In this blog, I’ll be reviewing the purpose of medical staff hospital credentialing, identifying who is responsible for credentialing, comparing the roles and responsibilities of the medical staff, and the hospital Board, and reviewing criteria-based systems recommended for the credentialing process.  It’s important to have an understanding of the above concepts to ensure that hospital systems have an effective credentialing process that promotes patient safety, sustains a system that mitigates the risk of malpractice litigation, while also mitigating the risk of restraint of trade. 

Credentialing Purpose: The primary purpose of credentialing is to protect patients by ensuring quality patient care.  A credentialing process appropriately overseen by the hospital Board reduces patient exposure to poorly performing providers, ultimately, reducing the risk of preventable patient injury. 

secondary purposes:

  • To ensure that only qualified providers are admitted and allowed to remain on medical staff.  Medical staff includes Physicians, Physician Assistants (PA), and Advanced Practice Registered Nurses (APRN): Certified Nurse Midwives (CNM), Nurse Practitioners (NP), and Certified Registered Nurse Anesthetists (CRNA).   
  • To ensure that providers are practicing within their scope, consistent with quality standards of the hospital.
  • The appointment, re-appointment into medical staff.
  • The granting, and renewal of privileges (delineation of privileges) – what a provider is allowed, and not allowed to do, types of patients a provider is able to manage, types of diseases the provider is able to treat, procedures the provider is able to perform, or not perform based on privileging delineations, and clear credentialing criteria.  For example, CNM management of low-risk obstetrical patients; CNM collaborative management with Ob/Gyn for high-risk obstetrical patients.

Who is Responsible for Hospital Credentialing? Medical staff credentialing is the core responsibility of the hospital Board, and serves to be the most important responsibility of the Board secondary to the impact on patient safety, and the role credentialing has within the hospital’s quality improvement and patient safety system. 

The legal structure (as shown below) needs to be understood by the Board, medical staff, and management to ensure clear role delineation, and to ensure an effective credentialing system.


Roles and Responsibilities: It’s important to have a clear understanding of role delineation to ensure that the hospital has an effective credentialing process that promotes safe work environments, while reducing the risk of patient injury. 


  • Reviews recommendations received from the medical executive committee and compares the recommendations against established credentialing criteria
  • Makes sure the credentialing criteria is consistently applied to all applicants: efforts need to be made to avoid loose criteria that could result in patient injury and increase the risk of malpractice litigation.  Contrary, efforts need to be made to avoid tight / biased criteria that could result in claims of negligent credentialing, and/or restraint of trade
  • Makes sure the medical executive committee has a credentialing procedure in place
  • Makes final decisions: grants privileges, grants admission into medical staff 

Medical Staff (Medical Executive Committee):

  • Makes recommendations to the Board
  • Identifies credentialing criteria for evaluating providers
  • Evaluates performance
  • Evaluates applicants

Credentialing is proven to be the most difficult governance function to perform effectively for the following reasons:

  • Many Boards and medical staff do not accept the Boards role to oversee the medical staff
  • Many lay Board members are not comfortable with the responsibility
  • Neither the Board, nor the medical staff know how to do credentialing

The hospital Board maintains liability for inappropriate decisions made regarding (re)credentialing and delineation of privileges.  The Board cannot exclusively rely on the recommendations of the medical executive committee as a defense to justify a poor decision.

How To Do Hospital Credentialing – The Use of Criteria Based Systems for (Re)Credentialing and Privilege Delineation: It’s best practice to have a clear decision criterion for credentialing and delineation of privileges that sets the hospitals quality and safety bar high.  The criteria should be based on internal information sources.  Additionally, privilege delineation should be unique and specific to each provider.  The Joint Commission requires provider specific data to be collected continuously and reviewed at the time of re-credentialing.  It’s recommended that this provider specific data is compared to the aggregate data as a means to identify how each individual provider is performing in each performance measure in comparison to his/her provider colleagues.  Typically, the specific credentialing criteria are developed by the clinical department, and submitted to the medical executive committee (MEC) for approval.  MEC then makes the recommendation to the Board who makes the final decision. 

Examples of Criteria Based Credentialing:

               Frequency Criteria: A number of professional organizations suggest frequency criteria for (re)credentialing and privileging.  For example, Surgeon A is required to perform 20 laparoscopic cholecystectomies in a 2-year period (credentialing term per Joint Commission is 2-years).

               Minimum Volume Required Criteria: For example, Surgeon A is required to perform a minimum of 10 laparoscopic cholecystectomies in a 2-year period. 

               Clinical Outcomes: Internal data – individual provider specific data (outcome measures).  For example, Surgeon A’s specific data (outcomes): post-operative complications, morbidity and mortality rates, returns to the OR, wound infections.

               Behavior Criteria: Patient complaints, malpractice claims per individual provider


American Hospital Association Trustee Service. 2017. The Role of the Board in Medical Staff Credentialing:

Credentialing and Privileging – Requirements for Physician Assistants and Advanced Practice Registered Nurses:

JCAHO’s new credentialing, privileging standards require provider-specific data:

P.S. Comment and share your experience with hospital credentialing.