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Staff Credentialing Checkl​ist​​


The credentialing and privileging process is at the heart of healthcare risk management. By periodically reviewing and refining your credentialing methods and policies, you can help improve patient safety, minimize the consequences of provider malpractice allegations and better manage your organization’s future. 

​STANDARD TO BE MEASURED ​CURRENTLY INSTITUTED? YES/NO DATE ​COMMENTS
Administrative Framework​
​The power to credential and appoint is vested in a clinical appointment committee.
​Qualifications and procedures for admission to practice are clearly delineated.
​Clinical privilege categories are well defined and include scope of practice.
The method of reviewing credentials is clearly stated. ​
​Ethical standards requiring staff adherence are noted.
​The hearing procedure for denial of staff appointment or other adverse rulings is specified
The structure of the credentialing process is documented and incorporates specific time frames. ​
​The credentialing process includes protections against antitrust liability.
Credentialing criteria comply with state statutes, standards developed by accrediting bodies and Medicare Conditions of Participation. ​
​Application
Application forms comply with local, state and federal regulations.
​The pre-screening form requests the applicant’s
​- name and address
​- education and training
- prior employment
- board certifications ​
- current state license and Drug Enforcement Administration (DEA) certification, if applicable
- current competencies
- written statement seeking clinical privileges ​
- personal and professional references (minimum of three)
The application form requests full information regarding​
- loss of medical professional liability coverage ​
- loss of DEA number
- suspension/revocation of privileges
- past claims history ​
​- criminal charges
- prior professional disciplinary actions
- Board of Medical Examiners’ investigations
Applicant executes a written consent and release from liability, to be attached to every reference inquiry. ​
​Applicant is provided a copy of applicable rules and regulations.
Applicant agrees in writing to exhaust administrative internal remedies before litigating adverse credentialing decisions. ​
​Verification and Review
Verify completion of education.
​Ask the director or other authorized responsible party of the applicant’s residency or training program to complete a questionnaire regarding the applicant’s performance and capabilities.
​Check dates of employment history and document any gaps in employment or appointment.
​Obtain a copy of applicant’s DEA certificate and state medical license, if applicable.
​Query the National Practitioner Data Bank and adhere to the requirements of the federal Health Care Quality Improvement Act of 1986.
​Verify the status of existing clinical privileges at other facilities.
Check with state and federal regulatory bodies for previous sanctions by Medicare and Medicaid programs.​
Obtain a copy of applicant’s current medical professional liability insurance certificate, including verification of limits of coverage and claims experience. ​
Verify by telephone all information contained in written references. ​
Delineation of Clinical Privileges​
​Applicant provides the clinical appointment committee with a written request for clinical privileges.
​Committee processes the written request for clinical privileges based on established protocols and criteria.
​Committee votes to approve or deny request.
​Administrative leadership receives committee’s recommendation and makes final decision.
Reappointment of Clinical Privileges​
​Reappointment process occurs annually or, at minimum, every two years.
​Committee verifies and documents the following information upon request for reappointment:
- any changes in certification, appointment, education or professional accomplishments
- verification of current license and DEA certification, if applicable
- any professional disciplinary action taken against applicant ​
- medical professional liability insurance coverage and claim experience
- status with National Practitioner Data Bank, if applicable ​
​Performance appraisal is completed and includes the following indicators:
- utilization of services
- drug utilization
- admissions data ​
- delinquent patient care records
- member/patient satisfaction ​
- quality improvement findings/outcomes
- clinical peer-review findings
​Clinical appointment committee reviews reappointment form and performance appraisal.
​Reappointment is granted either without change to prior privileges, or with modified privileges.
Reappointment is denied, and applicant is notified via a letter, which also provides information about hearing procedures. ​
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