Medical Staff Credentialing and Privileging

​​​A hospital has two major goals in medical staff credentialing. The first goal is to avoid patient harm by ensuring that individuals holding clinical privileges are qualified and competent to provide specific medical services. The second goal is to treat all applicants for credentialing and privileging fairly for initial appointment, reappointment, temporary appointment, appointment during disasters, and appointment for telemedicine providers.

This self-assessment questionnaire (SAQ) is designed to help risk managers evaluate their hospital's policies, medical staff bylaws, rules and regulations, and actual practices regarding credentialing to determine whether these two goals are being met. Regardless of an organization's risk level, Health System Risk Management recommends that hospitals complete this SAQ in its entirety annually, as...