Credentialing &

Privileging
Be Prepared!
Outline
Module 1 :Introductions and Overvie
Module 2 : CBAHI standards
Module 3: Credentialing and Privileging process
Module 4 : Types of Practitioners.
Module 5 : Decision-making Criteria and Process.
Module 6 : Managing files that meet Criteria.
Module 7 : Submitting Credentialing Application.
Module 8 : Appealing Credentialing Decisions.
Module 9 : Credentialing of Non-Physician Medical Practitioners
Module 10 : Confidentiality Agreement.
Module 11: Credentialing and Primary Source Verification
 Module 1
Introductions and Overview
Learning Objectives
•Direct the credentialing, privileging, and enrollment processes; monitors applications and follows-
up as needed.
•in charge of processing accreditation and verification information.
•Makes sure that all medical personnel including doctors, assistants and other healthcare
professionals comply with Credentialing & Privileging policies, JCI and CBAHI regulations.
•Oversee evaluation of credentialing/privileging requests and evidence of education, training,
competence, ability to perform, and experience to determine eligibility.
•Oversee the submission of complete and accurate applications and/or practitioner data/roster to
ensure timely approval and maintenance of network participation .
Learning Objectives
•Collecting and maintaining an accurate practitioner database and analyzing verification information
and keeping the databases accurate
•Maintains copies of current licenses, certificates, and any other required credentialing documents.
•Sets up and maintains provider information in credentialing databases system.
•Processes applications for appointment and reappointment of privileges in the hospitals .
What is Credentialing?

•The process of obtaining, verifying and assessing the qualifications of a healthcare

professional to determine if that individual can provide patient care services in or for a
healthcare organization.

❖ Credentialing Definition by the National Committee for Quality Assurance (NCQA):

organization reviews and evaluates qualifications of licensed independent
practitioners to provide service to its members.
❖ Ensures that all patients receive quality care by competent and qualified
practitioners

2 1
What is Privileging?

•The process of reviewing an individual’s credentials to determine the authority and

responsibility to be granted to a practitioner for making independent decisions to
diagnose, initiate, alter, or terminate a regimen of medical or dental care .
❖ Privileging determines the physician’s scope of practice in the organization
determined by his/her competencies.

2 1
Policy Definitions‫ سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬:

Clinical Privilege: yb noissimrep detnarg si renoititcarp htlaeh a hcihw yb ssecorp eht sa denifeD
raelc nihtiw ,)noitazilaiceps ot gnidrocca( secivres erac lacidem edivorp ot ,erachtlaeH ytilicaf a
iduaS eht ni noitartsiger dna gnisnecil ,gniniart dnA ecnetepmoc lacinilc no desab ,stimil
.seitlaicepS htlaeH rof noissimmoC

Special medical privileges: are specified By specialization according to the resources, devices,
equipment and systems available in the health facility and the scope of services.

❖ Privileges are granted Clinical appointments for a period of more than two years, after which
renewal takes place according to performance, with the privileges granted to him, or to add a
new privilege.
Policy Definitions‫ سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬:

Licensed Independent Practitioner: Any person who is permitted by law and by the health facility
to provide care and services. without direction or supervision, within the scope of the individual's
license and consistent with individually granted clinical privileges.

Verification of the main source: the accuracy of the qualification of the practicing physician.

● verification is determined in variety of ways, include but are not limited to:

.1correspondence Direct and verification over the phone

.2through the official e-mail of the university granting the academic qualification or the hospital the
grantor of the certificate of experience or the training center that grants the certificate of training.

❖ Verification can be done through a third party called Applicant verification organizations, for
example Dataflow
Policy Definitions‫ سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬:

Reference dna lanoisseforp tnerruc eht ot tsetta nac ro nac ohw snosrep ro nosrep a morf rettel A :
.ytilanosrep dna ecnetepmoc ,dnamed ,retneserp eht fo tnemgduj lacinilc

❖ Those references must fulfill the concept of “peer )elpoep yb dedivorp era yeht taht gninaem( ”
.)tnacilppa eht sa eerged dna rojam lanoitapucco emas eht evah
❖ For applicants who have recently completed or Those still in the training program or
postgraduate studies are required to submit one reference letter from the training program.
❖ Other applicants who are currently working in a health facility are required to obtain a letter of
recommendation from a president Doctors or department heads in the health institution
Policy Definitions‫ سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬:

● Basic privileges: taht ytlaiceps-bus ro noitazilaiceps eht rof segelivirp fo tes cificeps a snaem
taht rof doirep gniniart eht ni thguat ylenituor si taht secivres erac tneitap laitnesse sedulcni
.ytlaiceps-bus ro noitazilaiceps
● Additional privileges: medical privileges that are requested by the doctor according to what is
new in his scientific or practical field or what needed by the health facility in the scope of
services
❖ after the practitioner has obtained training, there must be an evidence of that training either by
a certificate or an evaluation of a “consulting doctor in the same specialty and having the same
privileges or a record of cases in which he practices. ”The privilege required at the time of
training is documented and stamped by the granting authority, or all of the above, as the
Privileges Committee deems appropriate.
Overview
Hospitals and other types of health care organizations often employ credentialing specialists to
make sure they are complying with Saudi Commission for Health Specialties, MOH, CBAHI and JCI
standards.
Credentialing and re-credentialing requirements are applied to all licensed practitioners
Classified by SCHS.
Overview

