Policy: Advanced Practice Professionals Credentialing and Privileging

CMS and The Joint Commission require individuals other than licensed physicians who provide a “medical level of care” in the hospital to be credentialed and privileged in the same fashion as physicians. As advanced practice professionals (APP) have a greater presence in medical centers, some questions regarding how to credential and privilege these healthcare professionals naturally arise. This policy and procedure outlines the requirements, application, appointment, and review process.

In the majority of medical staffs across the United States, APPs are not members of the medical staff although they are required to hold clinical privileges. This historical status is beginning to change and many medicals staffs include APPs among their members. In general, there is no compelling reason to treat the credentialing and privileging of APPs differently from physicians or other professionals granted clinical privileges. This sample policy is offered for those institutions where APPs are not members of the medical staff and where the medical staff chooses to have a separately defined process for the credentialing of these practitioners. This sample policy also posits a distinctive corrective action process for APPs. However, an increasing number of medical staffs choose to apply the same corrective action/fair hearing process to APPs as exists for other privileged practitioners.

In adopting a separate policy on APP credentialing, it is important to make sure that its provisions are consistent with language in the medical staff bylaws that address the status of APPs and the credentialing of practitioners. This sample policy from Medical Staff Governing Documents will help you get started.