SDS Accreditation Update

Compliance issue: clinical privileges

One of the accreditation standards causing the most headaches for ambulatory organizations is the one on credentialing. In fact, statistics gathered by The Joint Commission indicated that for the first half of 2011, 48% of ambulatory organizations and 56% of office-based facilities were noncompliant with standard HR 02.01.03: The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.

The process is difficult, acknowledges Virginia McCollum, MSN, RN, associate director of standards interpretation at The Joint Commission. In fact, the introduction to the standards manuals describes the process as "one of the most important and difficult responsibilities of an organization."

"The organization needs to have a process, ongoing, with a two-year cycle [three-year cycle in Illinois] for data collection and assessment," McCollum says. Credentialing and privileging require staff time to meet the time requirements. "Someone always needs to be doing that."

Managers at smaller organizations might not realize how much work the process entails, she says.

One of the biggest stumbling blocks for managers at accredited organizations is follow up, says Marsha Wallander, RN, assistant director of accreditation services at the Accreditation Association for Ambulatory Health Care (AAAHC). However, there are software programs that can help, Wallander says. "You can enter providers and dates of their different documents, licenses, board certification, and you get an automatic reminder when that is coming due," she says.

Additional help is available through credentials verification organization (CVOs) that can provide information on individuals in terms of their professional credentials, says McCollum. Some find it's more cost-effective to have someone do the credentials for you. Your organization makes the privileging decisions, after reviewing the credentialing information provided by the CVO, she says. The glossary in the Comprehensive Accreditation Manual for Ambulatory Care (CAMAC) — 2011 lists 10 principles that CVOs must follow for healthcare programs to use them.

AAAHC provides organizations with a sample medical staff application, Wallander says. "It's perfectly OK to develop their own, but they can use the template we provide as a sample," she says. "If they did that, they'd cover everything."

Another challenge is collecting documents, Wallander says. "If you want a new photocopy of an existing applicant's new license, you sometimes have to rely on someone to produce that piece of paper, but it is an important aspect," she says.

Do you know the difference?

Part of the difficulty with compliance might come from the fact that providers confuse credentialing and privileging, say leaders in accreditation groups.

Credentialing is "the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a healthcare organization," says McCollum, again quoting CAMAC — 2011. Credentialing includes relevant training, current license, current competence, and the ability (health) to perform requested privileges. In comparison, privileging is "the process whereby a specific scope and content of patient care services — that is clinical privileges — are authorized for a healthcare practitioner by a healthcare organization, based on an evaluation of the individual's credentials and performance," says McCollum, again quoting the handbook.

In summary, it is the process to "make sure someone who is who they say they are, and they have what they need to do what you want them to do," she says.