All clinical health professionals who work on permanent, part-time, visitor and locum basis
must be credentialed prior joining by the Saudi Commission for Health Specialties
Credentialing must include all Medical and Dental Physicians, all Health care providers including
Nursing, and any other independent practitioner have a relationship with the Patient care services
and provide Health care under SCHS medical benefit.
Overview

Medical staff members are allowed to practice only within the privileges granted by the
credentialing and privileges committee‫ز‬

The credentialing and privileging of the medical staff is based on an informed group
decision.
Continue …

Credentialing and privileging committee:

 oversight on the credentialing and privileging processes.
 preferably chaired by the medical director
 ensures that only qualified physicians and dentists are appointed and granted privileges
Module 2
CBAHI standards
CBAHI standards …
HR.5 The hospital has a process for proper credentialing of staff members licensed to provide
patient care.
 HR.5.1 The hospital has a written policy describing the process used for the verification of
credentials.
 HR.5.2 The hospital gathers, verifies, and evaluates the credentials (license, education,
training, certification and experience) of those medical staff, nursing staff, and other health
professionals licensed to provide patient care.
 HR.5.3 Credentials are verified from the original source.
 HR.5.4 Job responsibilities and clinical work assignments/ privileges are based on the
evaluation of the verified credentials.
 HR.5.5 The hospital ensures the registration of all healthcare professionals with the Saudi
Commission for Health Specialties.
CBAHI standards …
HR.5 The hospital has a process for proper credentialing of staff members licensed to provide
patient care.
 HR.5.6 Staff licensed to provide patient care must always have and maintain a valid license to
practice only within their profession.
 HR.5.7 The hospital maintains an updated record of the current professional license,
certificate, or registration, when required by laws, regulations, or by the hospital for every
medical staff, nursing staff and other healthcare professionals.
 HR.5.8 When verification of credentials is conducted through a third party, the hospital must
request for a confirmatory documentation.
 HR.5.9 Verification process applies to all clinical staff categories (full time, part time, visitor,
and locum).
CBAHI standards …
MS.3 The hospital has an effective process that supports the professional communication and
coordination of care amongst medical staff.
MS.3.4 The medical executive committee reviews all relevant reports of other hospital committees
for prioritizing the services needed and guiding the credentialing and privileging process
CBAHI standards …
MS.5 The credentialing and privileging of the medical staff is based on an informed group decision.
 MS.5.1 The hospital has a credentialing and privileging committee chaired by the medical
director or a designee.
 MS.5.2 The credentialing and privileging committee provides oversight on the credentialing
and privileging processes.
 MS.5.3 The credentialing and privileging committee ensures that only qualified physicians
and dentists are appointed and granted privileges.
 MS.5.4 Applicants for initial appointment submit a complete set of documents required for
the credentialing and privileging process , including:
 MS.5.4.1 Curriculum vitae, detailing the professional history of the applicant.
 MS.5.4.2 Education, training, certificates, courses, experience, published research, and
other relevant credentials.
 MS.5.4.3 List of references.
 MS.5.4.4 List of the privileges requested for approval
CBAHI standards …
MR.1 The Health Information Management (Medical Records) department has adequate qualified
staff
 MR.1.2 The department director is credentialed in health information management through
formal training as per the national/international guidelines.
 MR.1.4 Staff working in the department are credentialed in health information management
through formal training as per the national/international guidelines .
 MR.1.5 Clinical coding staff working in the department are credentialed/certified in clinical
coding through formal training as per the the national/international guidelines.
 MR.1.6 The department has one or more staff members who are credentialed in Clinical
Documentation Improvement (CDI) through formal training as per the national/international
guidelines.
 Module 3
Credentialing and Privileging process
 Why is Credentialing Important?

The primary
purpose of
credentialing is to
protect our patients.

Darling v. Charleston Memorial Hospital (1965),

Johnson v. Misericordia Community Hospital (1981), and
Frigo vs. Silver Cross Hospital (2007).
 Credentialing purpose:

1. To improve the quality of care

2. Met the accreditation
requirements
3. To participate in other Health care
program.
4. For Patient Safety
.
Credentialing and Privileging process

