Quarterly Compliance Article: Review of Credentialing and Privileging Files

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.  

  • Sample composition – As outlined by the Clinical Staffing Section of the HRSA Site Visit Protocol (Clinical Staffing) and the HRSA Sampling Review Resource Guide (Sampling Review Resource Guide), the sample of files provided to the reviewer should consist of the following:
    • Four to five Licensed Independent Practitioners (LIP) files
    • Four to five Other Licensed or Certified Practitioners (OLCP) files
    • Two to three files for Other Clinical Staff (OCS), as applicable

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:

  • Representation from different disciplines and sites (i.e., Medical, Dental, Behavioral Health)
  • Providers who are directly employed and contracted, as well as volunteers
  • Providers who do procedures that are outside of the core privileges for their discipline
  • Providers who have been initially credentialed and privileged
  • Providers who have been reappointed
  • File organization and completeness – File contents should reflect the requirements outlined for each category of staff, in accordance with the HRSA Credentialing and Privileging File Review Resource (Credentialing and Privileging File Review Resource).  Ensure files are complete, organized and contain up-to-date documents.  All documents with an expiration date must be current as of the date of review.  For example, if a provider’s license expires in January and their reappointment date is in March, the file must reflect the renewal as of January.  Ensure the health center has a mechanism in place for tracking expiration dates to avoid any gaps.
  • File Review – The health center has the option to upload files to the ShareFile system utilized by HRSA during a VOSV.  Files must have Personally Identifiable Information (PII) redacted, which can make it difficult for the reviewer to connect the documents with the individual.  An easier option is to review files via GoToMeeting, as PII does not need to be redacted.  In either case, files should be scanned into a pdf.  If the health center utilizes an electronic system for managing credentialing and privileging, live navigation can also be performed.  

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).

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