Credentialing is the number one problem for ASCs when it comes to successful surveys for accreditation or reaccreditation. It's important for centers to take this to heart when planning for successful credential processes. Here, Marshall M. Baker, MS, FACMPE, a surveyor for the Accreditation Association for Ambulatory Health Care, answers the question: What can ambulatory surgery centers do to ensure effective credentialing processes?
1. Prioritize. Make the process a center priority.
2. Create a formal process. "Adopt a uniform application and utilize a checklist to assure all required documents are present in the file, including documentation of peer review for reappointment and letters of reference for initial appointment," says Mr. Baker.
3. Use a center-specific privileging form. Mr. Baker suggests forms should only list privileges the practitioner requests to perform at the ASC. Ensure "core privileges" for any given specialties are approved by the governing body.
4. Keep the process independent. "Do not rely on privileges granted by another facility, organization or ASC," says Mr. Baker.
5. Document delegation. "If the granting of privileges has been delegated from the governing body, such delegation much be well documented in the governing body's minutes, including the granting of temporary privileges," says Mr. Baker.
6. Have credentialing files available and organized. Organization expedites the credentialing process and minimizes the potential for mistakes: "All of the material appropriate for a practitioner's credentialing and privileging should be readily available to the surveyors during the survey and filed in a manner that facilitates easy document review by the survey team," says Mr. Baker.
7. Keep timing in mind. "Appointment and privileging must be for a specific timeframe. The appointment letter must include these dates," says Mr. Baker. He also notes that while reappointment and re-privileging must occur at least every three years, organizations may select a more frequent timeframe for review.
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1. Prioritize. Make the process a center priority.
2. Create a formal process. "Adopt a uniform application and utilize a checklist to assure all required documents are present in the file, including documentation of peer review for reappointment and letters of reference for initial appointment," says Mr. Baker.
3. Use a center-specific privileging form. Mr. Baker suggests forms should only list privileges the practitioner requests to perform at the ASC. Ensure "core privileges" for any given specialties are approved by the governing body.
4. Keep the process independent. "Do not rely on privileges granted by another facility, organization or ASC," says Mr. Baker.
5. Document delegation. "If the granting of privileges has been delegated from the governing body, such delegation much be well documented in the governing body's minutes, including the granting of temporary privileges," says Mr. Baker.
6. Have credentialing files available and organized. Organization expedites the credentialing process and minimizes the potential for mistakes: "All of the material appropriate for a practitioner's credentialing and privileging should be readily available to the surveyors during the survey and filed in a manner that facilitates easy document review by the survey team," says Mr. Baker.
7. Keep timing in mind. "Appointment and privileging must be for a specific timeframe. The appointment letter must include these dates," says Mr. Baker. He also notes that while reappointment and re-privileging must occur at least every three years, organizations may select a more frequent timeframe for review.