 A hospital's medical staff plays a critical role in assuring quality care and improving patients' outcomes in the
hospital
 A good hospital should always have a clear structure of its medical staff, including departments, divisions,
and medical committees.
Credentialing Objectives:
1. Ensures that the credentialing and re-credentialing process is conducted in a manner that is
nondiscriminatory.
2. Ensures that the credentialing verification process does not exceed the prescribed time.
3. Ensures that practitioners’ re-credentialing occurs at least every 24 months.
4. Meets MOH, SCHS, CBAHI & JCI standards for credentialing.
5. Complies with SCHS requirements.
6. Ensures the confidentiality of all applications received.
7. Ensures that all practitioners providing care under SCHS are credentialed.
8. Ensure that licensed health care practitioners meet standards for participation in the Health
care practitioner panel.
The credentialing requirements:
The basic or the core requirements most often associated with application for medical staff
credentialing are reflected in the education, training, experience, and licenses of the applicants. The
listed requirements should be outlined in the policy, bylaws, rules, and regulations.
General Credentialing Qualifications:
1. Licensure: currently valid SCHS.
2. Professional Education and Training: Graduate of an Approved Medical or Dental School or
certified by the Educational council for foreign Medical Graduates, with approved postgraduate
training program.
3. Clinical Performance: current experience, clinical result and utilization practice patterns,
documenting a continuing to provide patient care services at an acceptable level of quality.
4. Cooperativeness: Demonstrate ability to work with and other Medical Staff members, members of
other health disciplines, hospital management and employees.
5. Satisfaction of Membership Obligation: satisfactory compliance with the basic obligations
accompany appointment to the medical staff as set in the Bylaws.
General Credentialing Qualifications:
6. Professional Ethics and Conduct: to adhere to generally recognized standards of medical and
professional ethics.
7. Disability: To be free of or have under adequate control any significant physical or mental health.
8. Verbal and written communication skills: Ability to understand and to communicate in written and
verbally in an intelligible manner.
9. Professional Liability Insurance: Professional liability insurance to cover malpractice when
occurs.
Specific Credentialing requirements: -
1. Employment Application Form
2. Copy of national ID / PASSPORT
3. Applicants Complete Updated Resume
4. Bachelor Degree/ or other Certificate
5. Residency Certificate (Doctors)
6. Fellowship Certificate (Doctors)
7. Specialty Board Certification (Doctors)
Specific Credentialing requirements: -
8. Sub-specialty Board Certification (if applicable)
9. Experience Certificates - Up to date 3 reference letters
10. Releasing of Information Letter or consent (as a form)
11. License Registration (must be valid)
12. Valid BLS, or ACLS, or any related to specific specialty
13. Insurance agreement or malpractice agreement (some specialty)
Medical staff bylaws:
Medical staff bylaws: govern the organization, functions, and responsibilities of the medical staff,
and serve as the primary source for the appropriateness of the professional performance and
ethical practice

• Approved by the governing body.

• Consistent with acceptable medical staff practices.
• Consistent with laws and regulations.
• Describe the organizational structure of the medical staff.
Medical staff bylaws address the following:
• The medical staff ranking and the qualifications required for each rank.
• Categories of the medical staff membership (e.g., full time, part time, and locum).
• Roles and responsibilities of the medical staff members.
• Appointment, promotion, and reappointment of medical staff members.
• Disciplinary procedures for medical staff members, including corrective actions and appeals.
• The process for verification of the medical staff credentials.
• Granting and maintaining clinical privileges, including temporary privileges
Credentialing

• Staff
• Providing Pt. care • Primary source
Gathering
documents Verification

Credentialing
• Certificates
Policy Process Evaluation
• Written
components • licence
• Approved
• Registration
Policy
Gathering Documents
 Curriculum vitae
 Detailed the professional history.
 Education
 Training
 Certificates
 Courses
 Experience
 published research
 List of references.
 Any and other relevant credentials.
Verification
Verification can be performed by:
 The organization
 3rd party: hospital must request for a confirmatory documentation

Verification process applies to all clinical staff categories

• Full time
• Part time
• Visitor
• Locum

Primary source verification

Policy : ‫سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬
The procedures for verifying credentials and documentation are as follows:

1. Verifying and documenting the medical credentials provided by the physician, including four
aspects (Saudi Council classification, academic qualification, training, and experience)
according to the type of privilege granted.

 at least basic Verification, which is the academic qualification and experience Training
according to the type of qualification required.

2. Verification and documentation must be through the source, university, hospital or training center.

3. Verification and documentation can be done through the health facility or through an approved
third party (for example, dataflow(.
Policy : ‫سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬
Methods of verification and documentation from the primary source include (but not limited to):

1) Verification and documentation through direct contact (and it must be properly documented so
that the Assign the contact person from the Human Resources Department and specify the
contact person with documentation date and time of call and response).

2) Verification and documentation through an official letter issued by the primary source.

3) Verification and documentation through the website or the official e-mail of the concerned
authority.

 Verification and authentication can be done through a third party (e.g. Dataflow).
Evaluation
The institution must have updated record for all employees for:
• Certificates
• License
• Registration

Evaluation is the basis for PRIVILEGING

Certificates
 Academic certificates
 Professional training
 Fellowships
 Residency programs
Licence
• Valid licence at all times
• Within profession
Registration
The hospital ensures the registration of all healthcare professionals

Required by laws

All members of the medical staff must be registered with the Saudi Commission for Health
Specialties before allowed to work independently
Re-credentialing:
1. Re-credentialing is the continuous cycle of credentialing practitioners, as well as upholding
quality of service.

