Understanding the Hospital Board’s Role in the Credentialing and Privileging Process

Do you know who’s responsible for determining if a physician is qualified to practice at your hospital? If you’re scrambling trying to think of one person’s name, you’re on the wrong track. The reality is, credentialing and privileging is a mutual process, and it takes a strong partnership of the medical staff, the medical executive committee and the hospital board to get right.

That said, while the medical staff and medical executive committee play necessary roles in the process, the board has the ultimate authority for granting, restricting, and revoking privileges. 

And this is not a responsibility rural hospital boards should take lightly. The board’s accountability and oversight of credentialing and privileging exists first to protect patients. A fair, thorough, and consistent process improves the quality of care that patients receive and lessens the probability of harm. The board’s participation also can protect the hospital against claims of negligent credentialing, which most states recognize as a cause of action in litigation. “Hospitals have a duty to investigate, select, and retain only qualified and competent physicians.,” says Carolyn St. Charles, Chief Clinical Officer for HealthTechS3. “What’s more, hospitals can be found negligent if they fail to follow their credentialing process—or the process itself is inadequate.”

St. Charles says one of the biggest credentialing and privileging mistake rural hospital boards make is rubber stamping recommendations made by the medical staff without reviewing the provider’s file and clarifying any questions they have about the file.

This happens a lot—and understandably so. Boards may feel uncomfortable and unqualified to be making decisions. In other words, “I’m not a doctor, I don’t speak medical.” At the same time, physicians and medical staff may feel threatened by non-medical professionals making decisions about who can practice in the organization. “Only physicians know which providers should have privileges. We do a great job reviewing these files—that should be enough.”

St. Charles says clarifying roles and responsibilities—and not oversimplifying them—is the key.

“While the final authority rests with the governing board, both the board and the medical staff play central roles in this process,” she says. “While the medical staff develops the actual credentialing process, the board should keep its focus on maintaining the integrity of this process.”

For example, as the medical staff determines how to evaluate applicants, the board works in tandem to ensure performance criteria set the quality and safety bars high. While the medical staff assesses the performance of physicians, it’s the board’s job to verify that the process is applied consistently for all applicants. Finally, it’s the medical staff’s responsibility to make recommendations to the board, but it’s the board that will ultimately appoint providers to the medical staff and grant privileges. On October 9, St. Charles will be sharing best practices in credentialing and privileging in the webinar, “Medical Staff Credentialing and Privileging: The Basics and Beyond.” In addition to defining basic terms—the difference between credentialing and privileging—and providing an overview of the Conditions of Participation and applicable Joint Commission standards, she will outline the must-haves in any applicant profile and identify red flags that are unique to initial applications and reappointment reviews. Don’t miss this important overview of credentialing and privileging. Reserve your spot today: https://www.healthtechs3.com/medical-staff-credentialing-and-privileging-the-basics-and-beyond/