I. INTRODUCTION

Regular verification of the credentials of health care practitioners and definition of their privileges are required for increased patient safety, reduction of medical errors and the provision of high quality health care services. This has been previously recognized via the credentialing requirements imposed upon Health Centers by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Bureau of Primary Health Care (BPHC). The BPHC Health Center Program Expectations (Policy Information Notice (PIN) 98-23 revised) states that a Health Center credentialing process should meet the standards of a national accrediting organization such as the JCAHO or the Accreditation Association for Ambulatory Health Care, Inc., (AAAHC), in addition to the requirements for coverage under the Federal Tort Claims Act (FTCA). However, there are inconsistencies among these requirements. The JCAHO requires primary source verification of the credentials of only licensed independent practitioners. The AAAHC requires credentialing of all licensed healthcare practitioners. The Federally Supported Health Centers Assistance Act of 1992 (Act) requires that each deemed Health Center that participates in the FTCA must credential all its physicians and other licensed or certified health care practitioners. This requirement under the Act covers more health practitioners than the JCAHO or AAAHC requirement. In order to bring clarity to the requirements health centers must meet, BPHC is adopting a credentialing and privileging policy that is consistent with the broader requirement of the Federally Supported Health Centers Assistance Act of 1992.

II. APPLICABILITY

This PIN applies to all BPHC health service delivery grants awarded under section 330 of the Public Health Service Act, including the Community Health Center, Migrant Health Center, Health Care for the Homeless, Public Housing Primary Care, and Healthy Schools, Healthy Communities Programs. It is recommended that all other BPHC affiliated organizations implement this policy.

III. CREDENTIALING POLICY

Credentialing is the process of assessing and confirming the qualifications of a health care practitioner. It is a complex process that includes collecting and verifying information about a practitioner, assessing and interpreting the information, and making decisions about the practitioner.

To bring uniformity and clarity to the credentialing requirements for BPHC grantees the BPHC is adopting the following policy for credentialing.

• All Health Centers shall assess the credentials of each licensed or certified health care practitioner to determine if they meet Health Center standards. This assessment must meet the requirement of 42 U.S.C.§233(h)(2) that calls for review and verification of “the professional credentials, references, claims history, fitness, professional review organization findings, and license status of its physicians and other licensed or certified health care practitioners.” The procedures used for credentialing these practitioners shall follow the requirements of the JCAHO or other nationally recognized accrediting organizations, and must include a query of the National Practitioner Data Bank.
• Health Centers may choose to have credentialing completed by a hospital or credentials verification organization. However, the Health Center must follow all guidelines that the JCAHO or other nationally recognized accrediting organization has placed on the use of these organizations for such a credentials verification process.

IV. PRIVILEGING POLICY

Privileging is the process that health care organizations employ to authorize practitioners to provide specific services to their patients. The BPHC adopts the following policy on privileging.

• A Health Center must verify that its licensed or certified health care practitioners possess the requisite skills and expertise to manage and treat patients and to perform the medical procedures that are required to provide the authorized services. It is incumbent on the Health Centers to assure their users that Health Center practitioners have met standards of practice and training that enable them to manage and treat patients and/or perform procedures and practices with a level of proficiency which minimizes the risk of causing harm. The organization must adopt its own policy that outlines specific privileging requirements and the periodicity of the review of privileges for all licensed or certified health care practitioners.

The privileging process could, for a physician, involve any combination of the following:

• primary source verification of a course of study from a recognized and certifying educational institution showing that the clinician met or passed a level of training required to perform a defined procedure or management protocol;
• direct, first hand one-on-one documentation by a supervising clinician who possesses the privilege of the particular procedure or management protocol;
• direct proctoring by a qualified clinician possessing a degree of expertise in the particular procedure or protocol beyond the level of expertise of most primary care providers. Whatever verification procedures used should be appropriate to the specialty of each practitioner, the breadth of clinical services offered by the Health Center and the particular circumstances of the clinic’s accessibility to ancillary and tertiary medical practitioners.

If you have any questions, please contact CAPT. Martin Bree, Director, Center for Risk Management at (215) 861-4373 or comments@hrsa.gov.

Issued July 17, 2001 - Last reviewed November 20, 2006