2. Re-credentialing is the process to obtaining and evaluating data to support the continued
competence of the healthcare practitioner to provide patient care service in or for a healthcare
institution.

3. The initial appointment process focuses on the practitioner’s education, training, and other
professional experience before obtaining membership and privileges at an institution. The
information required for this process comes mainly from external sources.
Re-credentialing:
4. The re-credentialing/reappraisal process focuses on the practitioner’s professional behavior and
competence while functioning within the institution. During this process the medical staff is required
to reappraise the individual’s adherence to medical staff membership requirements and the
performance of clinical privileges.

 For the Joint Commission accredited hospitals, the re-credentialing process includes a review of
information collected during the Ongoing Professional Practice Evaluation (OPPE) process.
Re-credentialing requirements:
1. Must include all that is required in the Credentialing requirements (if newly granted).
2. Ongoing Monitoring and Interventions must be included for re-credentialing:
a) Credentialing Office continuously monitors practitioners between re-credentialing and
privileging cycles and takes appropriate action when it identifies occurrences of poor
quality of member care and service.
b) Practitioners with an expired clinical license to practice are terminated or suspended.
c) Re-credentialing is conducted at least every 24 months in accordance with the
credentialing and re-credentialing process.
d) The re-credentialing process is conducted with the same standards as those for initial
credentialing.
e) The decision concerning re-appointment or failure to re-appoint will be conveyed to the
physician/provider in writing.
Activity 2.6: Recredentialing/Reappointment

• Review the scenario

• Discuss and list options

• Pick one person from your table

to report
 Verifying Expirables – Why is this Important?

Validate current credential and

1 disciplinary action

Ensure ongoing eligibility with the

2 organization – meet bylaws

requirements
Verifying Expirables

Meet accreditation and regulatory

3 requirements
Privileges
As credentialing practices vary despite a centralized body -
namely the SCHS - privileging, which is an internal or
institutional issue, varies largely from sector to sector and
from provider to provider.
The medical authorization and privilege grant policy provides
a mechanism for granting medical privilege to a health
practitioner ……… (POLICY)
Continue ….
 Most hospitals use some form of ‘laundry list’ for privileging, whereby the healthcare worker is
offered a checklist of privileges to choose from that can be initially verified by the Department
Head followed by the Credentialing and Privileging Committee (CPC) within this hospital, or in
the case of the General Directorate for Health Affairs - Riyadh, a final decision is taken based on
the simple verification of training and experience.
 the basic privileges for a given specialty are expected, while practices that are based on intuition
are excluded.
 Other hospitals and sectors may conduct competence-based privileging; in this process, the
training and experience per each privilege - especially for carrying out advanced or high-risk
medical procedures - is thoroughly evaluated in terms of training quality, actual experience, and
mentoring.
Policy : ‫سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬
 all practicing physicians are qualified and have clinical privileges according to their field and
Specialty.
 Each facility is obligated not to authorize any doctor to practice before obtaining the clinical
privileges
 Each practicing physician obtains clinical privileges according to the classification of the Saudi
Commission for Health Specialties for independent practice.
 A physician may be granted emergency medical privileges in an emergency without having the
emergency clinical privileges to save lives under specific conditions and according to the
standards of the Saudi Center for Accreditation Health facilities.
Policy : ‫سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬
 Each health facility must develop a mechanism for granting initial medical privileges, renewing
medical privileges, or refusing medical privileges.
 Privileges grant according to the need of the facility and the documents provided by the doctor.
 Before the health facility grants medical privileges, it must ensure that the physicians requesting
the medical privilege have appropriate specialization and classified by the Saudi Commission
for Health Specialties and all the credentials necessary to perform their privileges.
Policy : ‫سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬
 The health facility must collect information related to the requirements for granting medical
privileges to licensed physicians Verify and evaluate them, including:
1. Qualifications
2. Current license
3. Training
4. Current competency
5. Record or certificate showing the number of cases proving his experience of the required
privilege.
Policy : ‫سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬
privilege is classified into four categories:
1. Basic privileges : granted to any trainee in the training program for the same specialization
performs before complete the training and be classified in the Commission for Health
Specialties at least as a resident or deputy physician related specialty.
2. Advanced privileges in the same specialty after completing training and classified in the
Saudi Commission for Health Specialties at least as a first deputy or consultant in the same
specialty.
3. Additional privileges, which are the privileges for the subspecialties of the same basic
specialization, after being classified in the Saudi Commission for Health Specialties, and
obtains them in the same way as assessing the basic and advanced privileges.
Policy : ‫سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬
4. privileges for advanced or new skills in the field of specialization that require additional
training, which are not classified In the Saudi Commission of Health Specialties and for consultants
classified in the same specialty after evaluation auditing and submitting supporting documents
(such as a training certificate, its duration and source, a reference certificate and a record The
training cases are documented by the training supervisor, the training body, and the evaluation of
the training specialist consultant).
Policy : ‫سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬
Current Privilege: It is the medical privilege granted to the doctor after the approval of the Medical
Privileges and Accreditation Committee for a period not exceeding two years, The practitioner is
then re-evaluated according to his performance in applying the privileges granted to him or to add a
new privilege
Temporary Privilege: It is the medical privilege granted to a physician with a permanent or partial
contract, or a visiting physician who has been newly appointed to practice medicine. For a specified
period of time (provided that it does not exceed 90 days and it is not renewable).
Emergency Privilege: It is the medical privilege granted to a doctor in emergency cases (provided
that it does not exceed 90 days and is non-transferable) not renewable
Policy : ‫سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬

