Credentialing and Privileging Clinic NPs and PAs

Question about which NPs and PAs require bi-annual credentialing:

Our health system (four hospitals) has a network of employed physicians.  Some of these physicians have NPs and PAs working in their offices and they never set foot in the hospital(s).  We established a category of “clinic only” and do not privilege them.  We keep track of their licenses, OIG, etc., etc., but the DON for the Network does the privileging, which is reviewed by the network medical director.  My question is this: Do we need to have these clinic NPs and PAs complete a hospital application every two years as we do the ones that actually do rounds in the hospital for network physicians?  We established this category, which is only for network NPs and PAs who work only in the clinic.  We credential and privilege non-network and network PAs and NPs who work in the hospital every two years.

Thank you!

Marion Morrison, CPMSM, CPCS, Director of Medical Staff Services, Willis-Knighton Health System, Shreveport, LA



It seems that you are doing exactly what you should be doing. However, the answer to this question usually depends upon a number of factors such as the following:

  • What set of Accreditation Standards have you selected (TJC, DNV, HFAP)?
  • Are the NPs and PAs employed by the system or by one of the hospitals?
  • Do these individuals ever provide service in one of the hospitals?
  • Does your state require that they be “credentialed” through a hospital medical staff?

John Rosing, MHA, FACHEI assume that your hospitals are accredited by the Joint Commission. If so, and if a hospital is the official employer, then standards do not permit a hospital to employ physicians, PAs or NPs without going through the MS-defined credentials process.  If the individuals are not employed by one of the hospitals but do provide clinical services in one of the hospitals, they must have been granted clinical privileges authorizing them to do so.  If, however, the NPs and PAs are employed by an entity other than one of the hospitals, they do not need to have been credentialed and granted privileges through the MS-defined process. However, they should have been subjected to a rigorous human resource due diligence process and they should have had their duties defined by a leader with significant clinical experience and knowledge, such as would be afforded—it seems to me—by the DON/network medical director review process you described in your question.

Interestingly, if a hospital is accredited by DNV, its standards do not require that employed practitioners working exclusively in the ambulatory arena be credentialed though the medical staff process. This would apply to both physicians and NPs or PAs.  The standards of the Joint Commission do, conversely, require that they be reviewed and granted privileges through the MS.

John R. Rosing, MHA, FACHE, Vice President and Principal, Patton Healthcare Consulting

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