Medical staff credentialing, including the delineation of clinical privileges for each staff member, represents a cornerstone in the hospital quality assurance program. The process involves the evaluation and verification of a practitioner's professional competence and conduct based on his/her education and training, previous professional experience, personal background, and peer assessment. Once the practitioner's credentials have been confirmed and approved, clinical privileges are extended by the hospital, matching the practitioner's documented competence and skills with the standards and resources of the institution.
Because of the many significant differences between individual hospitals (ie, size, services provided, geographic location, population served, organization of the medical staff, fiscal and administrative characteristics), no one method for credentialing is universally applicable. The medical staff of each hospital is therefore responsible for establishing its own procedures for credentialing. There are certain elements, however, required in each hospital's credentialing process:
1. It must be thorough, fair, and timely and involve unbiased and good-faith peer review. Any possible malicious use of the peer review process is not acceptable.
2. The etire credentialing process must be clearly described in the medical staff bylaws. Included inn this description should be mechanisms for appeal and guaranteed due process for disputes concerning disciplinary actions and for changes in or revocation of privileges. The medical staff bylaws should also incorporate provisions of the federal Health Care Quality Improvement Act of 1986 as well as reference provisions of applicable state laws, to help achieve or describe available immunities annd protections for the hospital and peer review committee members from various legal liabilities.
- Received December 4, 1989.
- Accepted December 5, 1989.
- Copyright © 1990 by the American Academy of Pediatrics