Healthcare Risk GroupProj
MO-MO
HSA4502_CredentialingChecklistDrJohnHayden.docx.
Hospital of Hope
Credentialing Checklist Board Members: (enter the team name and names of team members)
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STANDARD TO BE MEASURED |
ACTION TAKEN? |
DATE |
COMMENTS |
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A: APPLICATION |
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Name of Applicant: John Hayden |
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Position Requested: |
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1. Applicant Identifying Information: |
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a. name and address |
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b. education and training |
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c. prior employment |
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d. board certifications |
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e. current state license and Drug Enforcement Administration (DEA) certification, if applicable |
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f. current competencies (i.e., skills and experience) |
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g. written statement seeking clinical privileges |
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h. personal and professional references (minimum of three) |
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2. Applicant Issues: |
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a. loss of medical professional liability coverage |
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b. loss of DEA number |
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c. suspension/revocation of privileges |
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d. past claims history |
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e. criminal charges |
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f. prior professional disciplinary actions |
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3. Release for background investigations: |
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a. Applicant executes a written consent and release from liability, to be attached to every reference inquiry. |
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b. Applicant is provided a copy of applicable rules and regulations. |
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c. Applicant agrees in writing to exhaust administrative internal remedies before litigating adverse credentialing decisions. |
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B: VERIFICATION AND REVIEW |
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1. Verify completion of education. |
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2. Ask the director or other authorized responsible party of the applicant’s residency or training program to complete a questionnaire regarding the applicant’s performance and capabilities. |
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3. Check dates of employment history and document any gaps in employment or appointment. |
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4. Obtain a copy of applicant’s DEA certificate and state medical license, if applicable. |
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5. Query the National Practitioner Data Bank and adhere to the requirements of the federal Health Care Quality Improvement Act of 1986. https://www.npdb.hrsa.gov/index.jsp * |
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6. Verify the status of existing clinical privileges at other facilities. |
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7. Check with state and federal regulatory bodies for previous sanctions by Medicare and Medicaid programs. |
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8. Obtain a copy of applicant’s current medical professional liability insurance certificate, including verification of limits of coverage and claims experience. |
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9. Verify by telephone all information contained in written references. |
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C: DELINEATION OF CLINICAL PRIVILEGES |
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1. Applicant provides the clinical appointment committee with a written request for clinical privileges. |
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2. Committee processes the written request for clinical privileges based on established protocols and criteria. |
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3. Committee votes to approve or deny request. |
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4. Administrative leadership receives committee’s recommendation and makes final decision. |
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D: REAPPOINTMENT OF CLINICAL PRIVILEGES |
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1. Reappointment process occurs annually or, at minimum, every two years. |
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2. Committee verifies and documents the following information upon request for reappointment: |
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a. any changes in certification, appointment, education or professional accomplishments |
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b. verification of current license and DEA certification, if applicable |
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c. any professional disciplinary action taken against applicant |
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d. medical professional liability insurance coverage and claim experience |
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e. status with National Practitioner Data Bank, if applicable |
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E: PERFORMANCE APPRAISAL IS COMPLETED AND INCLUDES THE FOLLOWING INDICATORS: |
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1. Service usage |
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a. admissions data |
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b. drug utilization |
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c. utilization of lab and radiology services |
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2. Ratio of completed patient care records to delinquent patient care records |
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3. Results of member/patient satisfaction survey results |
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4. Results of quality improvement findings/outcomes for the provider |
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5. Result(s) of clinical peer-review findings |
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6. Clinical appointment committee reviews reappointment form and performance appraisal? (If yes when and indicate whether annual or special review) |
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7. Results of clinical appointment committee review: (Select either a or b below and include comment as to why |
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a) Reappointment is granted either without change to prior privileges, or with modified privileges? (State which) |
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b) Reappointment is denied, and applicant is notified via a letter, which also provides information about hearing procedures. (Explain why denied) |
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For the purpose of this team assignment, this form created and modified from Health Provider Services Organization Checklist.
The complete form can be found at:
Staff Credentialing Checklist Health Providers Service Organization (HPSO)
http://www.hpso.com/risk-education/individuals/articles/Staff-Credentialing-Checklist
