Medical Staff Credentialing and Privileging

As of the end of 2016, a total of 953,695 actively licensed doctors of medicine or osteopathy were serving a U.S. population of 323 million, according to the biennial census conducted by the Federation of State Medical Boards (FSMB) (Young et al.), a national nonprofit organization whose membership includes 70 medical licensing and disciplinary boards in the United States and its territories. Physicians wanting to admit and treat patients at a hospital must request appointment to the hospital's medical staff and seek clinical privileges through a process typically referred to as "credentialing and privileging."

Credentialing is the process through which physicians provide their credentials for review, assessment, and recommendation to the hospital's governing board. Hospital boards approve or deny medical staff appointments and reappointments and grant, deny, expand, restrict, or suspend clinical privileges after considering recommendations made by the medical staff. Employing credentialing and privileging processes, hospitals act as gatekeepers, safeguarding patients from incompetent and dangerous healthcare practitioners.

Fiduciary and legal duties. Oversight of the quality of care provided to patients through the process of credentialing and clinical privileging is a core fiduciary duty of hospital governing bodies (Callender et al.). A majority of states have concluded that hospitals owe a legal duty to their patients to appropriately credential members of the medical staff. Case law from state courts and state statutes helps define the hospital's legal duty. In addition, credentialing and privileging are required by Joint Commission standards, as well as CoPs and interpretive guidelines issued by CMS (Joint Commission; 42 CFR § 482.22).

Negligent credentialing claims. Risk managers should be aware that many jurisdictions recognize a cause of action against hospitals for negligent credentialing. In those states, nearly every claim for serious patient injury arising from care provided in a hospital by a physician with medical staff privileges may result in plaintiff's counsel scrutinizing the hospital's credentialing and privileging processes (D'Attomo).

Negligent credentialing claims brought by or on behalf of injured patients typically allege that the hospital's negligence in credentialing or privileging a physician caused or contributed to the person's injury. Such claims focus on issues implicating the hospital's credentialing procedures and peer review processes, as well as compliance with regulatory requirements and accreditation standards.

Adverse credentialing decisions. Furthermore, an aggrieved physician may challenge a hospital's adverse credentialing decision through the facility's fair hearing and appeals process, or through litigation alleging violations of antidiscrimination laws or failure to meet standards established under the Health Care Quality Improvement Act (HCQIA).

Thus, it behooves risk managers to view the organization's credentialing and privileging process from a risk management as well as a patient safety perspective. By working in coordination with the facility's medical staff credentialing director or coordinator and the facility's legal counsel, risk managers can ensure that the facility's credentialing process meets legal and regulatory requirements, as well as applicable accreditation standards, thus facilitating patient safety.

This guidance article provides an overview of the process for credentialing and privileging of practitioners and discusses the role of risk management in minimizing potential liabilities associated with this process. It discusses aspects of federal and state...