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PEDIATRICS Vol. 110 No. 2 August 2002, pp. 414-418

AMERICAN ACADEMY OF PEDIATRICS

Medical Staff Appointment and Delineation of Pediatric Privileges in Hospitals

	ABSTRACT

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The review and verification of credentials and the granting of clinical privileges are required of every hospital to ensure that members of the medical staff are competent and qualified to provide specified levels of patient care. The credentialing process involves the following: 1) assessment of the professional and personal background of each practitioner seeking privileges; 2) assignment of privileges appropriate for the clinician’s training and experience; 3) ongoing monitoring of the professional activities of each staff member; and 4) periodic reappointment to the medical staff on the basis of objectively measured performance.

This statement examines the essential elements of a credentials review for initial and renewed medical staff appointments along with suggested criteria for the delineation of clinical privileges. Sample forms for the delineation of privileges can be found on the American Academy of Pediatrics Web site (http://www.aap.org/visit/cmte19.htm). Because of the differences in individual hospitals, no one method for credentialing is universally applicable. The medical staff of each hospital must, therefore, establish its own process based on the general principles reviewed in this statement. The issues of medical staff membership and credentialing have become very complex, and institutions and medical staffs are vulnerable to legal action. Consequently, it is advisable for hospitals and medical staffs to obtain expert legal advice when medical staff bylaws are constructed or revised.

Abbreviations: AAP, American Academy of Pediatrics • NPDB, National Practitioners Data Bank • ADA, Americans With Disabilities Act

	INTRODUCTION

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"Credentialing is the formal recognition of professional and technical competence. The process involves 2 distinct elements: it establishes what information is necessary to confirm professional and technical competence including mechanisms for the verification of the information received by the hospital, and it evaluates the information received with reference to an applicant."¹

"The delineation of clinical privileges is the process whereby the medical staff evaluates and recommends that an individual practitioner be allowed to provide specific patient care services in the institution. A clinical privilege is a specific grant or permission by a hospital for an individual practitioner to perform diagnostic or therapeutic procedures or other patient care services within well-defined limits."¹

Medical staff membership is not synonymous with clinical privileges. Medical staff membership involves the practitioner’s organizational rights and responsibilities. A member of the medical staff is not entitled to perform procedures or treat patients simply by virtue of being a member of the medical staff.¹

	CREDENTIALING PRINCIPLES

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The medical staff of each hospital is responsible for establishing its own procedures for credentialing.² These procedures must be reviewed by a lawyer who is familiar with these issues.³ The authority of the hospital to grant, change, or revoke clinical privileges is based on several principles.

1. The practice of medicine, including pediatrics, within a hospital is not a right of every physician but rather a privilege extended by the hospital in accordance with applicable law.
   
2. The hospital and its governing board are responsible for the safety of its patients and the quality of care provided by its staff.
   
3. The hospital must ensure that all members of its health care team are competent and qualified to provide the services for which they have been granted privileges.
   
4. The organized medical staff of the hospital is entrusted by the governing board with the responsibility of recommending that only competent practitioners treat patients in the hospital.
   

1. The credentialing process must be thorough, fair, and timely and must involve unbiased and good-faith review by peers within or outside the hospital as appropriate to the individual candidate. Any possible malicious use of the peer review process is not acceptable.
   
2. The entire credentialing process must be clearly described in the medical staff bylaws. This must include a description of mechanisms for appeal and guaranteed due process for disputes concerning disciplinary actions and for changes or revocation of privileges. The medical staff bylaws should incorporate provisions of the Health Care Quality Improvement Act of 1986,⁴ requirements of state laws that define immunities and protections for the hospital and peer review committee members from various legal liabilities, and other related legislation.²
   
3. Criteria for specific clinical privileges must be well defined and based on up-to-date national and local standards.
   
4. Confidentiality and protection of the information used in credentialing and peer review, subject to applicable law, must be incorporated into the process.
   
