Posted in: Triangle Times Today

Volume 2 | Issue 6 | June 2023

AAAHC publishes Credentialing and Privileging Toolkit

AAAHC just released its updated Credentialing and Privileging Toolkit to support efforts to demystify and provide guidance on the design and implementation of an effective credentialing and privileging process.
Create a standardized approach for credentialing, privileging, and peer review. According to the 2022 AAAHC Quality Roadmap, some of the greatest challenges with credentialing and privileging include incomplete information, missing or expired supporting documentation, missing peer references, missing or non-specific dates/timeframes that privileges are requested or granted, and absent or incomplete privileging lists, namely for radiology, anesthesia, and supervision of anesthesia services. Deficiencies in any of these areas can lead to providers performing services or procedures for which they need additional qualifications, more experience, and/or performance improvement. These deficiencies can be immediate threats to patient safety and increase risk of liability.

Improving compliance takes effort and includes these keys steps.

  1. Get organized and commit to process improvement. Review process to
    ensure standardization of flow and documentation (electronic and print). Review previous deficiencies and implementation of plans of correction to measure current compliance.
  2. Review governance documents, such as bylaws, policies procedures, etc. on a regular schedule to ensure continued compliance with Standards, state, and federal laws.
  3. Document and communicate any approved changes regarding policies, credentialing activities, and privileges to staff and providers routinely.
  4. Ensure that staff have the necessary training and tools to perform the credentialing function effectively and efficiently. Creating a basic checklist of all requirements and placing it at the front of the file standardizes practice and draws attention to missing or incomplete information.
  5. Create routine audits. Checklists can also serve as audit tools, support completion of the record, and monitor compliance with policies and procedures.

AAAHC Standards also require periodic scrutiny by peers of performance and patient care provided in the setting that is being surveyed. Deficiencies related to peer review include limited criteria and an inconsistent approach. Consider expanding the peer review criteria to include review of clinical records, infection, hospital transfer, and adverse event rates, patient satisfaction survey results, and compliance with medical staff rules and regulations as well as clinically based outcomes criteria decided by the privileged health care providers.

v42 Q&A, Part V

Strong processes and resources (e.g., toolkits, applications, checklists, and procedures) enable medical staff leaders to address concerns in a health care provider’s application quickly, promoting timely, well-reasoned governing body decisions.

Part V of our Q&A series focuses on the important topic of credentialing and privileging.

Does an organization need to privilege providers for new equipment?

Yes, introduction of new equipment, advancement of technology, or changes to scope of services requires the governing body to review and update the providers’ privileges, clinical policies, and the organization’s scope of services. Such changes also require a change notification to AAAHC.

Are allied health providers (AHP) required to be privileged by the governing body?

Yes, the governing body is required to ensure allied health providers undergo a process for initial appointment, reappointment, and assignment or curtailment of privileges every three years or more frequently, if state law or organization policy stipulates.

An independent AHP is also required to undergo peer review and an employed AHP may be evaluated through a process similar to an employee performance evaluation.

Are privileges required for supervision?

Yes, supervising providers require privileges for supervision. Examples include supervision of medical students, residents, physician assistants, and anesthesia providers.

How many peer reviews are required for each provider?

The number of peer reviews are determined by the organization and approved by the governing body. Deciding on the sample size is part of establishing the criteria. Factors to consider include patient volume, case complexity, clinical quality measures, adverse events, and patient satisfaction survey results. Privileged health care professionals are required to participate in the development and application of peer review criteria, and the volume and selection process for care to be reviewed should apply to all similarly privileged health care professionals. The peer review process should then be structured so that all providers participate on a regular basis. According to AAAHC Standards, all privileged health care professionals are reviewed at least annually by a peer or supervising health care professional.

Essentially, the key is to conduct enough reviews on each health care professional to adequately evaluate performance and quickly address emerging trends or concerns.

If an organization has more than one site, can it use a credentialing/recredentialing process that allows for one application requesting privileges for one or more sites? Also, can approval be done at the main site?

Yes, the credentialing process may be completed at a corporate level, whereby a health care provider may complete one application for multiple sites with separate names/Tax Identification Numbers (TINs). However, the governing body at each site must also approve the application.

Organizations that operate under a CMS Certification Number (CCN) must adhere to distinct entity requirements and fully credential and privilege health care providers for each individual location.

Conferences and Exhibits

  • National Association of Community Health Centers (NACHC)
    Aug 27–29
  • California Ambulatory Surgery Association (CASA)
    Sep 13–15
  • Ohio Association of Ambulatory Surgery Centers (OAASC)
    Sep 19–20
  • Becker’s ASC Business and Operations of ASCs
    Oct 26–28
  • IHI Forum — Institute for Healthcare Improvement
    Dec 10–13

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  • Virtual, Sep 18–20
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