Credentialing and Privileging for new healthcare staff in an organization and before renewal of contract.

1. Credentialing and
Privileging
Presented by: Dr Syed Raza

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Purpose
The purpose of this policy is to ensure that Awali Hospital has
qualified medical staff that appropriately matches its mission,
resources and patient needs. This is achieved by:
1.Identifying clinicians who are permitted to work
independently or under supervision
2.Specifying the types of care they are permitted to provide in
order to ensure they are qualified to provide patient care
without clinical supervision / with supervision if required
3.The policy also outlines the mechanism for the process of
granting clinical privileges

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What is credentialing?
• ID and right to work
• Staff adequately qualified
• Suitable training and experience for the job
• Practice license – NHRA and home country
• CPD
• Mandatory training and certificates
• Annual performance evaluation
• Physical fitness

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• Candidate selection for interview – CV
• Interview
• Data Flow –
• Degree and qualification certificate ,
experience certificate , medical practice
license ( home country)
• NHRA practice license
• Right to work in Bahrain – Passport/ RP/CPR
Process

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•
Primary Source Verification (PSV) is the act of
verifying the applicant documents directly
from the original or primary source by a
specialized international company called
“Dataflow”. Verification will be for educational
certificates, experience, health license and
good standing certificate.
Data Flow

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• 1. No objection from Primary healthcare
facility
• 2. Limited contract letter
• 3. Relevant documents –ie. part time practice
license
• 4. Right to work
Affiliates /LPP/Locums

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What is privileging ?
Clinical privileging: is the granting of
approval to clinicians, in order to render
specific diagnostic, medical or surgical
services, within pre-defined limits to be
based on the individual’s professional
licensure, education, training, experience
and demonstrated competence

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Types of privileges
• 1. Core clinical privileges – Independent /
under supervision
• 2. Special clinical privileges
• 3. Additional privileges
• 4. Temporary / provisional – probationary
period
• 5. Emergency

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Process of privileging
• 1. Request by staff
• 2. Recommendation by HOD
• 3. Review by C&P committee
• 4. Approval by C & P committee chairperson
• 5. CMO approval

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• Additional privileges
• Emergency privileges ( temporary)
• Review of privileges - Routine / Incidental
• Modification of privileges ( ie. supervision /
further training trecommendations )
• Withdrawal of privileges
Process of privileging

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Availability of privileges in concerned areas
1.On granting of privileges, a hard copy of the
privileges granted will be available at the area
where the clinician has been deployed e.g.
theatre, Urgent Care Clinic. Any change in the
privileges should be updated and informed to
the concerned area – this shall be the
responsibility of the Credentialing and
Privileging Committee.
2.The privileges file of the clinician shall be
updated every 2 years at the time of contract
renewal.

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Availability of privileges in concerned areas
3. In case of investigation by an outside party (NHRA, other
governmental body) or internal committees, in relation to a sentinel
event, significant incident report, the privileges of the concerned
clinician should be reviewed. CMO will be responsible for
determining whether severity of the incident report warrants privilege
review and inform the HOD.
•
4. If a clinician expresses an interest to perform a procedure not on his
approved privilege list, the manager of the relevant area must inform the
HOD and CMO immediately. The matter will be urgently discussed with
the concerned clinician.

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• Privileging forms must be kept in personal
file and a copy should be provided to the
staff
• Clinical privileges are confidential and can be
viewed only by the Nurse Managers of
respective units (theatre, endoscopy,
maternity), HOD, Medical Director and CMO.

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• The Awali Hospital HR Administrator will maintain a
schedule for the renewal of granted privileges and at 2
years will inform the clinician and HOD of the
requirement to renew the privileging form.
• Clinical privileges will be formally reviewed by the CMO
and reported to the Credentialing and Privileging
Committee every 2 years. However, any change,
addition, reduction or limitation of clinical privileges
may be approved by the CMO and Credentialing and
Privileging Committee at any time within that period.

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