, it certainly helps to inquire as to when and how often the committee meets. The medical staff office should easily be able to provide this information.   

The initial process of primary source verification by the medical staff office is usually fraught with frustration and delays, most of which are preventable. One of the most common delays involves state licensure. Ironically, it is also one of the most avoidable delays with appropriate planning and due diligence on the applicant’s part.

The following lists some of the most common requested documents during the credentialing process. Anticipate that the hospital will request some combination of the following documentation.

• State license
• DEA certificate
• ACLS/BLS certification
• Board qualification/certification status
• Surgical logs
• 10 year insurance claims report
• Updated curriculum vitae
• Professional reference(s)
• Immunization records
• School diploma
• Residency diploma
• Driver’s license
• Social Security card
• Documentation of hospital privileges

The requirements for podiatric physician licensure differ greatly by state. You can prevent many headaches and much agony by looking into the requirements prior to the hospital credentialing process. Some states require a straightforward application and fee, which results in a shorter turnaround time.

Other states, however, may require podiatric examinations or jurisprudence exams, which will take more planning on the applicant’s part. For example, the North Carolina Board of Podiatry Examiners requires all physicians pass a written and oral examination prior to conferring any new licenses. Some additional requirements may include advanced cardiac life support (ACLS), basic life support (BLS), FBI fingerprinting and background checks, opioid training, and child abuse training.

Timing is imperative. Any delays in obtaining your state licensure may result in an incomplete credentialing application, which translates into further delays.

In addition to state licensure delays, some of the most common “red flags” noted by the medical staff office include the following items: gaps in training and/or hospital affiliation, skipped questions on the medical staff application form, inconsistencies with application dates in comparison to verifications received, and a lack of the required number of peer references. Should any of those apply to you, be prepared to provide some sort of written explanation. By recognizing the importance of timing and planning with regard to the credentialing process and the paperwork involved, physicians can avoid many unnecessary delays and headaches.

How Hospitals Grant Privileges To DPMs

Granting privileges is one of the most basic tenets related to a hospital’s inherent responsibility to provide safe medical care to the public. The hospital must exercise due diligence when evaluating potential practitioners and awarding clinical privileges to physicians who serve on their hospital staff as cases of neglect may result in catastrophic outcomes. This process was first formalized in the early 1900s when the American College of Surgeons identified a minimum standard for practicing medicine in hospitals in order to exclude incompetent or unethical practitioners.

Again, privileging goes hand in hand with credentialing but at times, physicians may erroneously use these terms interchangeably. Privileging specifically relates to granting approval to perform a certain procedure, which is typically based on documented competencies set forth by the institution. Credentialing involves primary source verification including education, training, work experience, etc.  

Although standards for the credentialing and privileging of practitioners keep evolving, one central, underlying aspect must remain constant: the pursuit of excellence for the sake of patients. The need for an objective and evidence-based process for monitoring performance is equally crucial. As a profession providing essential services to the public, individual members of the podiatric medical community accept the responsibility to maintain and enhance their clinical skills and surgical knowledge.

This often translates into required continuing medical education hours for licensure renewal. In fact, the standards from the Joint Commission that went into effect on January 1, 2017 require a process for intervening in identified safety and quality of care issues.4 This translates into a greater need to collect more detailed information about practitioners on an ongoing basis, which is a responsibility that ultimately rests within the individual hospitals.

Essentially, organizations will find themselves continuously collecting additional information about physician performance in order to comply with this standard. The process to collect this information will certainly differ from institution to institution. Individual hospitals need to define their own criteria and clarify which set of information they should collect to assist with their ongoing professional practice evaluation. As a general guideline, the Joint Commission states that the information to be collected may include any of the following: review of operative and other clinical procedures performed and their outcomes, pattern of blood and pharmaceutical use, requests for tests and procedures, length of stay patterns, morbidity and mortality data, and the practitioner’s use of consultants.

How Does Board Certification Factor Into The Hospital Credentialing Process?

Interestingly, the Joint Commission does not specifically suggest board certification and/or recertification as part of the information to be collected by hospitals. Still, specialty board certification may be used as an assessment of physician competence.

Freed and colleagues in 2009 sought to better understand the relationship between board certification and credentialing policies for surgeons and nonsurgical subspecialists.5 The authors also examined the possible variation in the use of board certification among different types of hospitals. The authors report that the majority of institutions do not require board certification as part of their credentialing and privileging process.

