The review and verification of credentials and the granting of clinical privileges are required of every hospital to ensure that all members of its medical staff are competent and fully qualified to provide specified levels of patient care. The credentialing process involves: (1) a detailed assessment of the professional and personal backgrounds of each practitioner seeking privileges; (2) the assignment of privileges appropriate for the clinician's training and experience; (3) ongoing monitoring of the professional activities of each staff member through the hospital's quality assessment and performance programs; and (4) the penodic reappointment of the medical staff based on performance objectively measured by published standards.
Credentialing must be thorough, fair, timely, confidential, and clearly described in the medical staff bylaws. Criteria used for delineation of clinical pnivileges must be well defined, based on realistic national and local standards, regularly updated to reflect advances in medicine, and uniformly used for all applicants. The process should include reviews by peers and at least three of the following individuals or groups: department chairperson, department credentialing committee, hospital medical staff credentialing committee, medical staff executive committee, medical director, and the governing board of the hospital.
The statement examines, in depth, the essential elements of a credentials review for both initial and subsequent medical staff appointments along with suggested criteria for the delineation of clinical privileges in pediatrics. For ease of reference, credentialing checkoff lists and a sample form for the delineation of privileges are included. Because of the significant differences in individual hospitals (ie, size, services offered, location, population served, and organization of the medical staff) no one method of credentialing is universally applicable.
- Copyright © 1996 by the American Academy of Pediatrics