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May 1, 2013 Volume 77, Number 5
Credentialing Hot Topics Charles K. Anderson, M.D., M.B.A.


Credentialing and privileging are two formal and “hum-drum” activities that we all go through but often know little about. It defines who we are professionally. These functions are not only mysterious and misunderstood to most physicians but may also yield some disappointing and deleterious outcomes on our practices if not given the attention they deserve. A few of the most recent challenges medical staff credentialing committees have been dealing with are the issues of the development of deep-sedation policies and the integration of a growing number of employed physicians onto a medical staff, as employment contracts may conflict with the process contained within the medical staff bylaws.

First, it is advantageous to understand a little about the nature of these activities. Credentialing and privileging have a broad range of influences or drivers acting upon their decisions and execution such as the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (COPs), The Joint Commission (TJC) standards or other deemed accrediting bodies, state laws, community need, legal precedence, hospital and medical staff’s ability to provide support, and professional policies and standards.

The terms credentialing and privileging are often used interchangeably but have different meanings. Credentialing can be defined as “a standardized process of inquiry which validates the candidates identity, background, education and training.” This includes primary source verification where the medical staff office (MSO) receives information directly from the applicant’s medical school and residency program director or chair as well as any documentation from prior hospital affiliations where they may have been employed or had privileges. Also, any other training certificates that would provide qualification for the privileges the applicant is requesting need to be provided.

Gaps in the applicant’s training are also scrutinized and sometimes require detailed explanation as to the activities and locations during that time. Privileging is “the process of determining the boundaries of each applicant’s clinical knowledge, skills, competency and awarding clinical rights or ‘privileges’ to perform those procedures which fit their qualifications.” Depending upon the applicant’s training and experience, privileges are granted based upon the specific institution’s set of adopted privileging standards. That is to say, not everyone can get the same set of privileges based on their professional credentials wherever they go. Some hospitals may not offer the types of privileges that a physician requests. Oftentimes this will be a discussion or negotiation from two or more specialties with crossover clinical skills with dissimilar training and professional society standards.

Anesthesiology has seen its share of this situation, most recently with deep sedation privileges across the nation; however, we are not unique in that regard. As examples, endoscopy privileges between the specialties of gastro-enterology, general surgery, internal medicine and family medicine have been contentious, as well as endovascular privileges between interventional radiology, vascular surgery, cardiology, general surgery and cardiac surgery, are two competitive crossover privileges where standards become uniquely institutional.

The controversial issue of deep sedation is significantly different and unique compared to the above examples in that it falls “under the authority of the direction of one individual who is a qualified doctor of medicine (M.D.) or a doctor of osteopathy (D.O.).” That one individual’s qualifications, as defined by criteria set forth in the medical staff bylaws, rules and regulations and approved by the hospital’s governing body, will be the “director of anesthesia services” as described by the CMS’s COPs 482.52 under Anesthesia Services. There are a number of specialties that have a vested interest in the policies developed in any hospital in this regard, such as emergency physicians, critical care, cardiology, gastroenterology, orthopedics and ob/gyn. The COP also suggests that, although not required, the policies be developed in collaboration with other hospital disciplines and includes surgery, pharmacy, nursing, safety experts and material management.

For those looking to start this process of policymaking for their medical staff, the ASA’s Definitions, Guidelines, Standards and Statements are good places to begin. Regardless of what the final product of policymaking yields, it is strongly suggested that a well-thought-out Quality Assessment and Performance Improvement (QAPI) program be an integral part of the process, including quality and process indicators, data analysis and peer review, as well as initial credentialing and re-credentialing criteria. Care should be taken, however, to avoid commercial Web-based educational sites purporting to confer competency with a cursory review of information and skills to obtain a certificate of completion of training. These are generally felt to be grossly inadequate training and experience to be submitted as an appropriate credential for privileging deep sedation.

It is important to remember that a medical staff’s bylaws and credentials committee is not the final determinant of whether an applicant receives the privileges requested based on the credentials submitted. They review and recommend to the medical staff executive committee, which in turn reviews and recommends to the governing board of the hospital, which has the final authority to grant, amend or deny privileges.

Drivers that influence the need to perform credentialing are of the immutable type such as state and federal laws and regulations, standards from federal agencies and accreditation bodies, or the more flexible types that require thoughtful deliberation, analysis or negotiations, such as social, ethical, professional, political and budgetary considerations. Compliance with federal laws, rules, regulations and standards as well as deemed accreditation organizations is required to participate in federally funded programs such as Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). Many of the federal laws that govern employment of physicians also apply to credentialing as well, such as the Family and Medical Leave Act (FMLA), the Americans with Disabilities Act (ADA), the Age Discrimination in Employment Act (ADEA) as well as the Civil Rights Act of 1964 (for protected classes, e.g., race, ethnicity, national and religious minorities and women).

Medical staffs with a mixture of employed physicians under contract by the hospital and independent physician practitioners provide a number of challenges to interpret. Whereas the conduct of the employed physician is directed and governed by both the employment contract and the medical staff bylaws, the independent physician practitioner answers for activities only under the medical staff bylaws (hospital board policies notwithstanding). Medical staffs administrate the bylaws through a well-described process by physician peers, and the medical staff bylaws have been reviewed and accepted by the board of the hospital. In 22 states, the bylaws have been recognized as a contract between the medical staff and the board of the hospital. An employment contract may or may not seek remedies for technical and behavioral issues through the medical staff process but often will exercise a more expedient solution with a “termination without cause” clause in the contract. This may usurp the mandate of determining and maintaining quality medical care by CMS COP 482.22 before there has been an investigation through the medical staff process.

An applicant’s history and experience with encounters with the legal system are of interest to the credentials committee as well. Consideration should be given as to how the medical staff and the governing board are going to view applicants with misdemeanors and felonies. If exceptions are made to treat applicants differently by accepting some but not others, it will take a great deal of thought and circumspection to define strictly what the exceptions are and why. These should be stated clearly in policies lest they be interpreted as arbitrary and capricious and result in a discrimination cause of action.

The credentialing body of the medical staff is faced with many of the same restrictions as the human resources department of the health care system. There are a variety of questions that are not allowed to be asked of an applicant and protected by federal law. Bona Fide Occupational Qualifications (BFOQ) may allow pre-appointment testing if “essential functions” of job requirements of being a physician on staff are listed and described. In employment discrimination law in the U.S., both Title VII of the Civil Rights Act and the Age Discrimination in Employment Act (ADEA) contain a BFOQ defense. Form matters as to how it is stated in the medical staff bylaws under requirements of aging physicians and other ADA protections.

The ability and need of the community, hospital and medical staff to support a service and the hospital staff to supply that service is also an issue that will affect credentialing decisions. The expectation of a subspecialty physician may not match the need of the hospital or medical staff’s organizational structure. Neither may be able to supply the space, nurses, equipment or consultative support to allow for the subspecialty to adequately function in the hospital. Also as guidance for credentialing, the Emergency Medical Treatment and Active labor Act (EMTALA) helps to define specialties needed in a hospital and the medical staff’s ability to adequately cover that service for all hospitals accepting payments from U.S. Department of Health and Human Services (HHS).

This brief overview hopefully offers some insight into a few of the challenges and considerations involved with current credentialing issues. Deep sedation policies as well as those involving integration of employed physicians into a mixed medical staff are still evolving. There are many drivers that influence how a credentials committee views applicants for potential staff membership and privileging.



Charles K. Anderson, M.D., M.B.A. is Executive Director of Medical Staff Affairs for St. Charles Healthcare System, Bend, Oregon.


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