Credentialing and Privileging for Pharmacists
Credentialing and Privileging for Pharmacists
The privileging and credentialing processes used by health systems have evolved over the past 30 years, and the pace of that change is increasing. This evolution is driven by society's interest in protecting the public's health, liability law, and the emergence of regulation in response to these issues. This article answers basic questions that pharmacists may have about the privileging and credentialing processes and explains the purposes, terminology, rationale, and processes of clinical privileging. The differences between privileging and credentialing are explained, and background information about the privileging of other health professions is also provided. A glossary of terms can be found in the appendix, and several case studies are included in this article.
Credentialing is the process used by health care organizations to validate professional licensure, clinical experience, and preparation for specialty practice. Health care professionals must have some form of credentialing before they are hired by a health care system and before they are granted specific patient care privileges. For pharmacists, this process has generally been limited to verification by the health system's human resources or personnel department that the pharmacist is a graduate of an accredited pharmacy curriculum and is licensed to practice pharmacy in that state.
The Council on Credentialing in Pharmacy defines three fundamental types of credentials: college or university degrees; licensure and relicensure; and certificates, awards, or postgraduate work. In other health care professions, credentials include proof that the practitioner has completed either an accredited training program for a specific patient care activity or a defined number of specific patient care activities under the supervision of an expert. Other quantifiable means of determining competency for a specific patient care service are also sometimes used, such as log books' recording date, type of procedure or service performed, and signature of supervising health professional, or documentation of special education or training (e.g., board certification, competency-based continuing education, fellowship or residency training).
Credentialing was formally introduced into accreditation procedures in 1989, when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established standards that required health care organizations to perform credentialing functions. As organizations gained experience with credentialing, they recognized the need for more specific competency assessment of individual practitioners. Credentialing a health care practitioner can provide the health care organization with a broad assessment of a practitioner's qualifications in a subject area, but the process often lacks the specificity required to ensure competence for specific patient care functions. For example, the credentials needed to ensure competence depend on local standards of practice and the procedures determined by the health care organization for self review and peer review. Credentials that ensure competence in one health care organization or region may not be adequate to ensure competence in a different health care organization or region. Organizations have increasingly come to rely on privileging as a method of assessing the competency of independent practitioners.
Privileging is the process used by health care organizations to grant to a specific practitioner the authorization to provide specific patient care services. Privileging ensures that the individual requesting clinical privileges is capable of providing those patient care services in accordance with the standard of care of the facility granting the privilege.
Pharmacists have not generally participated in privileging. After a preemployment review of a pharmacist's credentials, health systems have generally allowed pharmacists to perform all the activities permitted by the state's pharmacy practice act. Pharmacists are facing mounting pressure to ensure competency as their patient care role expands and as pharmacy specialization increases. Privileging of pharmacists has been generally limited to ensuring competency in the provision of clinical services that are not specifically identified in state licensure to practice pharmacy. For example, a health system may require that pharmacists be privileged to provide pharmacokinetic monitoring and make dosage adjustments for patients receiving gentamicin. Dosing and monitoring are within the legal scope of practice for the pharmacist, but a health system may decide that the dosing and monitoring of gentamicin is a specific clinical privilege that will require the pharmacist to establish his or her competency.
Privileging and credentialing are distinct but related processes. When a health care practitioner applies for privileges from a health system, the organization grants the privileges only after thoroughly reviewing a defined set of credentials. Credentialing and privileging processes may overlap and can occur simultaneously.
The processes for credentialing and privileging must be clearly defined in the medical staff bylaws and in the policies and procedures of each health care organization. JCAHO standards require that the clinical privileges granted by an organization "fall within defined limits based upon the licensed independent practitioner's qualifications and current competence" and that consideration of initial, renewal, or revision of clinical privileges be based on peer evaluation of professional performance, judgment, and clinical and technical skills. JCAHO standards also stipulate that nonphysician providers may be appointed to the medical staff of the organization and granted clinical privileges if those privileges fall within the practitioner's scope of practice as defined by state law or regulations. However, once practitioners seek clinical privileges, they are bound by the requirements of the organization's bylaws.
