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The Joint Commission vs. AOA-HFAP standards surrounding expedited or fast-track credentialing

Credentialing & Verification Update, February 13, 2008

As the credentialing process has become more detailed and cumbersome over the past few decades, the time it takes to process an application for medical staff appointment and clinical privileges has become extremely lengthy. This is due to increasing regulatory requirements, as well as organizations implementing stringent credentialing processes to ensure that the practitioners are qualified and competent to perform the requested procedures.

Typically the application passes through three committees before an organization will grant the applicant membership and privileges: the credentials committee, the MEC, and the organization's governing board. At times, these committees may cancel meetings, reschedule, or schedule meetings so infrequently that the credentialing process can run into significant delays for applicants waiting for the organization to grant their requested privileges.

The fast-track credentialing process was developed to expedite the approval process. Although this process does not expedite the time it takes to process an application, nor does it eliminate any of the minimum credentialing verifications required by the organization, it does significantly expedite the committee approval process. The Joint Commission addresses expedited or fast-track credentialing in: MS.4.35:

If the hospital so chooses, it may implement an expedited process for appointment, reappointment, and privileges. Although this is addressed in the medical staff standards, the expedited approval process is a governing body function. The Joint Commission allows expedited credentialing by enabling the governing body to delegate appointment
and privileging decisions to a committee consisting of at least two voting governing body members. The medical staff develops the criteria for an expedited process for granting privileges. The expedited credentialing process may not be used if the applicant's application is incomplete or if the MEC makes a final recommendation that is adverse or has limitations.

There are some situations that should be evaluated on a case-by-case and would usually lead to ineligibility for expedited credentialing:

• There is a current challenge or a previously successful challenge to licensure or registration
• There has been an involuntary termination of medical staff membership at another organization
• There has been an involuntary limitation, reduction, denial, or loss of clinical privileges
• There is an unusual pattern of, or an excessive number of, professional liability actions that resulted in a final judgment against the applicant. Criteria for an expedited process, once developed, must be followed when recommending privileges.

The AOA-HFAP addresses expedited or fast-track credentialing in: 01.00.10:
HFAP allows fast-track credentialing to a committee or individuals for review of specific criteria. The process must provide for a thorough review of current competency and must include review and approval by the department chair, credentials chair, medical executive committee, CEO, and the governing body. This process can be used for applications that pose no problems (e.g., new graduates or physicians fully credentialed at a sister hospital).

If you would like to sample easy access to a standards crosswalk on a variety of credentialing topics, we invite you to try a free, 30-day trial of CPDR. Start streamlining your primary source verification research. To try a free 30-day trial, go to http://online-cpdr.com/free_trial.cfm

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