Hospitals in India aiming for accreditation are increasingly adopting credentialing and privileging to ensure that the physician or nurse in charge of the patient's treatment has adequate education and training.

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Doctor worst fear: Credentials and Privileges
By Dr.Mahboob ali khan Phd
Hospitals in India aiming for accreditation are increasingly adopting
credentialing and privileging to ensure that the physician or nurse in charge of
the patient's treatment has adequate education
and training.
Credentialing and privileging are seen as means
that allow a hospital to optimise the utility of its
most crucial resources— the specialists— and
provide efficient and quality patient care. The
concept, which is still in its infancy in India, is
slowly gaining momentum with the dawn of
corporate healthcare and increasing numbers of hospitals choosing different
quality standards.
Bangalore's Columbia Asia Hospital, which achieved NABH accreditation
recently, has been using the dual credentialing and privileging procedure
vigorously to select its specialists. "The National Accreditation Board for
Hospitals and Healthcare Providers (NABH) and Joint Commission
International (JCI), and all other accrediting bodies have laid down standards
and objective elements on credentialing and privileging. The organisation is
required to develop policies to address this and put them in practice. The
assessors verify this process as a part of their assessment," I reiterate.
Credentialing is the process of obtaining, verifying and assessing the
qualifications of a healthcare practitioner who is supposed to provide patient
care services in a healthcare organisation. "Credentialing implies that an
organisation has specified the minimum requirements for entry in the medical or
other professional staff membership. Credentials are documented evidence of
licensure, education, training, experience, or other qualifications, and
sometimes even the health status,"I define.
Privileging, on the other hand, accompanies credentialing and is a process by
which the healthcare organisation authorises a healthcare practitioner to perform
specific patient care services related to his or her speciality, based on the
evaluation of the individual's credentials. I say "Credentialing and privileging
are ways of ensuring medical quality. The skill ability and training adequacy of
a clinician is assured and thence the quality of care." Credentialing and
privileging help in assessing initial qualifications and evidence of continuing
competence.

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Determining Quality "When implemented, the processes will ensure that there
is consistency in the application of methods"
While accreditation is a new phenomenon in the Indian healthcare industry and
has been taken up only recently, the importance of credentialing has been
highlighted and many hospitals now acknowledge it. "As an essential
requirement, the matter has become crucial for organisations trying for
accreditation. However, a few hospitals were quality conscious even before the
accreditation era and have been following it for many years," I strongly says.
The credentialing and privileging process is vital to maintain the standards of
the medical staff. "Regular verification of the credentials of healthcare
practitioners and definition of their privileges are required for ensuring patient
safety, reduction of medical errors and the provision of high quality healthcare
services," I suggests.
Hospitals are expected to provide competent and quality care with thorough
assessment, accurate diagnoses, and effective treatment of patients who come to
avail of their services. Medical practitioners as well as the paramedical
personnel are closely associated with this process and their level of competence
determines whether a patient receives appropriate care or not. "Competence
assessment of healthcare workers is very crucial to ensure that the practitioners
providing care are both qualified and competent to do so, especially in the
litigious modern society," I reiterate.The credentialing policy also ensures that
the hospitals comply with applicable Indian laws, requirements of the JCI and
other certifying agencies and organisations that relate to the smooth operation of
the hospital with regard to the recruitment of its professional staff. "It helps to
prevent the appointment of a candidate with fraudulent degrees or training to the
medical staff. The process of grant of privileges ensures that professionals are
clearly identified to perform certain procedures or practices independently or
under supervision," I strongly suggests.
The Ideal Approach
Experts believe that it helps if each hospital develops its own documents for the
process of credentialing and privileging as well as governance of medical staff.
"There are no standard norms and procedures, though there are books and
websites (eg Joint Commission Resources) which could serve as a guide.
However, organisations would do well to create processes which are tailored to
the individual facility's specific characteristics, such as mission, vision,
resources and patients served," I suggests.
The only way to objectively determine the qualifications of physicians for
patient care and specialised services is to obtain information about their