The first step in the privileging process is usually application for clinical privileges by a practitioner. Organizations typically have application packets that list the information required for consideration. The applicant submits a comprehensive list of the requested privileges and provides evidence of his or her credentials. The initial task of credentialing is to verify the applicant's qualifications. While the applicant's credentials are being evaluated, temporary approval of privileges may be awarded.
Credentialing is usually governed by a health-system committee, often called the credentialing committee, which also grants patient care privileges. The credentialing committee includes representatives of providers who hold clinical privileges in that organization, and they make recommendations regarding the granting of privileges to the organization's governing body (e.g., the medical staff executive committee). The credentialing committee varies in composition. It may be composed primarily of medical staff with some administrative representation, although some organizations prefer a more interprofessional group.
In some organizations, the administrative aspects of the credentialing process are conducted by staff (such as a quality assurance department) who forward information to the appropriate administrative body (e.g., the credentialing committee) for a decision. Increased demand for credentialing has spawned the emergence of private credentialing services. These services process application packages, verify applicants' credentials, and present their findings to the organization. It is critical that, whatever the organizational approach, applicants are protected from potential bias from economic competitors and receive due process.
As a result of the Health Care Quality Improvement Act of 1986, the Health Resources and Services Administration (HRSA) developed a national registry of providers who lose malpractice claims or are subject to adverse actions of greater than 30 days on licensure, privileges, or society memberships. This registry, the National Practitioner Data Bank (NPDB), is operated jointly by HRSA and JCAHO. All health care organizations are required to query the NPDB each time an independent practitioner applies for medical staff appointment or clinical privileges and every two years thereafter. All health professionals should be aware of the NPDB and how it is used to contribute to the assessment of a health professional's competence.
JCAHO and the National Committee for Quality Assurance (NCQA) expect health systems to critically reappraise the qualifications and competence of their providers at least biennially for reappointment and renewal of clinical privileges. Emphasis is placed on the process of reappraisal to ensure that the professional continues to be competent and maintains the necessary clinical skills.
JCAHO currently requires privileging for "licensed independent health care practitioners," defined as those who are permitted by law and regulation and by the health care organization to provide patient care without supervision or direction, within the scope of the individual's license and individually granted clinical privileges. JCAHO does not currently consider pharmacists to be independent health care practitioners, but this classification may change, as JCAHO recognizes nurse practitioners and physician assistants as licensed independent practitioners where state law permits them to provide unsupervised patient care. As pharmacist involvement in collaborative practice agreements grows, health systems and regulators will face increasing pressure to ensure the competence of these practitioners. Hospitals and health systems may also choose to credential and privilege health care practitioners, including pharmacists, who are not independent practitioners but whose complex roles in patient care require an assurance of competence.
Credentialing and privileging are no longer limited to inpatient settings, as the Accreditation Association for Ambulatory Health Care and NCQA require their use. Managed care organizations, large group practices, ambulatory care organizations, and others are developing mechanisms to ensure standard qualifications and competence of all autonomous care providers. In 2003, JCAHO created a single set of credentialing and privileging standards that apply to all long-term-care and subacute care programs within the organizations it accredits.
Privileging minimizes a health care organization's legal liability, helps fulfill an organization's mission of providing quality patient care, and can reduce staff conflicts by establishing criteria required to provide specific patient care services.
Health systems are liable for services provided by health care providers on their premises. The duty of selecting medical staff and supervising or monitoring their actions cannot be delegated, meaning that the hospital or health system cannot shift this responsibility to another entity, such as state licensure boards or other bodies that offer specialty credentials or other measures of competency. Health systems and their medical staffs may be held liable for damages if they permit an unqualified practitioner to practice in the organization or if they allow even a qualified practitioner to provide specific clinical services that he or she has not been deemed competent to perform within that health system.
