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Separate medical staff membership from clinical privileges

Credentialing Resource Center Connection, August 18, 2004

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Dear credentialing colleague:

When faced with an initial application or reapplication submitted by a low- or no-volume provider, remember to separate the issue of medical staff membership from that of clinical privileges. 
 
Remember, the term credentialing refers to the overall process of gathering and verifying credentials information, reviewing that information, and making a decision to grant or deny medical staff membership. Although both appointment to the medical staff and granting of clinical privileges are part of the credentialing process, they are not one and the same.
 
Medical staff membership only allows physicians access to the physicians' dining room, hospital library, continuing medical education classes, and voting rights, if allowed by hospital policy. In addition, granting membership allows the physician to advertise his or her affiliation with your organization and satisfy managed care organizations' requirements. 
 
Physicians who only seek medical staff appointment should complete an application or reapplication form, submit letters or completed questionnaires from colleagues, and provide a description of his or her private practice or practice at another facility. The hospital should also require the physician to complete an intended practice plan (IPP).
 
Remember, appointing a physician to your medical staff does not automatically allow him or her to treat patients. Therefore, your credentials committee can recommend medical staff membership for a low- or no-volume provider who desires affiliation with your hospital but who does not want or need privileges to admit and treat patients.
 
If your organization wants the option of granting membership without privileges, the hospital's policy must allow you to take that route. For example, if your hospital's membership criteria require members to provide emergency department on-call coverage, your organization will not have the option of appointing a physician to the medical staff without also granting privileges.
 
Under such circumstances, the provider should be informed that he or she does not meet your organization's minimum criteria for membership and the medical staff office will therefore not process the application.
 
Keep in mind that your credentials committee and medical executive committee must recommend membership criteria to the governing board before applying them to a medical staff applicant. Once the board approves the criteria, write them into the medical staff bylaws and policies.

That's it for today.

All the best,
Hugh Greeley
www.greeley.com/seminars/

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