The Clinical Privileges and Privileges Policy applies to all medical practitioners who are
independent medical practitioners in health sector facilities at the Ministry of Health, including:
1. A practicing consultant physician who has obtained the registration of the Saudi Commission
for Health Specialties.
2. The physician is a senior specialist practitioner and holds the registration of the Saudi
Commission for Health Specialties.
3. A practicing specialist physician and holds the registration of the Saudi Commission for
Health Specialties.
Policy : ‫سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬

The Clinical Privileges and Privileges Policy applies to all medical practitioners who are
independent medical practitioners in health sector facilities at the Ministry of Health, including:
4. Resident physician and holder of the registration of the Saudi Commission for Health
Specialties.
5. A visiting doctor, a doctor on a part-time contract, or a volunteer who has obtained the
registration of the Saudi Commission for Health Specialties.
6. An intern or intern who works under the supervision of one of the medical categories above
Clinical Staff who require Privileging:
1. Clinical staff include all staff who provide clinical services (for example, medical services,
dental services, behavioral health services).
2. Clinical staff are licensed independent practitioners (LIPs), other licensed or certified
practitioners (OLCPs), and other clinical staff who are health center employees, individual
contractors, or volunteers.
3. Examples of LIPs include: physician, dentist, physician assistant, nurse practitioner, clinical
psychologist.
4. Examples of OLCPs1 include: registered nurse, licensed practical nurse, certified medical
assistant, phlebotomist, respiratory therapist, licensed or certified behavioral health support
staff.
Clinical Staff who require Privileging:
5. Examples of other clinical staff include: medical assistants, peer navigators or community
health workers in states, territories or jurisdictions that do not require licensure or certification.
6. The health center chooses the timeframe for recurring credentialing and renewal of privileges
(for example, every 2 years).
7. The health center chooses what specific credentialing activities apply to “other clinical staff.”
For example, if KSA does not certify medical assistants, you would verify their training instead
of licensure.
8. A health center that does not employ “other clinical staff” would not need to include them in its
operating procedures or make that type of provider file available for review.
Privileging

• Evaluation of
capabilities • Outcome of care
Physical &
Mental Health Competency

Privileging
• License Credentials Process Category • Consultant
• Education
components • Specialist
• Training
• Resident
• Experience
Privileging
Clinical privilege are granted for a period not exceeding two years, and consider when renewed the
qualification in terms of the number of cases served, number of serious events, medical errors, and
other issues related to privileges).

Temporary or emergency privileges can be granted:

Not more than 90 days
Not renewable.
The circumstances to be granted must be identified
Privileging
 Medical staff are allowed to practice only within the privileges granted by the credentialing and
privileging committee.
 When a new privilege is requested by a medical staff member, the relevant credentials are
verified and evaluated prior to approval.
 while it is an internal process carried out primarily by the hospital, health directorate or
equivalent - the SCHS establishes and oversees many scientific societies that can outline the
privileges for relevant specialties and subspecialties.
Privileging
 Members of the medical staff are not ALLOWED to practice any medical practices or privileges
different from their classified medical specialty.
 Members of the medical staff are not ALLOWED to practice any new medical practices or
privileges before studying it and obtaining approval from the Privileges Committee (Except in
the emergency cases stipulated at the beginning of the policy).
Privileging
 The performance & competency of the medical staff members is evaluated on an ongoing
basis to ensure competency:
 By department head
 Planned vs Unplanned
Planned: at least annually
Unplanned: when indicated
Policy : ‫سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬
 There must be a specialized department or entity to follow up the work of accrediting medical
privileges like HR or quality…..).
 This department is responsible for overseeing the process, Approval of granting medical
privileges to specialties according to the scope of services and the need of the health facility,
and confirmation the completion of the justifications for granting the medical privilege.
 the medical staff must fulfill the requirements of the Saudi Commission for Health Specialties
and the rules and regulations of the Ministry of Health for the practice of the medical
profession.
Policy : ‫سياسة االمتيازات والصالحيات االكلينيكية لألطباء‬
 The department head must ensure that all applicants have completed all requirement form to
obtain the medical privilege to practice in the health facility.
 The application must be submitted with a complete set of documents for the approval process
according to the approved policy.
Low/No Volume Practitioner Data
Peer recommendations: Peer recommendations should include reference to the applicant’s
competence and ability to perform the privileges requested
Data from other facilities: Peer recommendations should include reference to the applicant’s
competence and ability to perform the privileges requested
Procedure logs: Practitioners may be asked to provide procedure or case logs showing
procedures performed in the office setting.
Assessing Current Competency
• Proficiency requires practice
• High-risk procedures
• Use both internal and external sources to assess competency
• Assess low-volume practitioners
• Consider impact of age on competency
Performance & Competency evaluation

Examples

Assessment of patients.
Adverse events.
Moderate and deep sedation.

