Defining Roles of the Credentialing Process

Sep 24, 2021 | Blog, Credentialing | 0 comments

In this blog, Hugh Greeley identifies the four distinct parties and the primary activities of each party’s role involved in credentialing a new applicant for medical staff appointment. He recommends clear delegation and understanding the sequence for maximum efficiency. Reducing redundancy minimizes the stress on all four parties involved in the process. Reducing the amount of time it takes to fully credential and grant privileges to a provider creates a faster track to treating patients and subsequently revenue.

Contributed by Hugh Greeley

This message addresses basic provider credentialing guidelines for members of credentials committees, department chairs, and other significant medical staff leaders. Readers should feel free to copy and distribute to all physician leaders who play a role in the credentials process.

The Four Parties and Distinct Roles

  1. The applicant provides all information required by the hospital’s bylaws, policies, and procedures.
  2. The hospital medical staff professionals collect, compile, and verify the information provided by the applicant.
  3. Physician leaders review and formulate recommendations.
  4. The board (or agent) denies or appoints and grants privileges.

Avoid role confusion. There are four parties involved in the appointment process; each party has a distinct role, and each should avoid involvement in another party’s role.

  1. The Applicant

The applicant is responsible for furnishing complete information about his or her background and current clinical competence. Hospital personnel often assist in this role by confirming the validity of information and gathering additional information not provided directly by the applicant, such as a FACIS® search, an National Practitioner Data Bank report, letters of reference, confirmation of license and residency, etc. It is not necessary that the hospital undertake this role, but it is traditional, and confirmation of selected information by the hospital or its agent is required. Medical staff leaders play a small part in this activity, generally confined to interviewing and contacting references if necessary.

(It is important to note that these two activities involve data-gathering, the results of which should be reduced to contemporaneous notes accurately documenting who contacted whom, what was discussed or provided, when the contact took place, and how was the contact made.)

  1. The Medical Staff Team

The hospital (generally, but not necessarily through the medical staff office) has the responsibility for creating or acquiring an accurate and complete file about the applicant. Information spelled out in bylaws or associated policies must be gathered, verified, stored, and disseminated. The job of collecting and verifying all required information is complex and, in some instances, time-consuming. Physician leaders should avoid attempting either to speed up or to slow down this process by any action whatsoever. The hospital should not provide a file to physician leaders for review until all necessary and required data has been collected and verified.

(Time required: as much as is needed, but in most cases fewer than 15 days.)

  1. Physician Leadership

Physician leaders [departmental chairs, credentials committee members, and the medical executive committee (MEC)] are responsible for reviewing collected data and making recommendations. There is no requirement for either a credentials committee or for departments. However, if your staff bylaws or associated documents require them, they should have a defined role in the process. There is a requirement for executive committee review.

The medical staff’s defined process should be as simple and efficient as possible. Attempt to avoid delays among chair review, the credentials committee, and the MEC. Ideally, this process should be highly coordinated and should not be dependent upon the calendar, seniority, affiliation type (employment, contract, or appointment), temporary convenience, or any factor other than patient care concerns. Once a file is ready for review, the chair should conduct his or her evaluation immediately. The credentials committee may by policy designate its chair to review simple files, and the MEC may act through a specially called virtual meeting. The members of the department have no role in the process. All doubts regarding an applicant’s qualification and competence should be resolved in favor of the patient. Any question about any factor involving professional competence, behavior, qualification, or background should result in a full investigation. No recommendation with unresolved doubts should be forwarded to the board.

(Time needed: in most instances fewer than 5 days.)

  1. The Board

The board’s role is perhaps the most direct and it requires the least amount of expertise. It is to “act for the corporation” by making a legal decision to appoint, deny, grant, or otherwise impact upon a practitioner’s ability to treat patients in facilities covered by the organization’s operating license.

An authorized subcommittee acting on behalf of the board may perform this function. Such a subcommittee should be composed of three individuals, two of whom must be board members. An ideal committee structure might include the president of the staff, the chief executive officer (CEO), and one other board member, providing that either the CEO or staff president is a board member.

The board should exercise oversight of the entire process by requiring an annual internal audit of all credentialing policies, procedures, structures, and outcomes.

(Time needed: a day or so.)


More than 90 percent of all credentialing matters are easy and consist of little more than excellent collection and verification of information, minimal time spent in its review and development of a recommendation, and often less than 30 seconds of the board’s time. Reserve time for careful deliberation of the remaining 10 percent, for they are the purpose of the entire activity.

Hugh Greeley Written by Hugh Greeley
Credentialing and Healthcare Industry Expert
HG Healthcare Consultant