5. The credentialing process should take into account the standards recommended by the Joint Commission on Accreditation of Healthcare Organizations, the Hospital Medical Staff Section of the American Medical Association, state and federal agencies, or other appropriate accrediting organizations.^2,5
   
6. The credentialing process must not allow conflicts of interest (economic or otherwise) to impair due process or affect the credentialing process.
   

In some communities, the credentialing process for medical staffs of area hospitals, surgical centers, and managed care organizations has been consolidated and standardized under a centralized data collection and storage agency, such as the state or local medical society. This allows only 1 application and data verification for applications to more than 1 hospital. However, each hospital is still required to determine the applicant’s qualifications for clinical privileges. The American Academy of Pediatrics (AAP) approves of this model as a method that simplifies the process yet maintains its rigor.

Although credentialing standards have been used as a method of quality assurance, a recent study shows no correlation between stringency of hospital credentialing policies and clinical outcomes.⁶

	INITIAL APPOINTMENT

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When a practitioner applies for medical staff membership the first time, the medical staff must verify the practitioner’s training, experience, and qualifications. This involves verifying the following documents from primary sources or approved secondary sources if applicable:

1. Medical staff category requested
   
2. Current license in the state of practice
   
3. Other active state licenses
   
4. Drug Enforcement Administration certificate
   
5. Medical school education
   
6. Residency and fellowship training
   
7. Practice experience
   
8. Board certification or recertification
   
9. Current cardiopulmonary resuscitation or other lifesaving course (eg, pediatric advanced life support, neonatal resuscitation program) certification
   
10. Settled or pending litigation
    
11. Felony convictions
    
12. Involuntary license or medical staff resignations, suspensions, disciplinary actions, or denials
    
13. Sanctions received from professional organizations
    
14. National Practitioners Data Bank (NPDB) and Federation of State Medical Boards Physician Disciplinary Data Bank information
    
15. Malpractice coverage verification, if required
    
16. Current physical, mental, or substance abuse issues that may affect patient care, as allowed by the Americans With Disabilities Act (ADA).⁷ This information can be obtained after the applicant is determined to meet all other qualifications for medical staff membership.⁸
    
17. Signed release of liability form from the practitioner
    
18. Other information as determined by the individual hospital or department²
    

The NPDB serves as a central repository of information about health care practitioners’ malpractice payments, professional membership restrictions, and adverse actions regarding licenses or hospital privileges. Hospitals are required to check with the NPDB for all new medical staff appointments. They are also required to report any actions that affect the clinical privileges such as reduction, restriction, suspension, or revocation of clinical privileges for at least 31 days; voluntary resignation while peer review is taking place or instead of peer review; and the denial of clinical privileges to a new or existing medical staff member when a peer review judgment is involved. A review of reports to the NPDB from 1991–1995 found variable reporting rates by hospitals. This review hypothesized this variability was attributable to incomplete reporting and the use by hospitals of penalties that did not require reporting.⁹

In addition to concrete data about the applicant’s accomplishments, information from peers should be obtained regarding the practitioner’s ability to work with other staff, patients, and students if applicable. Hospitals may require that each applicant be covered by a minimum limit of medical liability insurance as a condition of membership on the medical staff. This may be waived for practitioners not participating in patient care (eg, retired physicians). For the hospital to verify the information, the applicant must sign a statement allowing the hospital to collect the information and releasing the hospital and references or sources from liability. Hospitals must ensure that all information collected and decisions regarding credentialing are kept confidential.

Depending on state law and hospital or medical staff bylaws, medical staff membership may include nonphysician licensed independent practitioners, such as psychologists, podiatrists, physician assistants, nurse practitioners, midwives, optometrists, dentists, and others who provide direct patient care. Advanced practice nurses also must be credentialed by the department of nursing. Advanced practice nurses who do not provide direct patient care are not credentialed through the medical staff.¹⁰ Guidelines for the practice and requirements for the supervision of nonphysician independent licensed practitioners and residents-in-training must be defined clearly in the medical staff bylaws.² Physicians providing telemedicine services must be credentialed by the hospital using the telemedicine services.²

Criteria for granting or restricting medical staff appointment cannot be based on gender, race or ethnic group, creed, national origin, sexual orientation, membership in professional societies, membership in a prepaid, closed-panel group practice, or solely economic factors. Criteria for medical staff appointment should relate to standards of patient care and to the objectives, purposes, and resources of the institution.

