Credentialing vs. Privileging

Credentialing is a straightforward function designed to validate the minimum qualifications needed to practice medicine and for membership on a medical staff. Its counterpart – privileging – is a more complex process designed to protect patients, the healthcare organization, and the practitioner through authorization of a defined scope of practice with associated eligibility criteria; both for the new applicant and for the practitioner with existing privileges to maintain or renew their privileges on a regular basis.

Criteria for membership and criteria for privileges should be separate and distinct. Membership and Privileges are two separate decisions and are not inherently linked in that (per policy) an individual practitioner can have membership without privileges (e.g. Community Staff, Honorary Staff), privileges without membership (e.g. APRNs, PAs or perhaps telemedicine or locum tenens providers). Membership categories define by policy the assigned member’s functions such as being eligible to vote, the right to hold office, access to the hospital CME programs, and the level of participation in the organized medical staff ’s responsibilities.

Minimum elements to qualify for membership typically include:

Current license
Education
Board certification*
Insurance coverage
Record free from sanctions or criminal conduct
Character and ethics references

* Alternatively, board certification may be a privileging requirement instead of a membership requirement if such certification is applicable to specific privileges only and not required of all members.

Membership categories and the definition of the type of practitioner who may be a member of the organized medical staff and associated prerogatives are not uniform across hospitals. Sometimes the same term for a particular staff category may have a different meaning at a different facility. For this reason, despite the fact that it can be burdensome to read the Medical Staff Bylaws in their entirety, it is recommended that at a minimum, applicants familiarize themselves with the nuances contained within the Medical Staff Bylaws related to membership categories and associated prerogatives, eligibility criteria for membership and clinical privileges, timeframes and the procedure for initial appointment and reappointment.

Membership qualifications specific to a podiatric physician may be as follows:

Successfully complete a residency program approved by the Council on Podiatric Medical Education (CPME), the credentialing body recognized by the American Podiatric Medical Association (APMA)
Be board certified or become board certified by the American Board of Podiatric Medicine (ABPM) or the American Board of Foot and Ankle Surgery (ABFAS).

Note: It is up to the hospital to determine what length of time after the completion of formal training to require board certification, if at all, but note that the two CPME-recognized boards give candidates longer than the industry standard five (5) years to complete the process.

What is Privileging?

Privileging is a mechanism to facilitate a practitioner’s clinical practice via a patient centered and risk adverse approach that takes into account an applicant’s education, training, and current experience to perform a specific set of privileges or an individual procedure and is a mechanism for the authorization to practice through the organized medical staff with approval by the governing body. Criteria-based privileging is a requirement of CMS and all other accrediting agencies with deemed status granted by CMS i.e., The Joint Commission, DNV GL, Healthcare Facilities Accreditation Program (HFAP) and others.

The process articulated in the medical staff bylaws, rules, or regulations must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners that considers:

Current clinical competence;
Individual training including residency and fellowship training, post graduate certification of training and/or preceptorship;
Individual experience or ongoing clinical practice in the privileges requested/granted; and
Individual judgment.

Often all of the qualifications for membership noted previously apply with additional specificity related to the applicant’s ability to perform privileges (health status), recent experience specific to the privileges requested, and (in many hospitals) a requirement for board certification in their primary area of practice. For the podiatrist, both the American Board of Podiatric Medicine and the American Board of Foot and Ankle Surgery are recognized by the Council on Podiatric Medical Education’s (CPME) Joint Committee on the Recognition of Specialty Boards (JCRSB) and indicate the demonstration of a cognitive knowledge of a special area of practice. CMS Conditions of Participation prohibits the use of board certification as the only criteria for qualification for privileges.

CMS: §482.12(a)(7): Ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship, or membership in a specialty body or society.

Note: This does not mean that a hospital is prohibited from requiring board certification but it may not be the sole factor.

Approaches to Privileging

One of the most difficult jobs of medical staff leadership is developing the right privileging approach.

An important first step is recognizing the benefits of well-designed and well-maintained criteria-based process. Privileging is a fluid activity and as such, privileging content (scope and eligibility qualifications) must be reviewed and updated (as applicable) on a recurring basis as determined by changes in the field and/or the complexity or evolution of the practice area. The evolution of podiatric education to today’s higher standards is a perfect example. Privilege delineations should be reviewed annually to ensure that they continue to reflect contemporary practice and industry standards.

One of the most effective means of meeting the requirement for criteria-based privileging is through the use of a core privileging methodology.

Many organizations have developed and implemented a criteria-based core privileging system to:

Simplify the process for the applicants by clearly stating the criteria and services/procedures offered
Establish consistency by requiring all practitioners within a clinical specialty / subspecialty to meet minimum threshold criteria.
Reduce focus on seldom-used privileges by placing the focus on like skills and techniques necessary to perform requested procedures.
Assist the medical staff leadership (Department Chairs and Credentials Committee) by clearly defining minimum threshold criteria that allows for objective, evidence-based decision making.

A successful core privileging system that meets accredication requirements should include:

Predefined criteria for each privilege (whether core or non-core) that outlines specific education, training and experience requirements
Descriptions of clinical privileges and accompanying procedures lists as applicable that are accurate, detailed, comprehensive and specific
A system that is designed to avoid denials by clearly stating the minimum education, training, experience, and current competence required to apply for specific clinical privileges
A mechanism for opting out of particular privileges or procedures within the core by the applicant if they don't wish to request them or wish for them to be granted.

External & Internal Influencers

The task of tracking all the requirements for proper credentialing can be a daunting one.

Depending on the type of organization, the external 'masters' they are accountable to, and their own internally defined considerations, the requirements can vary widely.

Credentialing and privileging are required functions driven by federal (CMS) and state laws and regulations (e.g., Healthcare Quality Improvement Act), as well as the healthcare organization’s applicable accrediting body e.g., The Joint Commission, DNV GL, HFAP, Center for Improvement in Healthcare Quality (CIHQ), and others who have been granted deemed status by CMS. For podiatrists, rules and requirements regarding their scope of practice vary from state to state, making it impossible to apply a single privileging standard across different parts of the country.

In addition to the external factors mentioned above, policies and procedures driving the workload and output of credentialing and privileging activities are also controlled by internal documents i.e., bylaws, rules, regulations, policies and procedures of each facility’s legally-constituted, organized medical staff. This accounts for the variation across separately organized and licensed hospitals whether connected within a healthcare system or operating under an entirely different nonassociated structure. Ideally, today’s organizations working to standardize the credentialing and privileging function in health care systems must also look to rationalize and standardize the medical staff dependent policies and procedures driving the credentialing and privileging function.