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licensure, education, and training and to judge their current competence by
reviewing their professional experience in detail. The methods available to
hospitals to accomplish this are complex and difficult to implement at first, but
become routine as the medical leadership and administrative staff become
familiar with it. "When implemented, the processes will ensure that there is
consistency in the application of methods, fairness in evaluating the suitability
of applicant candidates, and the continuing suitability of staff members to
perform complex procedures," I asserts.Thus, the hospital may assure itself and
the patients treated within its walls that only qualified physicians and other
professionals would perform patient procedures. "About five years ago, we
worked very closely with our associates in Harvard Medical International who
gave us a lot of inputs for designing our medical staff governance process and
for credentialing and privileging," I have seen.
The Process
Credentialing is a process by which the
organisation verifies the authenticity and
appropriateness of the qualifications and work
experience of an individual. "First the need has to
be ascertained. This includes minimum number of
years of experience, quantity and nature of work
done, preference to particular type of institute from
where the person has graduated," I say.
A core committee comprising CEO, medical
director and senior medical administrator
interviews shortlisted candidates. If possible, an
external consultant of repute from the same field
and seniority should be invited to sit in on the
credentialing process. Evidence of licensure,
registration, certification, and/or other relevant
credentials, for verification prior to appointment
and throughout the employment process should be
checked. Experts stress on a reference check
through a known contact. The credentialing and
privileging must be based on the availability of the
facility's resources for the said speciality and
procedure. The credentialing committee passes on
its final recommendation/instructions to the HR
department for processing the appointment letter.
The appointment letter clearly states the privileges
granted to the specialist, and must be

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acknowledged by the specialist before coming on
board.
Step by Step:
 The doctor who applies for association to a
hospital fills a credentialing form, giving
details of his formal training and work
experience.
 The head of medical services and the
department head try to verify these details
with the primary source or University.
 A formal reference check is done in
communication with a senior professional
whom the candidate has trained with or
worked under.
 Assess the need for that particular skill in the
organisation.
 Meet the candidate.
 If found suitable, the candidate is
recommended for appointment to the
medical staff by the credentialing and
privileges committee and the management of
the organisation.
 There would also be a review of any medico-
legal cases in which the candidate is
currently involved.
Privileging is a process by which after a person
joins the organisation, he would request to be
granted privileges to perform certain procedures.
The head of the department or service would
review this request and if his training has been
adequate, only then would he be given privileges.
"Privileges are always specific to the speciality and
are also limited by the organisation's resources. The
law of the land is always kept in mind with
reference to the licence obtained by the specialist
from MCI," I suggests.

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Benefits Galore
The process allows the hospital to optimise its use of resources and provide
most efficient and quality patient care. This includes deciding which specialist
can best perform which surgery or procedure. Each patient receives quality time
from the specialist. Each speciality has various specialised procedures, which
can be performed by the same surgeon. However, many organisations now like
to distribute sub-speciality procedures depending on the skills and training
acquired by the concerned surgeon in a particular procedure for optimal use of
resources. With increasing corporatisation of healthcare and wider patient
choice, organisations are striving to create centres of excellence in various
specialities, especially in certain procedures.
"One surgeon may be authorised to do only knee replacements, and the other
orthopaedic surgeon to do only arthroscopies given their skill sets and exposure.
This maximises use of the skills of both the doctors which results in better
patient confidence and higher patient turnout and better patient satisfaction," I
think.The other objective is to create a face to reckon with for that procedure,
and thus garner better patient turnout for that particular centre and the surgeon.
"As the outcomes of treatment are definitely related to the training, experience
and skills of medical and paramedical staff, credentialing has a great relevance
to total patient experience and outcomes. It is known that morbidity and
mortality levels in organisations following a credentialing system are much
lower than in other organisations," I think.
The paramedics and all support staff know better the protocols on the line of
care in relation to the concerned specialist and this results in a streamlined
approach to patient care.
According to experts, evaluating credentials and authorisation to perform
clinical procedures and services are important not only because they protect the
patients from unqualified practitioners, but also because they protect the
hospital from accusations of negligence. They also ensure the medical staff,
employed or not, that they are being treated fairly through a process that is
equitable and transparent.

