The primary objective of a well-designed credentialing and privileging system is good patient care. Period.

Other factors are also important, however. Of all the medical staff standards published by the Joint Commission, those pertaining to credentialing and privileging are the most detailed and most complex. Perhaps more important, beginning in 2007 broad new concepts became effective, including specific new privileging requirements and the requirement to continuously monitor every practitioner in the hospital. (For a review of these new rules in more detail, click here for the new privileging rules and here for the new credentialing rules.)

Those who do not take these standards seriously face a legal risk known as negligent credentialing. If a carelessly credentialed physician hurts a patient, the patient may sue not only the physician but also the hospital that allowed him to practice there.

To counter these legal and accreditation risks, we perform our work in credentialing and privileging based on several core ideas:

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• Privileges (for hospitals) and rights of participation (for HMOs) should be developed by physicians, clearly written, approved by the entity and freely available.

• Each privilege/right should specify minimum education, training and experience requirements.

• Applicants must affirmatively establish current competence to perform a requested privilege/right in a uniformly applied credentialing/certification process.

• Physicians must be carefully monitored to ensure practice within privileges/rights granted and to continually assess, from outcomes, the need for modified requirements.

To see examples of these ideas in practice, click here.