Individuals participate in the privileging process to gain authorization to perform specific patient care services within a health care system. Examples include the privileging of surgeons to perform surgical procedures not included in the core surgical training program (e.g., laparoscopic general surgery, comprehensive gynecological endoscopic surgery, colonoscopy) and the privileging of advanced practice nurses (nurse midwives, nurse anesthetists, and nurse practitioners) to admit patients to hospitals. Pharmacists may choose to participate in privileging to establish their competency in providing specialized patient care services (e.g., pharmacokinetic dosing; individualization of anticoagulation dosing and monitoring; design, ordering, and monitoring of parenteral nutrition services; preparation of specialized medications).
As pharmacists gain recognition through health care regulation as health care providers (e.g., Medicare-recognized providers), they may find it necessary to ensure their competence to gain authorization from their health system to provide certain patient care services. Some pharmacists may need to seek authorization for the clinical privilege to provide a patient care service for which they have developed a protocol or agreement with a medical staff member. Health care organizations are obligated to assess the competency of professional staff, regardless of collaborative practice agreements or departmental policy.
Some pharmacists are concerned that the recognition of pharmacists as health care providers under Medicare will encourage state boards of pharmacy or other government agencies to establish procedures beyond licensing to determine a pharmacist's competence to provide specific patient care services. Such an approach would deviate from the standard practice for other medical professions, in which competence to provide certain services is determined at the level of the health care organization, rather than by state boards or other government agencies. JCAHO states that "privileges awarded must be component specific and consistent with the organization's plan for service and its ability to support the care provided." In other words, competence to provide specific patient care services needs to be established locally by the health care organization, as only that organization can determine what it can support. Such an assessment cannot be made by a state board or other government agency. Although specific measures of competency can and will be debated, an examination of the processes used to privilege other health care professionals demonstrates that competency should be measured against a local, rather than a statutory, standard of practice.
As the use of privileging has expanded, health care organizations have increasingly sought the guidance of the health care professions for competency assessment. Dermatologists, rehabilitation medicine physicians, psychiatric nurses, and other professional groups have established task forces to provide such guidance.
The department responsible for the privileging process (typically the medical staff credentialing or quality assurance department) should be able to provide you with information about your institution's privileging process. The following Web sites, along with the references cited in this paper, provide additional information about privileging:
Below are illustrative case studies of privileging for pharmacists. A brief summary of their key points appears in Table 1 .
The privileging and credentialing processes used by health systems have evolved over the past 30 years, and the pace of that change is increasing. This evolution is driven by society's interest in protecting the public's health, liability law, and the emergence of regulation in response to these issues. This article answers basic questions that pharmacists may have about the privileging and credentialing processes and explains the purposes, terminology, rationale, and processes of clinical privileging. The differences between privileging and credentialing are explained, and background information about the privileging of other health professions is also provided. A glossary of terms can be found in the appendix, and several case studies are included in this article.
Credentialing is the process used by health care organizations to validate professional licensure, clinical experience, and preparation for specialty practice. Health care professionals must have some form of credentialing before they are hired by a health care system and before they are granted specific patient care privileges. For pharmacists, this process has generally been limited to verification by the health system's human resources or personnel department that the pharmacist is a graduate of an accredited pharmacy curriculum and is licensed to practice pharmacy in that state.
The Council on Credentialing in Pharmacy defines three fundamental types of credentials: college or university degrees; licensure and relicensure; and certificates, awards, or postgraduate work. In other health care professions, credentials include proof that the practitioner has completed either an accredited training program for a specific patient care activity or a defined number of specific patient care activities under the supervision of an expert. Other quantifiable means of determining competency for a specific patient care service are also sometimes used, such as log books' recording date, type of procedure or service performed, and signature of supervising health professional, or documentation of special education or training (e.g., board certification, competency-based continuing education, fellowship or residency training).
Credentialing was formally introduced into accreditation procedures in 1989, when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established standards that required health care organizations to perform credentialing functions. As organizations gained experience with credentialing, they recognized the need for more specific competency assessment of individual practitioners. Credentialing a health care practitioner can provide the health care organization with a broad assessment of a practitioner's qualifications in a subject area, but the process often lacks the specificity required to ensure competence for specific patient care functions. For example, the credentials needed to ensure competence depend on local standards of practice and the procedures determined by the health care organization for self review and peer review. Credentials that ensure competence in one health care organization or region may not be adequate to ensure competence in a different health care organization or region. Organizations have increasingly come to rely on privileging as a method of assessing the competency of independent practitioners.