The ADA covers hospital employees and may cover physicians with staff privileges. The ADA prohibits discrimination against qualified job applicants and traditional employees who, with or without reasonable accommodation, can perform the essential functions of their job. It may apply to hospital medical staff matters involving independent contractor physicians. As a result of the ADA, questions regarding personal health issues and alcohol and illegal drug use cannot be asked at the time of initial staff application. A conditional offer of medical staff membership can be made contingent on the applicant providing personal health information meeting certain criteria. In all issues when accommodations are requested for disabilities, the most important factor is the safety of the patient.⁸

Economic credentialing has been defined by the American Medical Association as "the use of economic criteria in determining an individual’s qualification for initial and continuing hospital medical staff membership or privileges that is unrelated to the quality of care or professional competency." Measures that have an economic component in addition to improving quality of care, such as length of stay and intensive care unit days, may be used in credentialing decisions. Several states have laws that prohibit use of economic credentialing.^11,12 In this regard, the AAP states that pediatricians should not be excluded from patient care panels solely on an economic basis.¹³

Initial medical staff membership starts with a provisional or temporary appointment for a defined period of time. This allows direct observation of the practitioner’s clinical skills, patient management style, and manner of care. The need for proctoring and mentoring for new medical staff members should be established by each department. Appointments must be renewed at a minimum of every 2 years.² Medical staff membership is awarded in several categories on the basis of the amount and type of patient care the practitioner delivers. There may be categories for hospital-based ambulatory care only, for full staff including ambulatory and inpatient care, and for those who no longer provide direct patient care in the hospital setting. Nonphysician licensed independent practitioners or residents-in-training may form other categories.

If a hospital medical staff decides to deny initial appointment or reappointment or deny, limit, or suspend privileges, due process and protection must be provided in accordance with customary legal principles and hospital bylaws. This must include procedural due process, which is defined as whether the rules are administered properly and applied equally to all staff members, and substantive due process. The latter is concerned with whether the rules and criteria stated in the bylaws are reasonable, fair, and not arbitrary and whether the decision made by the medical staff or hearing panel is based on the weight of relevant and reliable evidence and only on that evidence presented to the medical staff or hearing panel. Nonphysician licensed independent practitioners also must have similar due process and protection.²

	DELINEATION OF CLINICAL PRIVILEGES

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A major portion of the credentialing process is the delineation of clinical privileges. By this process, the medical staff evaluates and recommends that an individual practitioner is allowed to provide specific patient care services in the hospital on the basis of the mission and needs of the hospital and the practitioner’s training, experience, and skills. Privileges may be denied to an applicant if the hospital does not have the facilities for the requested procedure (eg, a pediatric cardiologist who requests privileges for cardiac catheterization from a hospital that does not have catheterization facilities).¹⁴

Departments within the hospital are responsible for defining the minimum education, training, and experience that a practitioner must possess to deliver care of varying complexity or perform specific procedures. This may be done across departments when patients are cared for by practitioners of different disciplines (such as pediatrics and nursing for nurse practitioners). Once criteria are established, these must be written and applied equitably across practitioners from different specialties (such as pediatrics, family practice, and surgery). Criteria for clinical privileges are based on the complexity of care needed by the patient, such as routine inpatient care, routine newborn care, subspecialty care, or intensive care. Criteria for privileges for procedures can be based on the levels of care, documentation of training, and continued competence in the procedures. Research has shown that skills in some procedures, such as laparoscopy or surgical procedures, improve with repeated use until a set number is reached.^15,16 Other data has shown that patient outcomes are improved for some procedures when a minimum number is performed in a hospital.^15,17 Competency for procedures also can be determined by evaluation of performance under clinical conditions (proctorship). Check lists may be used by the practitioner requesting privileges to document levels of care and procedures requested. Samples can be found on the AAP Web site (http://www.aap.org/visit/cmte19.htm).

