Medical Staff Appointment and Delineation of Pediatric Privileges in Hospitals

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 

The role of the hospital in credentialing its staff was first laid out by The Joint Commission on the Accreditation of Hospitals (later renamed The Joint Commission) in 1953 and has been regularly updated since then. This process is distinct from the recognition of competence within a specialty, which is the purview of the various members of the American Board of Medical Specialties.

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 

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.

Certain elements are required in every hospital’s credentialing process:

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, the Hospital Medical Staff Section of the American Medical Association, state and federal agencies, or other appropriate accrediting organizations.² 

Credentialing standards have been updated to include 3 new concepts. Credentialing should be informed by the 6 areas of “general competencies” developed by the Accreditation Council for Graduate Medical Education. Focused professional practice evaluation allows the medical staff to focus on a specific aspect of a practitioner’s performance, such as when competence is suggested but additional information is needed for confirmation. Examples of this are proctoring or peer review of cases. Lastly, ongoing professional practice evaluation provides for continuous evaluation rather than the traditional biannual renewal process.^2,5 Examples of this are direct observation and monitoring patient outcomes. The credentialing process must not allow conflicts of interest (economic or otherwise) to impair due process.

In some communities, the credentialing process for medical staffs of area hospitals, surgical centers, and health insurance companies 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 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 reveals no correlation between stringency of hospital credentialing policies and clinical outcomes.⁵ 

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, recertification, or other measure of ongoing competency

9. Basic life support or other lifesaving course (eg, pediatric advanced life support, neonatal resuscitation program) documentation of completion

10. Settled or pending litigation

11. Felony convictions and criminal background checks

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 information

15. Disciplinary Data Bank information

16. Malpractice coverage verification, if required

17. Current physical, mental, or substance abuse issues that may affect patient care, as allowed by the Americans With Disabilities Act (ADA)⁶; this information can be obtained after the applicant is determined to meet all other qualifications for medical staff membership⁷ 

18. Signed release of liability form from the practitioner

19. 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. Between 5% and 30% of privileging and licensure applications involving an NPDB report were not granted “as requested,” suggesting the NPDB data are important to the process. Unfortunately, underreporting was also evident: 60% to 75% of reportable actions were not reported, limiting the information to which health care entities have access.⁸ 

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.⁹ 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 and include the same level of fairness and rigor as those applied to physicians.^2,10 A physician providing telemedicine services must be credentialed by the hospital receiving the telemedicine services (ie, where the patient is receiving care).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.⁷ 

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, such as length of stay and ICU days, may be used in credentialing decisions. Several states have laws that prohibit use of economic credentialing,^11,12 although in most states, it is still legal and physicians need to be aware of the ramifications of participating in potentially competing entities.¹³ In this regard, the American Academy of Pediatrics states that pediatricians should not be excluded from patient care panels solely on an economic basis.¹⁴ 

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, but processes must also allow for interval evaluation as needed.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 

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).¹⁵ 

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. Experience may be defined as cumulative or as a certain volume in a period of time. This definition may be applied 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 revealed that skills in some procedures, such as laparoscopy or surgical procedures, improve with repeated use until a set number is reached.^16,17 Other data have revealed that patient outcomes are improved for some procedures when a minimum number is performed in a hospital.^16,18 Competency for procedures also can be determined by evaluation of performance under clinical conditions (proctorship). Checklists may be used by the practitioner requesting privileges to document levels of care and procedures requested.

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. Skill levels for individual practitioners caring for children can be determined by reviewing training and experience. Experience in procedures performed on children should also be documented. Standards for assessing competencies of nonpediatric physicians should be defined and rigorous and meet uniformed standards of care for children regardless of the physician’s training.

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 not inherent in their residency or fellowship training (such as use of ultrasonography or providing sedation) 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).^19,20 Data from some new procedures have revealed that the complication rate decreases significantly and competency increases significantly after a certain number of the procedures are performed.^17,21 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.

Standards from The Joint Commission 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) documentation of completion

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 or consider modifying the appointment to that of ambulatory-care only. 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 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.

It is the responsibility of each member of the medical staff to raise any concerns about physician performance because of waning skills, mental or physical health problems, or substance abuse that affects patient care. 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 1 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.

Hospitals should have an established policy on emergency privileges that allow current medical staff members to practice beyond their existing privileges to save a life, limb, or organ. Likewise, there should be a policy for disaster privileges that enable practitioners outside the current medical staff to treat patients in the case of a disaster in the community.² 

Daniel A. Rauch, MD

Jerrold M. Eichner, MD, Chairperson

James M. Betts, MD

Maribeth B. Chitkara, MD

Jennifer A. Jewell, MD

Patricia S. Lye, MD

Laura J. Mirkinson, MD

Chris Brown, MS, CCLS – Child Life Council

Kurt F. Heiss, MD – Section on Surgery

Lynne Lostocco, RN, MSN – National Association of Children’s Hospitals and Related Institutions

Richard A. Salerno, MD – Section on Critical Care

Jack M. Percelay, MD, MPH – Hospital Accreditation Professional and Technical Advisory Committee, The Joint Commission

S. Niccole Alexander, MPP

Daniel A. Rauch, MD, Chairperson

Jennifer A. Daru, MD, Chairperson-Elect

Matthew D. Garber, MD

Paul D. Hain, MD

Steve Narang, MD

Ricardo A. Quinonez, MD

Erin R. Stucky, MD, FAAP

Laura J. Mirkinson, MD, Immediate Past Chairperson

Elena Aragona, MD – Section on Medical Students, Residents, and Fellowship Trainees

S. Niccole Alexander, MPP

ADA

Americans With Disabilities Act

NPDB

National Practitioners Data Bank