The Governing Board’s Mission-Critical Role in Credentialing and Privileging
By Karma H. Bass, MPH, FACHE, CEO & Managing Principal, Via Healthcare Consulting
One of the core responsibilities of a governing board is overseeing the quality of care provided by the organization it is governing. This oversight provides the foundation upon which any hospital or health system provides high-quality care to its patients and communities.
Ensuring quality care is also part of the board’s fiduciary duty of care, an increasingly important aspect of the board’s role as hospitals face greater public accountability for patient safety and financial penalties for not meeting quality targets set by government and private payers.
One important way health systems safeguard the quality of care in their organizations is by ensuring that their physicians and other providers possess the appropriate credentials and are adhering to the highest standards of care. For hospital medical staffs, this effort centers on three processes: credentialing, privileging, and peer review. These processes require careful evaluation, review, and oversight under the responsibility of the organized medical staff and the hospital board.
Who Is the Organized Medical Staff?
Every hospital has a medical staff comprised of licensed clinicians who seek and are granted permission, or credentialed, to practice at the organization. The medical staff is structured to permit oversight of the hospital’s clinical care by the medical staff members themselves, according to a set of medical staff bylaws.
Among other functions, medical staff bylaws lay out the categories of medical providers who are permitted to join the medical staff and, therefore, practice at the hospital. In addition to physicians, a hospital’s medical staff includes certain types of advanced practice clinicians (APCs). These APCs are professionals who have medical training but are not physicians. The category typically includes nurse practitioners, physician assistants, and certified registered nurse anesthetists, among others.
Advanced practice clinicians are required to go through the hospital’s privileging and credentialing process to join the medical staff because their training and licensing permits them to care for patients more independently than nurses or other allied health professionals.
The Buck Stops with the Board
Importantly, it is the local hospital board that authorizes the medical staff to carry out its work. Although the board has the ultimate governing authority to oversee the quality of care the institution provides, it delegates authority over clinical quality to the medical staff. This function is spelled out in the medical staff bylaws. For this reason, any changes to medical staff bylaws must be approved by the hospital board.
The Three Key Processes
Credentialing
Credentialing is a detailed review process required by law to determine whether a licensed medical professional is qualified to join the medical staff of a hospital. The process includes obtaining documentation on, verifying, and assessing the qualifications of the medical practitioner. The review process involves validating the practitioner’s qualifications and career history, including education, training, residency, licenses, and any specialty certifications. Credentialing is required by the Centers for Medicare & Medicaid Services and The Joint Commission, among other agencies.
Privileging
While the credentialing process essentially grants a medical practitioner the authority to care for patients at a hospital, privileging is the process that defines the specific scope of practice permitted at the hospital for that practitioner. To care for patients at a hospital, any physician must be first credentialed, then granted privileges. A surgeon, for example, whose privileges include general surgery might not be permitted to perform neurosurgery according to his or her privileges.
Peer Review
Peer review is the process whereby medical staff members evaluate the quality of their colleagues’ work in order to ensure that prevailing standards of care are being met. A key feature of peer review is that it is performed by a clinician with similar qualifications to those of the clinician whose work is being reviewed. For this reason, peer review occurs within the organized medical staff. Medical staff members may be subject to a periodic peer review process to maintain their privileges. Additionally, patient cases where there have been adverse outcomes often trigger a retrospective peer review investigation.
Peer review should be considered confidential, protected, and not subject to disclosure or discovery. The results of a peer review may, however, on occasion be reported with appropriate legal guidance to the board.
Defining the Roles
The functions within the credentialing, privileging, and peer review processes are divided between the medical staff (which includes a number of working committees, such as the medical executive committee) and the hospital board. In general, the medical staff develops policies, evaluates qualifications, and makes recommendations while the board oversees processes, ensuring they are thorough and focused on patient safety, and grants approval of candidates.
There will be slight variations in the way an individual hospital handles these processes, but in general the medical staff develops the policy, which outlines the qualifications of a medical practitioner candidate that should be reviewed, such as training, education, experience, etc., in order to be admitted to the medical staff of the hospital. This policy typically resides in the medical staff bylaws.
The medical staff recommends the policy (as part of its medical staff bylaws) to the board, which is then charged with approving the medical staff bylaws. These bylaws are typically reviewed and updated every few years by specialized legal counsel working with medical staff leaders and approved by the board.
In the credentialing and privileging processes, the medical staff evaluates the candidate’s or existing medical staff member’s qualifications, scope of practice, and/or re-appointment and then, through the medical executive committee, makes recommendations to the board. The board is responsible for reviewing the recommendations and then either grants, denies, or approves the request for membership, privileges, and/or reappointment of the physician or clinician.
Ensuring Checks and Balances
Hospital or health systems that fail to enact such processes to ensure quality of care in a fair and comprehensive manner are at risk of harming patients, losing their accreditation, and damaging their reputations. They also risk potential lawsuits and financial penalties.
The board’s oversight role involves ensuring that these processes are rigorous and thorough so that only candidates who meet the standards of the hospital are allowed to practice at the facility and that these candidates are provided a fair review process.
Clearly, the credentialing, privileging and peer review processes represent layers of review, evaluation and expertise. For boards, it’s important to remember that the medical staff evaluates clinical qualifications and makes recommendations so that the board can approve them. In this way, a series of checks and balances are established within the hospital’s hierarchy to further safeguard and ensure patient care and clinical quality.
General Hospital Privileging and Credentialing Process for New Clinicians*
- Clinician submits credentials application and documentation to the hospital, indicating the scope of practice (privileges) being sought.
- The hospital’s medical staff office conducts primary source verification. (This step can be regionalized, centralized, or outsourced to a centralized verification office.)
- The medical staff’s credentials committee followed by the medical executive committee then review and approve the application.
- A recommendation from the medical staff (through the medical executive committee) to grant the clinician credentials and privileges is provided to the board; the board approves the recommendation.
- The hospital grants membership (credentials) and specified privileges to the clinician.
*Please refer to your organization’s board bylaws for specific accountabilities.
Questions for Boards to Consider
- How well do board members understand the hospital’s credentialing, privileging and peer review processes?
- How often does the medical staff update the criteria used in the hospital’s credentialing and privileging processes? When were the medical staff bylaws last updated? What resources or expertise does the medical staff rely on when revising its criteria?
- How frequently does the organization audit and identify risk areas in the credentialing, privileging and peer review processes? (For example, a physician allows his or her board certification to expire or doesn’t fulfill annual continuing medical education requirements.)
- Does the board feel comfortable that it is receiving the appropriate information to fulfill its oversight responsibility in this area? What additional information would be helpful?
- What is the process undertaken if a clinician is found to not be meeting medical staff expectations?
Gain Clarity with Expert Support – Overseeing Quality
Navigating the complexities of health care can be daunting. By partnering with Via Healthcare Consulting, organizations benefit from expert support and customized solutions tailored to their specific needs. With over 25 years of experience in healthcare governance, ViaHCC offers invaluable insights and guidance to enhance organizational effectiveness. From strategic planning to board development, Via empowers healthcare leaders to overcome challenges and transform their organizations. Book a call today to unlock the benefits of working with Via Healthcare Consulting.