According to this study, which included 183 non-children’s hospitals, approximately one-third of hospitals did not require surgeons and nonsurgical subspecialists ever to be board-certified in order to receive hospital privileges.5 Among the hospitals that required certification at some point, only 5 percent required surgeons and 3 percent required nonsurgical subspecialists to be board-certified at the point of initial privileging. More than three-fourths of hospitals had exceptions to their certification policies for surgeons and 77 percent had exceptions for nonsurgical subspecialists. Finally, 82 percent of all hospitals and two-thirds of hospitals whose policies required recertification allowed surgeons and nonsurgical subspecialists to retain privileges when their board certification expired.

Other Emerging Considerations With Hospital Privileges

Given the lack of defined criteria by the Joint Commission, it is not surprising that many institutions are moving toward “core” privileges for many procedures that physicians can perform by virtue of their training.

For instance, for podiatric surgeons, digital amputations may be part of an institution’s core podiatric privileges whereas “non-core” privileges (total ankle joint replacement, for example) may require special or additional documentation of training and experience. The Joint Commission does not reference the concept of core privilege nor does it suggest or promote a particular format for granting privileges. Hospitals typically take on this responsibility, which is also why some differences in core privileges may exist from different institutions.  

It is crucial for hospitals to establish privileging criteria that are reasonable and ensure high quality care to patients while simultaneously ensuring that the criteria are fair and obtainable. Hospitals certainly should not protect the interests of a group of practitioners who do not want other specialties competing with them to provide similar type of care. The ability to deny privileges to a practitioner who does not meet the required standards is an additional benefit of establishing privileging criteria.

The need for stringent documentation to obtain special privileges becomes even more paramount when one takes into account medical advances. As medicine and technology constantly improve, the implementation of new procedures must also be guided by the physician’s sense of professionalism and responsibility to the public. Hospitals concurrently share in the medicolegal risks by confirming the qualifications of licensed physicians (credentialing) and by authorizing those physicians for specific patient care services (privileging).

The Joint Commission’s hospital standards state that in order to provide safe, high quality care, the hospital’s medical staff organization is responsible for credentialing and privileging all licensed independent practitioners. As of 2007, at least 25 states recognize negligent credentialing as a valid malpractice claim against hospitals.6 The medicolegal risks remain large for hospitals as they bear joint responsibility for medical malpractice resulting from poorly credentialed and privileged physicians.

Final Thoughts

Although evaluating physician competence can be complex and extremely time-consuming, it is paramount that an institution’s credentialing and privileging mechanism ensures a high level of quality medical care and patient safety. The goal of the process is to prove physician competence and maintain a high standard of care for the public. Concurrently, as surgical innovations continue to arise in addition to the desire of patients and hospital administrators to be part of the cutting edge of technology, strengthening hospital credentialing and privileging should remain a priority for all institutions and physicians alike.

Dr. Van is the Chairperson of the Department of Surgery and Clinical Assistant Professor at the Temple University School of Podiatric Medicine. She is also the Chief of Podiatric Surgery at Temple Jeanes Hospital in Philadelphia and the Director of Education for the American College of Foot and Ankle Surgeons for the Tri-State Region of Delaware, New Jersey and Pennsylvania. She also serves on the Credentialing Committee for the Temple University Healthcare System and the Credentialing and Privileging Advisor Team for the American College of Foot and Ankle Surgeons.  

1.     Joint Commission on Accreditation of Hospitals, Standards for Hospital Accreditation. Joint Commission on Accreditation of Hospitals, Chicago, 1953.
2.     Joint Commission. 2006 Hospital Accreditation Standards (HAS). JCAHO, Oakbrook Terrace, IL, 2006.
3.     Deutsch SM, Christine S. The Credentialing Handbook. Aspen Publishers, Gaithersburg, MD, 1999.
4.     Joint Commission. Joint Commission measures effective Jan. 1, 2017. Available at . Published Sept. 7, 2016.
5.     Freed GL, Dunham KM, Singer D. Use of board certification and recertification in hospital privileging: policies for general surgeons, surgical specialists, and nonsurgical subspecialists. Arch Surg. 2009;144(8):746–752.
6.     Pradarelli JC, Campbell DA, Dimick JB. Hospital credentialing and privileging of surgeons: a potential safety blind spot. JAMA. 2015;313(13):1313–1314.
7.     JCAHO’s new credentialing, privileging standards require provider-specific data. Hospital Peer Review. Available at. . Published Sept. 1, 2006.

By Jennifer C. Van, DPM, FACFAS, FACFAOM
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