Questions are often raised on how one determines that an applicant is competent to care for children in the hospital if the applicant is not a pediatrician or pediatric-trained specialist or subspecialist. Board certification or board eligibility in pediatrics or a pediatric subspecialty or training in a pediatric specialty is assumed to define a basic set of skills and knowledge needed to care for sick children. Many nonpediatrician physicians can document by their training and experience that they are competent in caring for children of varying ages and with varying illness severities. Experience in procedures performed on children should also be documented.

As new procedures and treatment modalities develop, guidelines for clinical privileges must also develop. New procedures and treatment modalities can be divided into major new procedures, such as endoscopy or laparoscopic surgery, or minor changes, such as a new way to perform laparoscopic surgery. Practitioners wishing to be granted privileges in a major new procedure or treatment modality must document sufficient hands-on-training to be deemed competent. Physicians may gain this training through supervised training programs. A practitioner may also gain provisional privileges allowing him or her to perform the procedure under the supervision of another practitioner skilled in the procedure (proctoring).^18,19 Data from some new procedures have shown that the complication rate decreases significantly and competency increases significantly after a certain number of the procedures are performed.^16,20 Guidelines for competency in new procedures or treatment modalities must be developed on the basis of a review of the literature and the technical aspects of the procedure. Once the guidelines are successfully met by the practitioner, full privileges are granted.

	REAPPOINTMENT

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Standards from the Joint Commission on Accreditation of Healthcare Organizations state that reappointment must occur at least every 2 years. This reappointment is based on ongoing monitoring of information concerning the practitioner’s professional performance, judgment, and clinical or technical skills.² The content of the reappointment request must be defined in the medical staff bylaws. The minimum information required from the practitioner includes:

1. Medical staff category requested
   
2. Current license in the state of practice
   
3. Other active state licenses
   
4. Drug Enforcement Administration certificate
   
5. Continuing medical education credit, as required
   
6. Original certification date and certification renewal dates
   
7. Current cardiopulmonary resuscitation or other lifesaving course (eg, pediatric advanced life support, neonatal resuscitation program) certification
   
8. Settled or pending litigation
   
9. Felony convictions
   
10. Involuntary license or medical staff resignations, suspensions, disciplinary actions, or denials
    
11. Sanctions received from professional organizations
    
12. NPDB and Federation of State Medical Boards Physician Disciplinary Data Bank information
    
13. Malpractice coverage verification, if required
    
14. Quality assurance or continuing quality improvement activities and results
    
15. Listing of all hospitals where the practitioner holds privileges and any changes in this status
    
16. Signed release of liability form from the practitioner
    
17. Current physical, mental, or substance abuse issues that may affect patient care, as allowed by ADA
    

In most cases, information should be reviewed in a similar manner to that occurring for initial appointment. If an applicant for reappointment rarely cares for patients in the hospital facility, the medical staff office may need to request information from another hospital where the applicant is more active to help delineate appropriate clinical privileges. If concerns are raised about reappointment or granting initial clinical privileges because of irregularities in clinical activity profile or quality assurance, this information needs to be reviewed by peers and the department head in a confidential manner, as defined in the medical staff bylaws. If concerns persist, the review committee or medical staff must communicate these concerns to the applicant in a confidential manner, as defined by the medical staff bylaws. Due process, as defined in the medical staff bylaws, must be followed.

At times, concerns about physician performance because of waning skills, mental or physical health problems, or substance abuse that affect patient care are brought to the medical staff office between reappointment times. These must be investigated in a confidential and fair manner, as defined in the medical staff bylaws, without waiting for the next reappointment.

The process of credentialing and granting of privileges must be seen as one way for hospitals to help ensure that their patients receive quality care. Pediatricians or pediatric-trained specialists and subspecialists must be involved in defining guidelines to ensure that children receive optimal care.

