Follow your policy to get the best credentialing results

Before beginning any complex process, it is imperative to have a blueprint for that process in place. Such a blueprint for credentialing allows the process to be both efficient and consistent. Making up a process as you go along takes a lot of time and effort, and runs the risk of appearing to be arbitrary. Having the proper policies in place both makes the process much easier and saves time because all participants follow the same method.

Although it sounds obvious, do not proceed with ad hoc actions in the absence of a policy.

Consider: If an acupuncturist approaches the medical staff wanting to apply for privileges at a hospital, but the hospital has never credentialed an acupuncturist and has no policy or criteria for doing so, what should the medical staff do? There are two possible responses: 

  1. “There are no acupuncturist provisions for our medical staff. We therefore cannot process such an application.”

That works fine if keeping acupuncturists off the medical staff is the desired result. However, let’s say there is a need for a good acupuncturist on the staff and many others have been asking about adding such a service.

  1. “There are no acupuncturist provisions for our medical staff. Should we create a policy?”

The first step would be to have a discussion about whether the hospital wants to add this service. Although the medical staff and administration may have opinions and recommendations regarding the acupuncture service, the governing body must ultimately make this decision, for all the reasons discussed earlier regarding restraint of trade and competition.

If the governing body decides that, yes, the organization should include acupuncture as a service, then the governing body would look to the medical staff for recommendations on criteria for bringing such a practitioner on board. The medical staff can weigh in on criteria for licensure, education, training, and experience, as well as what specific privilege scope should be allowed. Again, final approval would rest with the governing body.

Once this policy is complete and in place, the medical staff can process the acupuncturist’s application as long as he or she meets the criteria established by the hospital. The same criteria would be applied to any other acupuncturist who applies for privileges as well.

Source: The Credentials Committee Manual