Qualifications: Credentials and privileges of medical staff and LIPs

June 28, 2012
Credentialing Resource Center Digest - Volume 13 Issue 26

In my last article concerning accreditation, it was noted that having a qualified third party evaluate the many complex and inter-related processes that constitute the delivery of high quality hospital care in the modern environment would be a valuable service (i.e., an accreditation survey).  It would help balance the needs of the patients, technology, medical professionals, and hospital delivery systems. These processes make up the nine major areas of accreditation review, and include:
  1. Qualifications of the professional staff and licensed independent practitioners
  2. OPPE/FPPE, quality assurance systems, and core measures
  3. The maintenance of the medical record, history and physicals, and information flow
  4. Medication management and physician orders
  5. Technology and the changing delivery methodologies
  6. Infection control and protection
  7. The relationship of the medical staff leadership and the governing body
  8. Patient rights
  9. Physical plant and patient safety

Over the next few issues of this publication, we will address each of these nine areas. This week, we will discuss qualifications of the medical staff and licensed independent practitioners.

The hospital and the medical staff have a duty to create a process to determine appropriate credentials and privileges for providers who care for patients. During an accreditation survey, the surveyors will discuss and evaluate these processes. The processes should be objective, evidence-based methodologies that serve as the basis to ensure credentials, such as licensure, are in place and all verifications, such as a National Practitioner Data Bank report and primary source verifications, have been completed. Policies related to professional interactions, roles, and behavior should also be available. Once the credentials are deemed complete, the process to evaluate competency as a basis for granting clinical privileges begins.

This starts with a well designed delineation of the things practitioners do to patients and will be the basis to evaluate the practitioner’s performance. Specialty designs vary, from the surgical, procedure-oriented lists to the cognitive, adult, and pediatric medicine/psychiatry fields.  Each specialty is unique in what its members do, how they do it, and what outcomes might be anticipated.

Delineations include “core” activities that would be exercised by any actively practicing member to new tools, instruments, and techniques that would require experience/ training.  Procedural specialties could be grouped in “competency clusters,” the skills of that cluster being similar and therefore transferable. These designs involve significant clinical judgment and participation.

Regardless of the method utilized, it must have a rationale that lends itself to being the basis to grant and evaluate all that practitioners do in caring for patients. How this relates to quality assurance will be discussed in the next issue.

Richard Turbin, MD, FACPE, faculty is a speaker for The Greeley Company's medical staff leadership national seminars and onsite education programs.