1. Credentialing
And Privileging
Of Clinicians
JOVEN BOTIN BILBAO, RN, MA
N
Director of Nursing
Healthcare Accreditation Specialist
Al Inma medical Services

2. The primary responsibility of providing appropriate clinical care to a patient rests with
the doctor under whose care the patient is receiving treatment. Thus, the outcome of
care in a patient, to a very large extent, depends upon the expertise of the treating
doctor. A doctor who is inadequately qualified or competent to handle a patient’s case
can in-fact do more harm than good. Hence, it is extremely important that the patients
are being treated by the right doctor. When doctors are employed or contracted by
hospitals, it is the responsibility of the hospital to ensure that their patients are being trea
ted by the right Healthcare team. Hence it is a must for a hospital committed to
provide high quality clinical care to have a robust policy on credentialing and privileging
of clinicians.
Introduction

3. CREDENTIALING

4. Credentialing refers to the process of collection an
d verification of the evidences of credentials of a d
octor who is to be given the responsibility of
treating patients in the hospital. The process
ensures the authenticity of the details provided
by the healthcare practitioner or doctor.
Collection of evidences of credentials:
Documentary evidences of following credentials should be
collected for Medical Practitioner

5. 1. Education
 Mandatory basic qualification to practice Nursing, medicine, or other
healthcare practices as per) regulations
 Post-graduation, Diploma, Fellowship etc. from recognized
institution with details of the specialization
 Trainings, workshops, certificate courses etc. undertaken by the
medical staff with details of the topics/skills covered
2. Past Experience
 Total number of years/duration of clinical practice
 Specialization practiced by the doctor with its duration
 Type of medical intervention / surgeries performed by the doctor
 Hospitals/Settings with which the doctor has been associated for
medical practice

6. 4. Others
 Registration with requisite councils
 Details of two references who can confirm the
credentials of the doctor
 Proof of identity
 Detailed curriculum Vitae
 Equivalence and legal permit to practice , for a
doctor with medical degree from a foreign
country.
 Other educational or training programme
attended to maintain current competencies

7. Verification Of Credentials:
After collection of evidences of credentials, a verification of the key details should be undertak
en. This include verification of medical qualifications, experience of clinical practice and registra
tion to practice. Verification can be done in following ways
1. For verifying qualification, original medical degree should be verified. For further verificatio
n the university/institute from where the degree is obtained can be contacted and requeste
d to confirm the authenticity of the doctor’s qualification claim.
2. For verifying the experience, original experience certificates must be verified. For further ve
rifications past organizations can be contacted to confirm the details.
3. Verification should also be done from references to confirm various other details provided
by the Staff .
The verification should be documented and recorded with the identification of person who did
the verification. As the work of doctor involves life of patient, verification of every necessary d
etails should be done meticulously. In case of doubt, additional evidences should be collected.
If possible services of a professional employee verification agency can also be availed.

8. Updation of Credentials:
Credentials once collected should be updated from time to time. A specific duration,
such as annual or six monthly should be determined by the organization, after which
the further credentials added by the doctor should be collected and included his/her
file.

9. PRIVILEGING

10. Privileging refers to determining the scope of clinical practice
that a doctor can be permitted for undertaking independently in
the hospital. The scope of doctor’s permitted clinical practice is
also called as ‘clinical privileges’ of the doctor and the process
of granting the clinical privileges is called as ‘privileging’.
Decision of clinical privileges to be granted to a doctor should
be undertaken by a ‘clinical committee’ or a ‘credentialing and
privileging committee’ in consultation with the concerned
doctor. For efficient privileging process, the hospital should
classify the scope of clinical practice in two parts, ‘core clinical
practices’ and ‘clinical practices with specific credentialing
requirements’.

11. Core Clinical Practices – These are the aspects of clinical practice that can be
allowed to be undertaken by all clinician having a particular qualification. The
committee should determine the scope of core clinical practices for each type of
medical qualification. These practices should be such that a doctor with specific
qualification can reasonably be assumed to have the competency of undertaking them.
For example, core clinical practice for a doctor with at-least MBBS degree can be
 Admitting a patient
 Providing medical consultation
 Physical assessment of patient
 Providing basic life support care
 Ordering routine investigations
 Prescribing medicines that are not in high risk category
 Teaching, training and supervising
The committee can modify the core clinical privileges from time to time as per the
prevailing local situation. The purpose of defining core clinical practices is that, a doctor
with requisite qualification can be readily granted these clinical privileges. This enables
the committee to focus on those practices for which there are special credentialing
requirements.

12. Clinical practices with specific credentialing requirements – Certain clinical
procedures requires specific competency on part of the doctor over and
above the requisite qualifications. These competency can be gained by
doctor through additional training or experience. The committee should
identify all such procedures and specific credentials required for the same.
Privileges for performing these should be given to doctors after evaluation of
the fitment of their credentials, by the committee. For example, a general
practitioner when provides evidence of credentials of handling obstetric
cases or emergency medicine cases can be given privileges for handling
these cases. Similarly a general surgeon with virtue of experience in
operating specific kinds of tumors can be given privileges to operate upon
such patients.
The criteria for assigning these privileges should be determined by the
committee and should be carefully determined considering safety of patient
and effectiveness of treatment.

13. Temporary and Permanent Privileges – As the process of privileging
can take some time to complete a policy of granting temporary privile
ges can be made by the organization. With this the doctor will be able
to practice as per the temporary privileges till the time credentialing a
nd privileging process is completed and permanent privileges are gran
ted. For safety reason, temporary privileges should be limited to ‘core
clinical practices’ and if any additional clinical practice is assigned it sh
ould be supervised by a senior doctor with same privileges. Temporary
privileges can also be given to a doctor who would want to associate
with the hospital on a temporary basis.
Review of privileges – From time to time, the privileges of the doctor
should be reviewed and additional privileges can be granted. In certain
situation, where the doctor cease to have the required competency, cli
nical privileges can also be withdrawn.

14. PROCESS OF
CREDENTIALING
AND
PRIVILEGING

15. THE CREDENTIALING AND PRIVILEGING PROCESS CAN BE UNDERTAKEN
IN FOLLOWING STEPS
1. The concerned healthcare should be requested to fill the credentialing and privileging form a
nd submit a copy of documentary evidence of all stated credentials.
2. The doctor should also specify in the form all the clinical privileges that he/she would like to
have
3. The form should be checked for completeness and appropriateness.
4. The information pertaining to the credentials in the form and submitted evidences should be
verified through appropriate means
5. The form should be given to the committee responsible for credentialing and privileging, for
review and determination of clinical privileges. Simultaneously the doctor should be given te
mporary privileges by the chairperson of the committee responsible for credentialing and pri
vileging.
6. The committee after reviewing the form and the privileges being sought should take a decisi
on on whether the same could be granted or any modification needs to be made.
7. The committee should also consult the doctor concerned before finalizing the privileges.
8. After finalization, the temporary privileges should be updated into permanent privileges.
9. All clinical departments head and in-charges should be informed about the clinical privileges
of the doctor, to ensure that same gets practices. Periodic reviews and medical audit should a
ssess the compliance to the assigned clinical privileges.