Perform credentialing audits to monitor compliance and check outcomes
Perform credentialing audits to monitor compliance with various processes involved in credentialing and privileging and to check the outcomes of these processes. Many aspects of credentialing lend themselves to an audit. The focus of an audit will depend on the data that the organization seeks about the credentialing process.
When organizations monitor compliance, they are checking whether they meet expectations and are detecting any violations of "the laws" (i.e., accreditation and regulatory requirements, as well as internal standards) applicable to credentialing and privileging. Performing credentialing audits is similar to conducting patient record audits in that it is usually more productive to audit specific aspects of the process to answer explicit questions.
Perform credentialing audits to monitor compliance by determining whether:
all practitioners who provide care or services in a healthcare organization are properly credentialed and privileged.
practitioners exercise only those privileges that they have been granted.
the credentialing of physicians and other practitioners is performed in compliance with state, federal (i.e., the Centers for Medicare & Medicaid Services, the Health Care Quality Improvement Act [HCQIA]), or accreditor (i.e., National Committee for Quality Assurance, The Joint Commission) requirements.
the organization is in compliance with its own internal credentialing standards as stated in bylaws, documents that supplement the bylaws, credentialing policies and procedures, privilege delineation criteria, etc.
methods are in place to ensure that all licensed independent practitioners are continuously licensed, have professional liability insurance, maintain U.S. Drug Enforcement Agency registrations, etc.
adequate systems are in place to ensure that all practitioners are credentialed and reappointed within permitted time frames.
the organization is in compliance with the HCQIA by querying and reporting to the National Practitioner Data Bank, as required by federal law.
information was available to make a decision but was not obtained.
evaluators make use of all information available when recommendations are made to the organization's governing board.