Quality of medical records.

Medication errors.
Performance & Competency evaluation

Examples

Sentinel events.
Outcome of high-risk procedures and surgeries.
Morbidities and mortalities.

Blood and blood product usage.

Discrepancies between pre and post-operative pathological diagnoses.
Appropriateness of admissions from the ER & OPD.
Performance & Competency evaluation

The data and information resulting from the medical staff performance review are used to:

 Provide feedback and counseling to the medical staff regarding their performance.
 Recommend plans for improvement
 Amend clinical privileges as necessary

• Expansion
• Limitation
• A period of counseling and oversight

• Other appropriate action

 Make informed decisions regarding reappointment.
 Recommend training and continuous education as needed
Performance & Competency evaluation
The outcomes of the medical staff performance evaluation and actions taken are documented in
the physician’s credentials file
Data and information resulting from the medical staff performance review are used to
continuously improve the quality and safety by :
• Studying and minimizing variances in the processes.
• Taking actions to avoid preventable medical errors and adverse events.
• Recommending equipment needed in specified areas.
Appeals

Hospitals must have a process in place for appeals against credentialing or privileging decisions
Credintialing & Privileging Red Flags
• Gaps / Missing dates
• Discripancies between applicant’s information & verification
• Previous adverse actions
• Drug & alcohol abuse
• Felony convictions
• Many lawsuits settlments
• Cancelled malpractice insurance
• Frequent job changes
• Suscpicious reference letters
• Altered documents
Continuous monitoring of privileges
 some hospitals conduct periodical performance evaluations,
 others do it routinely only to fulfill paperwork,
 while others do not do it at all.

 Based on this evaluation, the privileges and at times the credentials may be revisited to make
sure they are rightfully granted and aligned with the professional practice.
Module 4
Types of Practitioners
All Practitioner Classified by the SCHS:
- Medical Physician.
- Non-physician practitioners who are licensed, certified or registered by the SCHS to practice
independently (without direction or supervision), and treating patients such as (Nurse Practitioners,
Nurse Midwives, Dentists).
- Telemedicine consultants interacting with patients
- Physical Therapists, Occupational Therapists, Speech and language therapists
- Behavioral healthcare practitioners (Psychiatrists and other physicians, Addiction medicine
specialists, Doctoral or master's-level psychologists who are state certified or licensed,
- Social workers who are certified or licensed, or any other healthcare specialists, who are licensed,
certified or registered by the SCHS independently.
Advanced Practice Professionals (APPs)
Credential and privilege grant for advanced practice professionals is based on the regulations and
accreditation standards, as well as its bylaws.
Advanced Practice Clinicians – also known as Allied Health Professionals (AHPs) or Advanced
Practice Professionals (APPs) typically include:
• Advanced Practice Registered Nurses
• Clinical Nurse Specialists
• Nurse Practitioners
• Certified Nurse Midwives
• Psychologists
 Module 5
Decision-making Criteria and Process
Decision-making criteria and process
Determines in advance what should be done.
A medical services manager would:
• Determine department objectives
• Set goals
• Formulate policies and procedures, programs, rules and regulations
• Schedule review and updates of governance documents
Decision-making criteria and process
Determines how work in a department will be accomplished.
A medical services manager would:
• Identify roles and responsibilities for staff
• Assign duties to staff
• Assign levels of supervision
• Coordinate activities and teams to achieve departmental goals
Decision-making criteria and process
• Credentialing and privilege decisions are based on the collection of information regarding an
applicant’s qualifications, including education, training, licensure, malpractice and competence.
Decision-making criteria and process
- The Credentialing & Privileging Committee holds the responsibility for reviewing credentialing
and privileging for each applicant.

- All licensed practitioners by the SCHS must be approved by the credentialing committee.

- When issues are found during the credentialing & Privileging processes, the reviews make the
determination to approve or reject the practitioners’ application.

- The chair of Credentialing & Privileging committee, has the authority to approve or disapprove
practitioners’ credentialing or re-credentialing files.
Decision-making criteria and process
- Only when the reason for the exception is in benefit of member care, or when the timeline for
Committee review exceeds the established schedule, the Chair of Credentialing committee will
review and provide final approval on all of the clean files approved by the CMO.

- All provisionally credentialed practitioners must complete a credentialing application.