Privileging is the process used by health care organizations to grant to a specific practitioner the authorization to provide specific patient care services. Privileging ensures that the individual requesting clinical privileges is capable of providing those patient care services in accordance with the standard of care of the facility granting the privilege.
Pharmacists have not generally participated in privileging. After a preemployment review of a pharmacist's credentials, health systems have generally allowed pharmacists to perform all the activities permitted by the state's pharmacy practice act. Pharmacists are facing mounting pressure to ensure competency as their patient care role expands and as pharmacy specialization increases. Privileging of pharmacists has been generally limited to ensuring competency in the provision of clinical services that are not specifically identified in state licensure to practice pharmacy. For example, a health system may require that pharmacists be privileged to provide pharmacokinetic monitoring and make dosage adjustments for patients receiving gentamicin. Dosing and monitoring are within the legal scope of practice for the pharmacist, but a health system may decide that the dosing and monitoring of gentamicin is a specific clinical privilege that will require the pharmacist to establish his or her competency.
Privileging and credentialing are distinct but related processes. When a health care practitioner applies for privileges from a health system, the organization grants the privileges only after thoroughly reviewing a defined set of credentials. Credentialing and privileging processes may overlap and can occur simultaneously.
The processes for credentialing and privileging must be clearly defined in the medical staff bylaws and in the policies and procedures of each health care organization. JCAHO standards require that the clinical privileges granted by an organization "fall within defined limits based upon the licensed independent practitioner's qualifications and current competence" and that consideration of initial, renewal, or revision of clinical privileges be based on peer evaluation of professional performance, judgment, and clinical and technical skills. JCAHO standards also stipulate that nonphysician providers may be appointed to the medical staff of the organization and granted clinical privileges if those privileges fall within the practitioner's scope of practice as defined by state law or regulations. However, once practitioners seek clinical privileges, they are bound by the requirements of the organization's bylaws.
The first step in the privileging process is usually application for clinical privileges by a practitioner. Organizations typically have application packets that list the information required for consideration. The applicant submits a comprehensive list of the requested privileges and provides evidence of his or her credentials. The initial task of credentialing is to verify the applicant's qualifications. While the applicant's credentials are being evaluated, temporary approval of privileges may be awarded.
Credentialing is usually governed by a health-system committee, often called the credentialing committee, which also grants patient care privileges. The credentialing committee includes representatives of providers who hold clinical privileges in that organization, and they make recommendations regarding the granting of privileges to the organization's governing body (e.g., the medical staff executive committee). The credentialing committee varies in composition. It may be composed primarily of medical staff with some administrative representation, although some organizations prefer a more interprofessional group.
In some organizations, the administrative aspects of the credentialing process are conducted by staff (such as a quality assurance department) who forward information to the appropriate administrative body (e.g., the credentialing committee) for a decision. Increased demand for credentialing has spawned the emergence of private credentialing services. These services process application packages, verify applicants' credentials, and present their findings to the organization. It is critical that, whatever the organizational approach, applicants are protected from potential bias from economic competitors and receive due process.
As a result of the Health Care Quality Improvement Act of 1986, the Health Resources and Services Administration (HRSA) developed a national registry of providers who lose malpractice claims or are subject to adverse actions of greater than 30 days on licensure, privileges, or society memberships. This registry, the National Practitioner Data Bank (NPDB), is operated jointly by HRSA and JCAHO. All health care organizations are required to query the NPDB each time an independent practitioner applies for medical staff appointment or clinical privileges and every two years thereafter. All health professionals should be aware of the NPDB and how it is used to contribute to the assessment of a health professional's competence.
JCAHO and the National Committee for Quality Assurance (NCQA) expect health systems to critically reappraise the qualifications and competence of their providers at least biennially for reappointment and renewal of clinical privileges. Emphasis is placed on the process of reappraisal to ensure that the professional continues to be competent and maintains the necessary clinical skills.
