February 6, 2020

* * *
QUESTION:      What do you recommend for the composition of the Credentials Committee and the terms for service for the members?
* * *

ANSWER:         A Credentials Committee is best composed of experienced leaders, such as past chiefs of staff or other physicians who have had medical staff leadership experience.  Many Medical Staffs have representation from a variety of specialties to ensure that the committee has the expertise necessary to address difficult credentialing and privileging issues.  With the increasing number of advanced practice clinicians (e.g., nurse practitioners and physician assistants) providing services in hospitals, more and more Medical Staffs are appointing at least one advanced practice clinician to the Credentials Committee as a voting member and for that individual’s input and expertise on the topic of credentialing and privileging these providers.

Service on the Credentials Committee should be the primary medical staff obligation of the members and terms should be at least three years so that committee members have an opportunity to gain some experience and expertise in credentialing.  The terms should also be staggered so that there is always a repository of expertise on the committee.  This Credentials Committee’s primary responsibility is to review and make recommendations on applications for medical staff appointment and clinical privileges.  It can also oversee the development of threshold eligibility criteria for clinical privileges.

March 26, 2015

QUESTION:   Can advanced practice clinicians and other non-physicians be appointed to the medical staff?

ANSWER:   Yes, as long as your state hospital licensure regulations and medical staff bylaws allow them to be medical staff members. The Interpretive Guidelines of the Medicare Conditions of Participation for Hospitals, at §482.12(a)(1), say:

  • The governing body has the authority, in accordance with state law, to grant medical staff privileges and membership to non-physician practitioners.
  • The regulations allow hospitals and their medical staffs to take advantage of the expertise and skills of all types of practitioners who practice at the hospital when making decisions concerning medical staff privileges and membership.
  • Granting medical staff privileges and membership to non-physician practitioners is an option available to the governing body; it is not a requirement.

Practitioners who can be on the medical staff may include any of the following:

  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • CRNAs
  • Certified nurse-midwives
  • Clinical social workers
  • Clinical psychologists
  • Anesthesiologist assistants
  • Registered dieticians or nutrition professionals
  • Physical therapists
  • Occupational therapists
  • Speech language therapists

Mind you: you don’t have to appoint any of these categories of practitioners to the medical staff, but unless your state law says otherwise, you can.