- The Credentialing & Privileging Staff will complete primary source verification, and review
malpractice claims and settlements from malpractice carriers prior to submitting recommendation
for committee approval.
 Module 6
Managing files that meet Criteria
Managing files that meet criteria
1. Credentials & Privileging files are treated as confidential and are kept with restricted access to
the Credentialing & Privileging Staff, and Compliance Department.
2. Documents in these files may not be reproduced or distributed, except for confidential peer
review.
3. Primary source verification is obtained and the provider file is updated.
4. The following documents will be current and maintained in the practitioner’s file:
- Current License.
- Verification of education and training.
- Verification of board certification.
- Work history-including gap inquiry.
 In addition to the above listed, each file contains a signed and dated checklist that includes:
- The source used.
- The date of verification.
- The signature or initials of the person who verified the information
- The report date, if applicable
Managing files that meet criteria
Each file contains a signed and dated checklist that includes:
- The source used.
- The date of verification.
- The signature or initials of the person who verified the information
- The report date, if applicable
File Audits
• Help verify compliance with the requirements of bylaws, accrediting agencies, and regulations.

• Tools should include necessary documentation and completion within the required timeframe.

• Audit tools vary depending on the processes being audited.

• Must be in compliance with current accreditation standards.

• Audit for required timeframes, if applicable.

Database Audits
Best practices include:
• Run reports from credentialing database containing information.
• Compare data from credentialing database with information from credentials file.
• Look for missing data.
• Correct discrepancies.
• Run audits of who is accessing database to assure no breach in confidentiality.
• Utilize software capabilities to track errors and educate staff to increase accuracy.
• Develop a policy that includes how often you should perform these audits and who is
responsible.
 Module 7
Submitting Credentialing Application
Submitting Credentialing Application
1. Upon receipt of the credentialing application, the credentialing specialist verifies that the
application is signed and dated.

2. Applications that are missing signature and date are returned to the practitioner or to the
submitted department.

3. All applications must have signature; electronic signatures are not accepted.

4. The application should be typed or legibly printed in black or blue ink.

5. The documents must be completed and submitted along with the application

6. Before the credentialing decision, the practitioner must attest that the information on the
application remains correct and complete application with the new attestation form when it requests
the practitioner to update the attestation.
Submitting Credentialing Application
7. Credentialing application includes at minimum the following responses:

- When this statement is answered “yes” in the attestation, practitioners must submit in writing the
reason for their inability to perform the essential functions of the position.

- The Credentialing Office will review the credentialing file, conduct further investigation, and will
submit recommendations for next steps to the Committee.

- The Credentialing Chair makes the final decision in the credentialing process.
 Module 8
Appealing Credentialing Decisions
Appealing credentialing decisions
“Appeal” means a request by a Licensed Independent Practitioner, to reconsider a Professional
Competence or conduct decision that affects a Licensed Independent Practitioner, participation in
the Health care facility.

 Providers have the right to appeal credentialing determinations with which they disagree.

 The process for appealing credentialing result is outlined in the credentialing notification letter.
Appealing credentialing decisions
 An appeal is a formal request by a practitioner to request reconsideration of any adverse
action.
 A hearing is a formal proceeding at which evidence and argument are presented on the matter
to a person or body having decision-making authority.
 The purpose of a hearing is to provide the opportunity for each side of a dispute, and
particularly the person deprived of this or her membership or privileges, to present its position.
Appealing credentialing decisions
To comply with this policy, applicant responsibility is to: Follow the instructions outlined in the
ineligibility letter to appeal an ineligibility determination.

 Credentialing office responsible to:

1. Notify the candidate in a timely manner of the determination that if He/ She do not meet
credentialing criteria.

2. Consider any appeals submitted in accordance with the instructions outlined in the ineligibility
notification letter.
Appealing credentialing decisions
 Practitioner appeal rights:

1. Health care organization uses objective evidence and patient-care considerations when deciding
the course of action for practitioners who do not meet quality standards.

2. Health care organization must notify authorities as appropriate of practitioners’ terminations or

suspension.

3. Health care organization Notification to Authorities of Practitioner Disciplinary Actions describes

the process for handling quality of care issues and related decisions.
 Module 9
Credentialing of Non-Physician Medical Practitioners
Credentialing of non-physician medical practitioners (NPMP)
 If a NPMP accepts member assignment as a Primary Care Provider (PCP), medical care
organizations and its delegated medical groups follows the full credentialing procedures.

 Credentialing requirements listed below:

• Verification time limit: must be in effect at the time of the decision.

