Accreditation and Regulatory Requirements

Regulatory and accreditation bodies require healthcare institutions to obtain peer references during the credentialing process to validate applicants’ current clinical competence. Created to comply with Joint Commission standards, this confidential peer review reference form captures the...

Many medical staffs fail to screen for conflicts of interest in their decision-making processes, despite the need to ensure clinical decisions are made for the betterment of patient care, rather than for fame, glory, or the bottom line. Joint Commission standard LD.04.02.01 states that conflicts...

In the hospital setting, a completed checklist prefacing a credentials file can demonstrate to department chairs, the credentials committee, the medical executive committee, and the governing board that an application has been thoroughly vetted and properly prepared. Credentialing checklists can...

There are a variety of viable ways to approach the delineation of medical history and physical exam (H&P) privileges. Attached is a sampling of core privilege statements for various disciplines. Some address H&Ps in explicit terms, and others use alternative language. 

The Joint Commission has identified the Accreditation Council for Graduate Medical Education’s core competencies as a potential framework for evaluating practitioners who are credentialed and privileged through the medical staff. The competency domains provide the foundation for identifying and...