Accreditation is essential for ambulatory surgery centers to maintain a high standard of care and an excellent reputation. While most centers achieve accreditation, there are areas that surveyors often find in need of improvement. One such area is credentialing. Here are 14 steps for ASC leaders to know to ensure effective credentialing, according to the Joint Commission's Ambulatory Care Program: The Who, What, When, and Where's of Credentialing and Privileging report.
1. Define the scope of care your ASC is providing.
2. Identify who is considered a licensed independent practitioner and therefore will need to be credentialed/privileged at the surgery center. Always refer to state law and regulations to ensure compliance.
3. Determine the scope of care the licensed independent practitioner will be providing at the ASC. Ensure the scope of care is in accordance with all state laws and regulations.
4. Establish the qualifications needed to be met to receive credentials/privileges at the center.
5. Ensure each practitioner formally requests privileges at the center through an application, letter of request or documented conversation with the center's medical director.
6. Obtain all information pertinent to the credentialing criteria, including the practitioner's current license and any actions against that license.
7. Place all information gathered into the ASC's files.
8. Ensure all organization-specific requirements are met, such as board certification or DEA certification.
9. Obtain a written statement from the licensed independent practitioner that includes information covering his or her ability to perform requested functions and any issues related to licensing and past employment.
10. Allow the medical director time to review all submitted information to confirm qualifications are met.
11. Ensure the medical director obtains approval from the ASC's governing body and/or administrator.
12. Give the licensed independent practitioner notice of the decision in writing.
13. Always maintain documentation of the practitioner's appointment in a credentialing file.
14. Establish a system to keep all information current and easily accessible.