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Q&A: Do I need to credential residents?

Credentialing & Verification Update, December 27, 2006

Q: Residents often rotate through my facility. Do I need to credential these residents according to the typical medical staff standards?

A: You need not process the residents rotating through your facility through the medical staff standards for credentialing and privileging. They function under a job description and care for patients under the supervision of a licensed independent practitioner who holds appropriate clinical privileges at your organization.

Academic medical centers have a great deal of experience delineating affiliation agreements with community hospitals that establish the following guidelines:

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

If your facility is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 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. Your institution must comply with these if you allow residents to rotate in your institution.

Editor's note: Questions and topic suggestions can be e-mailed to Credentialing & Verification Update at mcoler@hcpro.com.

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