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A closer look at HFAP's privileging system requirements

Credentialing Resource Center Connection, March 26, 2009

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Annette Van Veen Gippe is the deputy director of the American Osteopathic Information Association in Chicago.

Dear credentialing colleague:

Whether you work at an HFAP-accredited facility and need a refresher on the basics or are curious to see standards from an accrediting agency other than your own, it’s always beneficial to take a closer look at privileging criteria.

The Healthcare Facilities Accreditation Program’s (HFAP) standards require that medical staff bylaws contain criteria for granting, withdrawing and modifying clinical privileges for individual practitioners. In addition, a procedure must exist for applying these criteria to all credentialed practitioners. (This includes physicians, allied health practitioners who are permitted by the state and the organization to practice without supervision, and other individuals authorized by the state and the organization to function as a licensed independent practitioner.)

The standard further states:

• Privileges granted must be within the scope of demonstrated competency of the individual practitioner and must also be based on the capabilities of the facility.
• Privileges are granted based on the medical staff’s review of the individual practitioner’s qualifications and the medical staff’s recommendations for that individual.
• Applicants for initial appointment must provide documentation regarding clinical activity (from residency or from facilities where the applicant has been practicing medicine) and competency for consideration of privileges requested.
• Applicants for reappointment must provide recommendations from the department in which privileges are sought.
• If a practitioner has a low volume of patients, this may require review of procedure logs and/or competency assessments from other institutions to verify competency including:
  • Scope of specific privileges based upon recent experience
  • Recommendations from quality assurance committee and/or other staff committees based upon peer review findings

If you have questions about HFAP standards or would like more information on the program please send an email to info@hfap.org

All the best,

Annette Van Veen Gippe

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