• NPMPs hold a current license.
• Nurse Practitioner: Nursing License
• Certified Nurse Midwife: Registered Nursing License, Nurse Midwife certification.
• Clinical Nurse Specialist: Registered Nursing
• Physician Assistant: Physician Assistant license.
Module 10
Confidentiality Agreement
Confidentiality agreement
The Health care organizations must have a legal and ethical responsibility to safeguard the privacy
of all members and Providers, and to protect the confidentiality of their health and other information
Confidentiality agreement
Physicians and Health care providers, must fill and signee a confidentiality agreement, and need to
be filled as following: (I agree that)

- I will not intentionally or unintentionally disclose or discuss any Confidential Information with
others, including friends or family, who do not have a need to know it. Should I have any doubts
as to whether information is Confidential Information or not, I seek clarification from the Chair of
(Health Organization Name), or the Chief Executive Officer.

- I will not access or view any Confidential Information other than that required for my duties on
(Health Organization Name).
Confidentiality agreement
- I agree to abide by all laws, rules and regulations protecting the confidentiality of the Confidential
Information.

- Upon termination of my participation on (Health Organization Name), I will immediately destroy

or return any documents or other media containing Confidential Information to (Health
Organization Name).

- I understand that violation of this Agreement may result in termination of my participation on

(Health Organization Name), as well as potential legal liability.
 Module 11
Credentialing and Primary Source Verification
Credentialing and privileging processes are both interdependent
In KSA, The credentialing of healthcare practitioners is centralized in the Saudi Commission for
Health Specialties (SCHS).

Two main courses for credentialing

• Credentialing of Saudi healthcare practitioners with local qualifications.

• Credentialing of expatriates and Saudi healthcare practitioners with overseas qualifications.

Credentialing and privileging processes are both interdependent
Primary Source Verification (PSV)
1. No Dataflow Group Primary Source Verification (PSV) is required for KSA credentials issued
from the country.

2. Dataflow Group verification applies only for foreign credentials even for Saudi clinicians.

3. Others who are exempt from PSV include Saudis who have undertaken an equivalency from
the Ministry of Higher Education (unless required by their facility), as well as non-Saudis who
were born in KSA or graduated from KSA high schools who do not need to submit/verify their
experience when registering with the SCHS.
Primary Source Verification (PSV)

1. The SCHS applies PSV for the following components only:

a) education qualification.
b) Last one year of experience.

1. The SCHS is currently addressing overseas applicants through the Mumaris system, which
allows applicants to begin their registration and PSV processes from their home countries
before arriving to KSA.
Primary Source Verification (PSV)
 Currently, universities under the Ministry of Higher Education do not mandate SCHS
registration for promotions, therefore the rule is faculty staff do not acquire the SCHS license
unless required by the private hospital they practice within.

 Implementing PSV globally across the board for all applicants through a unified process of
verification for all types of healthcare professionals will result in a healthier and more
competent workforce.

 The addition of components to the verification process such as increasing the number of years’
experience, health license, logbook and Certificates of Good Standing will ensure the standard
of expertise.
Primary Source Verification (PSV)
Stakeholders for Credentialing and Privileging in KSA
Stakeholders for Credentialing and Privileging in KSA
Stakeholders for Credentialing and Privileging in KSA
Responsibilities
Responsibilities
1. Director of the health facility and the medical director: The director of the health facility is
primarily responsible for setting up a program for accreditation of privileges.

 The medical field is within the authority delegated and stipulated in the rules and regulations of
the Saudi Commission for Health Specialties. And it is considered the medical director is
responsible for making the final decision reliable.

2. Medical Privileges and Accreditation Committee: The committee is responsible for reviewing
credentials for professional competence and status health care for all applicants for granting
medical privilege eligibility, and verifying that all applicants are provided with Medical privileges,
with a copy of the health laws and regulations, with a declaration of compliance
Responsibilities
3. Head of Department: The head of the department is responsible for receiving all requests to
obtain the appropriate medical privilege for doctors Who supervises them and review all supporting
documents to be submitted to the Medical Privileges and Accreditation Committee. And must The
head of the department ensures that doctors practice according to the scope of powers granted to
them by the Privileges Committee classification levels.

4. The department head may assign any practitioner within his department who is suitable (in
terms of classification and privileges) to evaluate New practitioners requesting new benefits or
evaluating existing benefits.

 As for if the required privileges are outside it Regarding the scope of the resident or department
head, the practitioner's privileges must be evaluated by another medical institution that has the
same status Practitioner’s academic level. Privilege applicants and privilege categories
Responsibilities
5. Applicant: The medical internship application form must be submitted with supporting
documents for pre-employment verification And during the recruitment process, as required and the
applicant must adhere to health regulations and regulations. Make sure of the following if submitting
the application:
 It is a basic human resource requirement for any employee who joins the facility, whether on a
clinical or non-clinical position. clinical. Our employees must certify compliance with medical
privileges granted to them by the Accreditation Privileges Committee medical
Responsibilities
6. Human Resources Manager: The Human Resources Manager acts as a technical advisor to
the committee and reviews all documents for compliance, legal and regulatory requirements.

7. Department of a competent authority to follow up the work of accrediting medical

privileges: This department or this entity is responsible for Follow up on all requests for obtaining
medical privileges and monitor the process of accreditation and medical privileges that take place in
the facility through the Medical Accreditation and Privileges Committee
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