The following article appeared in the Sept. 2010 issue of Connection, the bi-monthly e-newsletter from the AAAHC.
Q: At re-appointment time, do medical staff members need to complete an application for re-credentialing?
Alsie Fitzgerald, RN, CASC, AAAHC Surveyor: Standard 2.II.B-5 states that "Medical staff must apply for reappointment every three (3) years, or more frequently if state law or organizational policies so stipulate. At re-appointment, the organization requires completion of a Re-appointment Application..."
Medical staff by-laws define the re-appointment period for your facility. Re-application, whether every two years or three years, is necessary to identify any changes or events that may have occurred during the previous period. The re-application form does not need to be as comprehensive or contain all the information of the initial application since some data, such as education and training, does not need to be re-verified. Questions related to professional sanctions, criminal background, health status and chemical or alcohol abuse included in the initial application should also be included in the re-application form as this information can change during the credentialing period. The 2010 Accreditation Handbook has a Sample Application for Privileges included with the resources (page 150). It contains a list of questions that may be applicable to the re-application form as well.
As with the initial application, the re-application should contain a signed statement releasing the organization from liability and attesting to the correctness and completeness of the submitted information.
Another area that is important in the re-application process is granting of privileges. The delineation of privileges needs to be updated with each re-application. This includes review of the procedures listed for any additions or deletions if core privileges are not utilized. Most common findings in surveys are lack of privileges for local and topical anesthesia, supervision of IV sedation, use of fluoroscopy and interpretation of images.
It is also important to note that solo practitioners must have an outside physician review their re-application and documents and make recommendation to the governing body for re-appointment and privileging.
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