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If a Hospital Learns That Another Facility Has Sanctioned One of Its Privileged Physicians, How Should the Hospital React to Such a Situation?

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Credentialing is the process of obtaining, verifying and assessing the qualifications of a healthcare practitioner to provide patient care services in or for a healthcare entity

Recredentialing is the process of obtaining and evaluating data to support the continued competence of the healthcare practitioner to provide patient care services in or for a healthcare organization. If the patient suffers an adverse outcome at the hospital, the hospital can be held liable. If the provider has problems that would have been revealed by credentialing, but credentialing was not performed, the hospital may be liable for any patient harm caused by the substandard clinician.

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Though all hospitals must follow their own specific bylaws in regard to credentialing, the process is relatively similar at most institutions. After receiving an application, the medical staff office begins the primary source verification. Essentially, the staff’s job is to confirm that you are who you say you are in regard to education, training and work experience. Once the verification is complete, the application and file go to the Department Chair or Section Chief for review. Depending on the hospital, this part of the process may involve a face-to-face meeting or telephone call with the Department Chair or Section Chief. Once the application and file are approved by the Department Chair or Section Chief, a Credentialing and Privileging Committee completes the file review process while taking the clinician’s requested privilege into account. When all those steps are complete, the Medical Staff Executive Committee typically grants temporary privileges and subsequently full privileges. With all those steps involved with hospital credentialing, it should come as no surprise that strategic planning and timing are of great importance. Additionally, hospital bylaws typically mandate the frequency of committee meetings. Some committees meet once a month while others may meet once a quarter and so on. Knowing this information can prove to be vital when submitting your credentialing application in a timely fashion for consideration. For instance, if the hospital credentialing committee meets on the first Monday of every other month and you happen to miss this deadline by one day, then your application will essentially sit and wait until the next meeting. This translates into an easily avoidable delay in your application. When obtaining your initial appointment application, it certainly helps to inquire as to when and how often the committee meets. The medical staff office should easily be able to provide this information. The initial process of primary source verification by the medical staff office is usually fraught with frustration and delays, most of which are preventable. One of the most common delays involves state licensure

Ironically, it is also one of the most avoidable delays with appropriate planning and due diligence on the applicant’s part.

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Credentialing is a formal process that utilizes an established series of guidelines to ensure that patients receive the highest level of care from healthcare professionals who have undergone the most stringent scrutiny regarding their ability to practice medicine (MacDonald J., 2017). Credentialing also assures the patient that he or she is being treated by providers whose qualifications, training, licensure, and ability to practice medicine are acceptable. Credentialing also ensures that all healthcare workers are held to the same standard.In the current era of medical practice, all healthcare institutions have the onus of ensuring patient safety and delivering an acceptable standard of care

While employing excellent medical staff is vital for success, the healthcare institution must have medical bylaws that define the required minimum credentialing and privileging requirements to validate the competency of healthcare providers. In the past, only hospitals used to perform credentialing, but today almost all healthcare facilities, ambulatory care centers, long-term care institutions, and even urgent care clinics perform credentialing. Credentialing is a vital process for all healthcare institutions that must be performed to ensure that those healthcare workers who will be providing the clinical services are qualified to do so. There are ample cases reported in the literature about healthcare workers who worked in hospitals with bogus certificated and falsified experience. Over the past 20 years, the credentialing process has become complex and onerous primarily due to the expansion of the provider scope of practice, accrediting bodies, and requirements of third-party payers like Medicare, Medicaid, and private insurers (Barnett SD, 2015).

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By and large, if the denial or limitation of privileges is the result of a professional review action and is related to the practitioner's professional competence or professional conduct, then the action must be reported to the NPDB. If the denial or limitation of privileges occurs solely because a practitioner does not meet a health care institution's established eligibility threshold criteria for that particular privilege (e.g., lacks the required number of clinical hours in a specialty), it should not be reported to the NPDB. The latter type of restriction or denial is not deemed the result of a professional review action relating to the practitioner's professional competence or professional conduct.

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MacDonald J. Protecting the public in action. 2017 SpringAlta RN. 73(1):4.

Barnett SD. Growing pains of credentialing research: discussions from the institute of medicine workshop. J Contin Educ Nurs. 2015 Feb;46(2):53-5.

Baumann MH, Simpson SQ, Stahl M, Raoof S, Marciniuk DD, Gutterman DD., American College of Chest Physicians and the American Association of Critical-Care Nurses. First, do no harm: less training ≠ quality care. Am. J. Crit. Care. 2012 Jul;21(4):227-30.

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