JCAHO currently requires privileging for "licensed independent health care practitioners," defined as those who are permitted by law and regulation and by the health care organization to provide patient care without supervision or direction, within the scope of the individual's license and individually granted clinical privileges. JCAHO does not currently consider pharmacists to be independent health care practitioners, but this classification may change, as JCAHO recognizes nurse practitioners and physician assistants as licensed independent practitioners where state law permits them to provide unsupervised patient care. As pharmacist involvement in collaborative practice agreements grows, health systems and regulators will face increasing pressure to ensure the competence of these practitioners. Hospitals and health systems may also choose to credential and privilege health care practitioners, including pharmacists, who are not independent practitioners but whose complex roles in patient care require an assurance of competence.
Credentialing and privileging are no longer limited to inpatient settings, as the Accreditation Association for Ambulatory Health Care and NCQA require their use. Managed care organizations, large group practices, ambulatory care organizations, and others are developing mechanisms to ensure standard qualifications and competence of all autonomous care providers. In 2003, JCAHO created a single set of credentialing and privileging standards that apply to all long-term-care and subacute care programs within the organizations it accredits.
Privileging minimizes a health care organization's legal liability, helps fulfill an organization's mission of providing quality patient care, and can reduce staff conflicts by establishing criteria required to provide specific patient care services.
Health systems are liable for services provided by health care providers on their premises. The duty of selecting medical staff and supervising or monitoring their actions cannot be delegated, meaning that the hospital or health system cannot shift this responsibility to another entity, such as state licensure boards or other bodies that offer specialty credentials or other measures of competency. Health systems and their medical staffs may be held liable for damages if they permit an unqualified practitioner to practice in the organization or if they allow even a qualified practitioner to provide specific clinical services that he or she has not been deemed competent to perform within that health system.
Individuals participate in the privileging process to gain authorization to perform specific patient care services within a health care system. Examples include the privileging of surgeons to perform surgical procedures not included in the core surgical training program (e.g., laparoscopic general surgery, comprehensive gynecological endoscopic surgery, colonoscopy) and the privileging of advanced practice nurses (nurse midwives, nurse anesthetists, and nurse practitioners) to admit patients to hospitals. Pharmacists may choose to participate in privileging to establish their competency in providing specialized patient care services (e.g., pharmacokinetic dosing; individualization of anticoagulation dosing and monitoring; design, ordering, and monitoring of parenteral nutrition services; preparation of specialized medications).
As pharmacists gain recognition through health care regulation as health care providers (e.g., Medicare-recognized providers), they may find it necessary to ensure their competence to gain authorization from their health system to provide certain patient care services. Some pharmacists may need to seek authorization for the clinical privilege to provide a patient care service for which they have developed a protocol or agreement with a medical staff member. Health care organizations are obligated to assess the competency of professional staff, regardless of collaborative practice agreements or departmental policy.
Some pharmacists are concerned that the recognition of pharmacists as health care providers under Medicare will encourage state boards of pharmacy or other government agencies to establish procedures beyond licensing to determine a pharmacist's competence to provide specific patient care services. Such an approach would deviate from the standard practice for other medical professions, in which competence to provide certain services is determined at the level of the health care organization, rather than by state boards or other government agencies. JCAHO states that "privileges awarded must be component specific and consistent with the organization's plan for service and its ability to support the care provided." In other words, competence to provide specific patient care services needs to be established locally by the health care organization, as only that organization can determine what it can support. Such an assessment cannot be made by a state board or other government agency. Although specific measures of competency can and will be debated, an examination of the processes used to privilege other health care professionals demonstrates that competency should be measured against a local, rather than a statutory, standard of practice.
As the use of privileging has expanded, health care organizations have increasingly sought the guidance of the health care professions for competency assessment. Dermatologists, rehabilitation medicine physicians, psychiatric nurses, and other professional groups have established task forces to provide such guidance.
The department responsible for the privileging process (typically the medical staff credentialing or quality assurance department) should be able to provide you with information about your institution's privileging process. The following Web sites, along with the references cited in this paper, provide additional information about privileging:
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Below are illustrative case studies of privileging for pharmacists. A brief summary of their key points appears in Table 1 .
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