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Medical Staff Credentialing Self-Assessment Questionnaire July 2005 (Operating Room Risk Management) 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA Tel +1 (610) 825-6000 Fax +1 (610) 834-1275 Web www.ecri.org E-mail orrm
@
ecri.org
Operating Room
Risk Management
VOLUME 3
July 2005
Medical Staff Credentialing
Self-Assessment Questionnaire
Self-Assessment Questionnaires 3
Initial assessment by:
Date:
In consultation with:




Date of previous
assessment:
A hospital has two major goals in medical staff credentialing. The rst goal is to avoid patient harm by ensuring that
individuals holding clinical privileges are quali ed and competent to provide speci c medical services. The second
goal is to treat all applicants for initial appointment, reappointment, and privileges fairly and consistently.
This Self-Assessment Questionnaire (SAQ) is designed to help operating room (OR) risk managers evaluate
their hospitals policies, medical staff bylaws, rules and regulations, and actual practices regarding credentialing to
determine whether these two goals are being met.
The Operating Room Risk Management (ORRM) System recommends that this SAQ be completed annually.
Listed below are sources used to develop the questions in this SAQ. This list is not intended to be comprehensive.
State laws and regulations as well as case law in a facilitys jurisdiction may also affect credentialing requirements.
For additional information, refer to the Analysis on medical staff credentialing in your ORRM System.
Centers for Medicare & Medicaid Services Conditions of Participation for Hospitals, 42 CFR 482.22.
Economic credentialing [risk analysis]. In: Healthcare Risk Control (HRC) System. 2005 July;3:Medical staff 1.1.
Health Care Quality Improvement Act of 1986 (HCQIA), Pub. L. No. 99-660
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Comprehensive accreditation manual
for hospitals. Oakbrook Terrace (IL): JCAHO; 2004.
Medical staff credentialing [analysis]. In: Operating Room Risk Management (ORRM) System. 2005
July;3:Education/Credentialing 13. OPERATING ROOM RISK MANAGEMENT
©2005 ECRI Institute. May be reproduced by member institution only for distribution within its own facility.
JULY 2005
2
Self-Assessment Questionnaires 3
MEDICAL STAFF BYLAWS
1.
Do the hospitals medical staff bylaws
and rules/regulations contain a detailed
description of all steps in the credential-
ing process?



2.
Do the bylaws separately delineate the
steps involved in the following:
a. Initially appointing individuals to
the medical staff?



b. Reappointing existing members of
the medical staff?



c. Reviewing and recommending
individual, hospital-speci c
clinical privileges during the initial
appointment and reappointment process?



d. Reviewing and recommending
individual, hospital-speci c clinical
privileges requested within an
appointment period?



e. Reviewing and recommending
temporary privileges for specialist
physicians who may be called in to
ful ll an important patient care need?



f. Reviewing and recommending
temporary privileges (when a patient
care need must be met or when a new
applicant who provided a complete
and clean application has been veri-
ed and is awaiting review and
recommendation by the medical staff
executive committee and approval by
the governing body) for applicants
with clean applications (de ned
by JCAHO as having no current or
previously successful challenge to
license or registration, no involuntary
termination of membership from a
medical staff, and no involuntary
limitations, reductions, denials, or
losses of clinical privileges at another
institution) who are awaiting review
by and approval of the medical staff
executive committee and governing body?



*N/I stands for Needs Improvement.
YES
NO
N/I*
N/A
COMMENTS OPERATING ROOM RISK MANAGEMENT
©2005 ECRI Institute. May be reproduced by member institution only for distribution within its own facility.
JULY 2005
3
(continued)
Self-Assessment Questionnaires 3
YES
NO
N/I
N/A
COMMENTS
g. Reviewing and recommending
expedited privileges (granted to
practitioners by a subcommittee of
the governing body once the medical
executive committee has reviewed
and recommended approval of the
application, but before the application
is presented to the governing body)
for applicants with clean applications
who are awaiting review by and
approval of the governing body?



h. Reviewing and recommending
disaster credentialing and privileging
of licensed independent practitioners
when the hospitals disaster
management plan is activated?



i. Reviewing and recommending
credentialing and privileging of
licensed independent practitioners
who provide diagnoses or treat
the hospitals patients via a
telemedicine link?



