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The process of Credentialing and Privileging is essential to safeguard the delivery of quality care, promote patient safety and reduce the level of risk taken on by the health center. One of the most important components to ensure compliance with Chapter 5 – Clinical Staffing (Chapter 5: Clinical Staffing) of the Health Services and Resources Administration (HRSA) Health Center Program Compliance Manual, as well as HRSA Federal Tort Claims Act (FTCA) Requirements, is to maintain up-to-date and complete credentialing and privileging files. Depending on the size and complexity of the health center, the process of maintaining credentialing and privileging files can be extremely labor intensive. As a result, some health centers have migrated from utilizing paper files to electronic systems.
During an Operational Site Visit (OSV), the clinical reviewer is expected to review a “sample” of the health centers credentialing and privileging files. With the transition to Virtual Operational Site Visits (VOSV), review of credentialing and privileging files has become more challenging. Below are some guidelines health centers can use to not only prepare for their VOSV, but also streamline the review of files.
If the health center does not utilize OCS, they will not have files for this category of staff. Additionally, the sample composition selected for the review should include the following:
It is important to remember that file contents must be reflective of the health center’s documented policies and associated procedures. The inability for the reviewer to put “paper to practice” can result in findings of non-compliance for numerous elements.
To ensure continuous compliance, health centers should audit credentialing and privileging files on a regular basis. A self-evaluation of compliance can be completed by answering the questions in the Clinical Staffing Section of the HRSA Site Visit Protocol.
To ensure compliance with HRSA Health Center Program Requirements, health centers should follow the guidance outlined in the HRSA Health Center Compliance Manual (Chapter 10 – QI/QA) and HRSA Site Visit Protocol (QI/QA – Site Visit Protocol). Additional resources for Quality Improvement initiatives, as well as how to conduct a Plan-Do-Study-Act and Root Cause Analysis can be found by accessing ECRI (ECRI | Trusted Voice in Healthcare).