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Do residents need to be credentialed the same as through medical staff standards?

Credentialing Resource Center Connection, November 16, 2006

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A Credentialing and Privileging Advisor reader recently asked:

"Our hospital will soon, for the first time, allow residents to come to our facility.  Are they credentialed the same way as a physician?"

Residents rotating through your facility would not be processed through the medical staff standards for credentialing and privileging. They would, rather, function under a job description, and provide care to patients supervised by a licensed independent practitioner (LIP) with appropriate clinical privileges. 

Academic medical centers are well-versed at delineating affiliation agreements with community hospitals that establish the relationship between the two. These agreements typically:

• define the level of supervision required
• name the residents are in the program
• state the residents' level of training
• specify patient care responsibilities based on their level of training
• provide health status and insurance information

If you are a Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredited facility, you will find JCAHO requirements for graduate education programs in the medical staff standards under MS.2.30. In this situation you will want to review the nine elements listed there which your institution must comply with if you are to allow residents to rotate in your institution.

Some of the highlights of those elements of performance include defining a process for LIP supervision, and creating written descriptions of resident roles, responsibilities, and patient care activities. Can the resident write orders?  If so, under what circumstances may they do so?  Is a countersignature required by their supervising LIP?  The standards require all of these questions are answered.

In addition, it is necessary to institute effective communication to the organized medical staff and the governing body about the patient care, treatment, and services, and related educational and supervisory needs of the residents.

(Editor's note: Questions and topic suggestions can be e-mailed to Credentialing and Privileging Advisor at mphillion@hcpro.com.)

That's all for this week.

All the best,
Sally J. Pelletier, CPMSM, CPCS

Sally J. Pelletier, CPMSM, CPCS, is a consultant with The Greeley Company, a division of HCPro, Inc. specializing in the areas of credentialing and privileging.

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