By Rommie Johnson, MPH
ACHC standards for credentialing in ASCs and hospitals include lists of required elements, but surveyors frequently identify missing items.
Maintaining current, accurate, and complete credentialing files is required for all accreditable healthcare settings, but it’s an especially critical process for procedural teams. Credentialing not only validates the qualifications of healthcare providers based on education, licensure, and background checks, but the process also upholds patient care standards and manages risk by ensuring that competent, verified professionals are granted specific, relevant clinical privileges.
Larger organizations often have dedicated resources to manage credentialing and privileging, but even smaller, resource-limited facilities can adopt practical strategies to simplify this important function.
What’s the goal?
Credentialing files serve as a primary record of each provider’s qualifications and ongoing competence. Focusing on best practice for these files is essential for:
- Patient Safety: Comprehensive credentialing ensures that care is delivered by capable, trained professionals.
- Quality Assurance: Thorough credentialing protects the organization from potential liability.
- Operational Efficiency: Efficient credentialing facilitates faster approvals that minimize interruptions in clinical operations.
The most common compliance error is incomplete credentialing files. Often, this is identified at the time of renewal of privileges rather than during the initial credentialing process. Examples include:
- Missing documentation
Accreditation standards list the minimum required documentation that constitutes a complete credentialing file. Organizational policy may include a different list, making additional elements required. Many surveyors note that a specific document is missing. For example, ACHC requires an attestation that the applicant will abide by the organization’s medical staff bylaws with each three-year renewal cycle. That means a document signed and dated within the past three years must be present for the credentialing file to be considered complete. - Reliance on external credentialing without verification
Some facilities depend on external credentialing from other organizations. You must independently verify credentials and establish privileges. For example, if your organization has multiple locations, privileging must be specific to each of these locations. Sometimes deficiencies are noted because the credentialing file for a provider privileged at several locations, is approved for procedures that are not performed at the organization being surveyed. - Missing governing body authorization
The organization’s governing body holds ultimate responsibility for its operations. Approving applications for privileges is part of this responsibility. The decision can be based on medical staff recommendation, but it must be authorized (approved, amended, or denied) in writing, by a representative of the governing body. - Insufficient procedural documentation
Many organizations fail to document provider competency on an ongoing basis. Consistently tracking key metrics on patient outcomes can provide a portion of the expected evidence of competency. Peer reviews complete this aspect.
Create a simple ‘what, when, and how’ process
A cost-effective, streamlined solution for achieving and maintaining credentialing compliance depends on a clear process that addresses what data points you need, when they must be obtained, and how they are documented.
- Develop a credentialing checklist
Your checklist should include all required elements (regulatory and organization-specific) such as provider identification, licensure verification, background checks, and peer reviews. You may want to capture elements of the process like governing body approval. - Monitor expiration dates
Credentialing software or even a shared calendar with expiration alerts, accessible to relevant team members, can help ensure timely renewals. Calendar reminders, either on an electronic scheduling system or a dedicated tracking sheet, offer a budget-friendly way to monitor upcoming license or certification expirations to avoid lapses that put your organization and its providers at risk. - Simplify verification procedures
Each credentialing file must include primary source verifications (PSV) for licenses, certifications, and education. Working with a credential verification organization (CVO) is acceptable and can be a cost-effective option. Establishing a direct contact at the CVO allows for quick access to verifications, saving time and reducing the burden on internal staff. - Make competency review the norm
Asking providers to judge their professional peers can make some people uncomfortable but peer review is used to confirm current provider competence, particularly in facilities that may handle specialized procedures. Make it an ongoing process with frequent, brief surveys comprised of open-ended questions. If all providers are engaged in peer review on a regular basis, it presents opportunity for real-time qualitative perspectives. In addition, tracking key metrics like complications and post-procedure outcomes provides quantifiable evidence of each provider’s competency.
Double check for compliance
An annual policy review and targeted internal audits ensure long-term compliance.
Depending on the size of your organization, your governing body may be making privileging decisions more or less frequently. An annual review of your credentialing policies ensures that these individuals are engaged with the purpose and importance of this responsibility and offers a structured opportunity to align policy with current regulations and facility needs. A shared calendar with annual alerts can help you stay on top of scheduling policy review.
Periodic, targeted audits to spot-check credentialing files can reveal areas for improvement without demanding excessive resources. This approach identifies gaps and allows your organization to address them ahead of surveys. Risk management should always be proactive!
– Rommie Johnson, MPH, is program director for ambulatory surgery centers and office-based surgery settings at Accreditation Commission for Health Care (ACHC) where he leads a team of talented staff and surveyors. He can be reached at rjohnson@achc.org.