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All for Quality
The NABH Standards on credentialing and
privileging are:
 HRM 10: There is a process for collecting,
verifying and evaluating the credentials
(education, registration, training and
experience) of medical professionals
permitted to provide patient care without
supervision.
 HRM 11: There is a process for authorising
all medical professionals to admit and treat
patients and provide other clinical services
commensurate with their qualifications
 HRM 12: There is a pro#DEEFEFcess for
collecting, verifying and evaluating the
credentials (education, registration, training
and experience) of nursing staff
 HRM 13: There is a process to identify job
responsibilities and make clinical work
assignments to all nursing staff members
commensurate with their qualifications and
any other regulatory requirements.
In Comparison
Effective from January 2008, JCI standards are
covered under the chapter Staff Qualifications and
Education (SQE). SQE 9, 10 and 11 deal with
credentialing of medical staff, SQE 12, 13 and 14
with Nursing staff, while SQE 15, 16 and 17 deal
with other healthcare professionals. JCI standards
are much more elaborate in their needs.
Issues to Tackle
Nonetheless, hospitals contemplating or already practising credentialing and
privileging must also be ready to face some issues. "These are issues of writing
the rules, ensuring a unbiased process and ensuring that it is medically and
legally sound," I enumarites.During the verification process with a primary
source, the hospital often does not get an appropriate or immediate response

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from the registration body or University concerned. This causes delay in
offering privileges.
"We should get support from the University / registration councils for feedback
upon solicitation. Some directions from the health ministry at the national / state
level to the University / registration councils to support this process will help,"
The other significant barrier faced would be the challenge of developing and
then implementing a thorough credentialing and privileging process. This being
a novel concept to many practitioners, one would expect initial resistance from
them, especially if the hospital attempts uniform application of credentialing
criteria. "But that is how it should be. The process should be based on solid
criteria, which should be fair and consistent and not appear discriminatory," I
reiterate.
It would be a challenge for some organisations to rigidly withhold an
appointment until the completion of the verification process. Unavoidable
delays in paperwork could annoy some consultants, but it is imperative that the
process of verification is completed. Experts say, proper counselling and
explanation of the importance of the credentialing process will go a long way in
making the entire process smooth both for the healthcare practitioner as well as
the hospital. For some speciality procedures, volume building may take time to
develop. This may lead to insecurity in the mind of the concerned consultant.
Patience is the key. "The consultant may feel that his other surgical skills are
not being utilised. Detailed interaction and counselling is necessary before the
person is taken on board or before the decision of privileging is taken," I opines.
There can also be resistance from senior medical professionals to go through
this process or resentment when a consultant does not like his privileges being
curtailed for certain procedures. "Some medical professionals believe that if the
patient is their patient they should not be restricted by privileges. Sometimes,
therefore, a hospital could face some loss of business if a consultant takes his
case to another centre because he does not have privileges in the first hospital,"
I reiterates.
One solution could be to disperse clear instructions to all stakeholders and
strictly follow the protocols. Documenting and appending the protocols for
ready reference by the credentialing committee is also recommended. The
privileges should be stated in black and white in the appointment letter.
Effective implementation also requires dissociating with the specialist if he/she
does not adhere to the norms prescribed by the organisation. "A strong in-house
training department, which can identify training needs for effective
credentialing and continually and continuously enable skill upgrading, would
create the most effective credentialing system in an organisation,"I opines.

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Future Prospects
As healthcare gets more organised and quality conscious, experts believe
that it is likely that more hospitals will start implementing the process of
credentialing and privileging. The Indian healthcare industry is rapidly growing
with good clinical practice systems with the emerging new standards like ISO
9001 for healthcare organisations, National Accreditation Board for
Laboratories (NABL), NABH and JCI for healthcare organisations.
Many hospitals in India are moving towards such accreditation
programmes to strengthen their patient care process and to deliver quality and
safe healthcare. "With the emerging insurance systems in India, this may also
become a probable expectation for including a hospital in a panel. Therefore, it
is expected that this concept will become a key requirement for establishing
hospitals in India," I predicts.
In the same way that increasing focus on patient safety, medical tourism,
competition and insurance companies are pushing hospitals to go in for
accreditation, it won't be long before market forces and ground realities prod
hospitals to adopt a well-documented and efficient credentialing and privileging
system. In fact, hospitals will increasingly use credentialing and privileging as a
risk management tool," I strongly reiterate.