Do residents need to be credentialed?

To determine whether residents need to be credentialed through the medical staff process, we need to separate them into two categories:

1) residents in training who are working in a training capacity
2) residents in training who are working outside their training program in a paid position in the same or a different facility.

Resident or fellows in training who are working in solely a training (learning) capacity do not need to be credentialed through the medical staff process. Even if the resident or fellow is not training in his or her home institution, the institution in which he or she is training does not need to credential them. Consider the following sample bylaws language for these individuals:

Special conditions for residents or fellows in training
Residents or fellows in training in the hospital shall not normally hold membership on the medical staff and shall not normally be granted specific clinical privileges. Rather, they shall be permitted to function clinically only in accordance with the written training protocols developed by the VPMA, chief education officer, a professional graduate education committee, or medical director in conjunction with the residency training program. The protocols must delineate the roles, responsibilities, and patient care activities of residents and fellows, including which types of residents may write patient care orders, under what circumstances they may do so, and what entries a supervising physician must countersign. The protocol must also describe the mechanisms through which resident directors and supervisors make decisions about a resident’s progressive involvement and independence in delivering patient care and how these decisions will be communicated to appropriate medical staff and hospital leaders.

The post-graduate education program director or committee must communicate periodically with the MEC and the board about the performance of its residents, patient safety issues, and quality of patient care and must work with the MEC to ensure that all supervising physicians possess clinical privileges commensurate with their supervising activities.

In many organizations, residents moonlight (work for pay outside their training responsibilities) frequently as house officers, ED physicians, or as locums tenens physicians. In these circumstances, the residents or fellows are working independently and must be credentialed using the usual medical staff process for either regular or temporary privileges. But many medical staffs have provisions in their membership qualifications that the applicant must have completed his or her residency training and, frequently, is on the path toward board certification. The applicant must fulfill all the requirements needed for the credentialing process, with the exception of completion of residency training. There must be a proviso in the bylaws for privileges without membership for these individuals, which allows these practitioners to fulfill these vital services.  For this to occur, the following sample bylaws language can be used:

Exercise of privileges
A practitioner providing clinical services at the hospital may exercise only those privileges granted to him or her by the board or emergency or disaster privileges as described herein. Privileges may be granted by the board on recommendation of the MEC to practitioners who are not members of the medical staff. Such individuals may be advance practice registered nurses (APRNs), physician assistants (PAs), physicians serving short locum tenens positions, telemedicine physicians, or house staff such as residents or fellows moonlighting in the hospital, or others deemed appropriate by the MEC and board.

Depending on the circumstances in which residents or fellows may be working in your institution, make sure that you have appropriate language in your bylaws and that you credential those who are working independently and have no need to credential those that are in a training circumstance.

Mary Hoppa, MD, MBA, CMSL, is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.