	Committee on Hospital Care, 2001–2002

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John M. Neff, MD, Chairperson

Jerrold M. Eichner, MD

David R. Hardy, MD

Jack M. Percelay, MD, MPH

Ted Sigrest, MD

Erin R. Stucky, MD Liaisons

	Liaisons

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Susan Dull, RN, MSN, MBA

National Association of Children’s Hospitals and Related Institutions

Mary T. Perkins, RN, DNSc

American Hospital Association

Jerriann M. Wilson, CCLS, MEd

Child Life Council Consultant

	Consultant

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Mary E. O’Connor, MD, MPH Staff

Stephanie Mucha, MPH

	REFERENCES

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1. Kristeller AR. Medical staff: privileging and credentialing. N J Med.1995; 92 :26 –28[Medline]
2. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2001
3. American Medical Association. Report of the Board of Trustees. Medical Staff Legal Status, Legal Counsel, and Conflict of Interest. Available at: http://www.ama-assn.org/meetings/public/annual99/reports/bot/botrtf/botrep3.rtf. Accessed November 29, 2001
4. Health Care Quality Improvement Act. 42 USC 11101 (1986)
5. American Medical Association. Physician privileges and credentials. In: CME Resource Guide. Chicago, IL: American Medical Association;1993. Available at:http://www.ama-assn.org/cmeselec/cmeres/cme-8-2.htm. Accessed November 29, 2001
6. Sloan, FA, Conover CJ, Provenzale D. Hospital credentialing and quality of care. Soc Sci Med.2000; 50 :77 –88[CrossRef][ISI][Medline]
7. Americans With Disabilities Act. Pub L No. 101-336 (1990)
8. McLaughlin EE. Physicians and the ADA. Hospitals should examine policies and procedures. Hospitals.1993; 67 :36 –38[ISI][Medline]
9. Baldwin LM, Hart LG, Oshel RE, Fordyce MA, Cohen R, Rosenblatt RA. Hospital peer review and the National Practitioner Data Bank. JAMA.1999; 282 :349 –355[Abstract/Free Full Text]
10. Lumb EW, Oskvig RM. Multidisciplinary credentialing and privileging: a unified approach. J Nurs Care Qual.1998; 12 :36 –43[ISI][Medline]
11. Schafermeyer RW. Economic credentialing. Ann Emerg Med.1997; 30 :759 –764[CrossRef][ISI][Medline]
12. Blum JD. Economic credentialing moves from the hospital to managed care. J Health Care Finance.1995; 22 :60 –71[Medline]
13. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine and Committee on Medical Liability. Pediatric physician profiling. Pediatrics.1999; 104 :970 –972[Abstract/Free Full Text]
14. Peterson JL. Reviewing credentials and granting privileges. Tex Med.1998; 94 :91 –99[Medline]
15. Hannan EL, Racz M, Kavey RE, Quaegebeur JM, Williams R. Pediatric cardiac surgery: the effects of hospital and surgeon volume on in-hospital mortality. Pediatrics.1998; 101 :963 –969[Abstract/Free Full Text]
16. American Society for Gastrointestinal Endoscopy. Guidelines for credentialing and granting privileges for gastrointestinal endoscopy. Gastrointest Endosc.1998; 48 :679 –682[CrossRef][ISI][Medline]
17. Jenkins KJ, Newburger JW, Lock JE, Davis RB, Coffman GA, Iezzoni LI. In-hospital mortality for surgical repair of congenital heart defects: preliminary observations of variation by hospital caseload. Pediatrics.1995; 95 :323 –330[Abstract/Free Full Text]
18. American Society for Gastrointestinal Endoscopy. ASGE guidelines for clinical application. Proctoring for hospital endoscopy privileges. Gastrointest Endosc.1999; 50 :901 –905[CrossRef][ISI][Medline]
19. Tandy TK III, Hoffenberg S. Emergency department ultrasound services by emergency physicians: model for gaining hospital approval. Ann Emerg Med.1997; 29 :367 –374[CrossRef][ISI][Medline]
20. Dent TL. Training and privileging for new procedures. Surg Clin North Am.1996; 76 :615 –621[CrossRef][ISI][Medline]

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