3.
Are all changes to the bylaws adopted
by the medical staff and approved by the
hospitals board before becoming effective?



4.
Are all changes to the bylaws also
incorporated into the medical staff devel-
opment plan, hospital or board policies
and procedures, disaster management
plan, and other relevant documents?



5.
Do the bylaws outline a process for the
medical staff to review and approve all
administrative policies and procedures
related to appointment, reappointment,
privileging, and due process for creden-
tialed practitioners?



6.
Are the bylaws in compliance with state
statutes regarding the appointment of
credentialed practitioners?


OPERATING ROOM RISK MANAGEMENT
©2005 ECRI Institute. May be reproduced by member institution only for distribution within its own facility.
JULY 2005
4
Self-Assessment Questionnaires 3
YES
NO
N/I
N/A
COMMENTS
7.
Are the bylaws in compliance with
federal statutes and regulations, includ-
ing Centers for Medicare & Medicaid
Services Conditions of Participation,
regarding the appointment of creden-
tialed practitioners?



8.
Do the bylaws require all currently cre-
dentialed practitioners to report to the
hospitalin a predetermined amount of
timeall claims, disciplinary proceed-
ings, or adverse actions taken at other
hospitals?



9.
Do the bylaws require all currently cre-
dentialed practitioners to report to the
hospitalin a predetermined amount of
timeany felony convictions or exclu-
sions from federally funded programs?



10.
Do the bylaws outline the grievance
process available to credentialed prac-
titioners whose clinical privileges are
involuntarily limited, reduced, or revoked?



11.
Does the grievance process include provi-
sions for a fair hearing and an appeal?



12.
Do the bylaws state that sole authority
for granting privileges is retained by the
governing body?



13.
Have the bylaws been reviewed by
an attorney?



CREDENTIALING CRITERIA
14.
Do criteria for medical staff membership
and/or clinical privileges pertain, at
minimum, to evidence of the following:
a. Clinical competence?



b. Current licensure?



c. Physical and mental capacity to
perform the privileges requested?



d. Relevant training?



15.
Are criteria for reappointment and re-
newal or revision of clinical privileges
based on the following:
a. Clinical performance based on quality
assessment results?


OPERATING ROOM RISK MANAGEMENT
©2005 ECRI Institute. May be reproduced by member institution only for distribution within its own facility.
JULY 2005
5
(continued)
Self-Assessment Questionnaires 3
YES
NO
N/I
N/A
COMMENTS
b. Ability to work with others?



c. Knowledge of and adherence to
patient safety initiatives, such as
the completion of medical records
(with an emphasis on legibility and
the use of only those abbreviations
permitted by the facility)?



d. Health status regarding ability
to perform?



16.
If clinical and professional performance
data is not available, are peer references
used to assess competence?



17. Are
hospital-speci c guidelines in place
for assessing clinical competence regard-
ing new technology and/or new medical
procedures and techniques?



18.
Are the criteria used to assess compe-
tence developed using statements or
guidelines from recognized medical
specialty organizations?



19.
Are these criteria department and spe-
cialty speci c?



20.
Are these criteria developed using a
multidisciplinary approach within
the hospital?



21.
Do all clinical criteria for medical staff
membership and clinical privileges relate
to the quality of patient care?



22.
Are clinical criteria unrelated to the
economic well-being of individual prac-
titioners or practitioner groups or to
maintaining the market share of current
medical staff members?



23.
Are criteria using economic factors, such
as exclusive contracts or nancial impact
on the hospital of a practitioners invest-
ment in competing facilities or his or her
resource utilization patterns, developed
only by the governing body?



24.
Are all criteria using economic factors
included in the governing bodys bylaws
and policies/procedures?