The Privileging Puzzle: Requirements for Providers and Organizations

The Privileging Puzzle: Requirements for Providers and Organizations

Dec 20, 2022
  • Author:
    Noelle Abarelli

Medical credentialing allows healthcare practices to confirm the qualifications of their healthcare professionals. Privileging ensures that physicians have the experience and clinical competency necessary, within their area of medicine, to care for patients. Together, privileging and credentialing ensure patients have access to safe and reliable care. In our Privileging 101 Webinar Series, we go into all the details you need to become a privileging expert. In part five of the series, Privileging 101 - Introduction to Privileges: Part 5 - The Privileging Puzzle, we uncover the documentation required for credentialing and privileging, and how it all comes together to showcase a provider’s qualifications in detail.

Credentialing and Privileging Checklist

Numerous steps and pieces of documentation must be obtained during the credentialing and privileging process. A checklist includes:

  • Primary source verification
  • Education and training
  • State licensure
  • Board certification
  • Peer references
  • Work history and affiliations
  • NPDB/OIG/Sanctions
  • Malpractice and/or liability history
  • Background checks and criminal history
  • Registration and certifications
  • Current competence
  • Ability to perform privileges

These documents all fit together like pieces of a puzzle to demonstrate a provider’s overall qualifications. Some of these terms may be unfamiliar to those new to credentialing and privileging, so let’s examine a few.

Primary Source Verification (PSV)

It is the responsibility of the accredited organization (hospital, medical center, etc.) to complete PSV. The Joint Commission defines PSV as “Verification of an individual practitioner’s reported qualifications by the original source or an approved agent of that source.” PSV can be conducted in many ways, be it by direct correspondence, documented telephone verification, secure electronic verification from the original source, or reports from credentials verification organizations (CVOs) that meet The Joint Commission requirements.

Selected agencies have been determined to maintain specific items of credential information that are identical to the information at the primary source, these are referred to as Designated Equivalent Sources (DES). DES may be used to verify certain credentials in lieu of using the primary source. Some DES sources are:

These sources determine what method is used to document the primary source and must have information on what PSV was completed, the methodology, who conducted it, what was verified, and the result of the verification. Simply presenting a copy of the license in lieu of evidence of a PSV completed by the organization does not meet the requirement.

State Licensure

Applicants are required to hold a current and active state license to practice. Each state will have different requirements for obtaining licensure, which can be found in the documentation provided by the Federation of State Medical Boards (FSMB). Some states do not accept credential verification services from the FSMB, which means the organization would need to contact the state licensing board directly to obtain primary source verification.

Advanced practice registered nurses, in addition to their state licensure, are required to maintain their registered nursing license, which means both licenses must be verified and kept up to date with no disciplinary action against any license. When you receive verification of a state license, you want to examine the verification closely to ensure you’re not missing any important information, like whether the license is active or if there have been adverse events reported.

Current Competence and Clinical Activity

The importance of confirming current competence cannot be underestimated. Every accreditation body requires that the current competency of medical practitioners be evaluated and confirmed prior to the granting of clinical privileges.

Accreditation Body Legal Requirements
  • The medical staff must have a mechanism to examine evidence of professional education, training, documented experience, and supporting references of competence.
The Joint Commission
  • Each applicant’s professional and clinical performance must be verified through contact with appropriate teaching facilities, hospitals, and/or relevant organizations.
  • Established criteria that determines a practitioner’s ability to provide a patient within the requested privileges, including the physical ability to perform the privileges requested.
  • Medical staff selection outlines qualifications to be met by the applicant that includes current competence via PSV.
  • If available, performance data should be reviewed for variation from criteria determined by the medical staff.
  • Consideration is given to the applicant’s competence and judgment.
  • Evaluation and granting of clinical privileges must be commensurate with the individual’s documented training, experience, and current competence.
  • Applicants must provide clinical activity documentation to be used in consideration of the privileges requested.
  • Procedure logs with outcomes to support privilege requests for procedures not attested to in postgraduate references.
  • OPPE information is factored into the decision to maintain existing privileges, or to revoke an existing privilege prior to or at the time of renewal.
  • Data is collected on an ongoing basis.
  • Initial application for privileges must provide documentation of current competency in performing the requested procedures.
  • Documentation of current competence is obtained from peers.

At the time of reappointment or renewal, references must be obtained from practitioners who have direct knowledge of how the applicant has performed with their granted privileges and procedures. There is no substitute for recommendations provided by knowledgeable practitioners, like department chairs, chiefs of staff, or chief medical officers.

Staying Current with Credentialing and Privileging Requirements

All of this information correlates to current and/or ongoing competency for requested privileges, which is why keeping it up to date is of the utmost importance. Documentation on education and training, malpractice or liability history, all of it, must be verified at initial and reappointment every time, through a primary source. This is how Medical Service Professionals (MSPs) can ensure their providers are up to the task.

Most hospitals and healthcare organizations re-credential their physicians every two years, the same goes for granting privileges. Case logs, procedure reports, and peer reviews all go into building a physician profile to ensure they are qualified to continue providing care. Meeting the requirements established by the medical staff and accreditation bodies to confirm current competency is critical in ensuring patient safety.

To learn more about the documentation must be obtained during the credentialing and privileging process, be sure to watch our webinar, Privileging 101 - Introduction to Privileges: Part 5 - The Privileging Puzzle.