ASC industry report underscores importance of credentialing, privileging and peer review


Today’s healthcare industry, continuously changing and evolving, demands that organizations stay on the cutting-edge of best practices and innovations in order to succeed. Strategies that strengthen and improve patient safety and performance require processes and procedures that support efficiencies and enhance communication across departments – and attention to detail is a critical aspect in that effort.

According to the Accreditation Association for Ambulatory Health Care’s annual Quality Roadmap 2018, which analyzed data from more than 900 ambulatory healthcare accreditation surveys conducted in 2017, areas of both high and low compliance were identified. Most facilities surveyed are in compliance with the majority of standards with one exception: Meeting the standards for credentialing, privileging and peer review remains a challenge for many ambulatory organizations.

Credentialing, privileging, and peer review are three separate but related processes. For example:

  • Credentialing means validating a provider’s qualifications to offer healthcare services.
  • Privileging is the process of governing body approval for a provider to deliver specific treatments, procedures, or to use specific equipment.
  • Peer review is confirming a provider’s competence by enlisting others of similar license to review clinical records and other aspects of care (e.g., infection rates, patient wait times, compliance with medical staff rules and regulations, and patient satisfaction surveys).

Never lose sight of the details

The details matter – a lot.

If a facility is found deficient in any of the three areas mentioned above, it runs the risk of allowing its clinicians to perform services or procedures without the proper qualifications or experience. Making sure all the appropriate checks have been made before granting privileges is a key component to improving patient safety while limiting risk of liability. According to AAAHC surveyor findings, the most common causes of deficiency include:

  • A lack of formal or sufficient documentation of credentialing, privileging and peer review findings
  • Inconsistent practices
  • Reliance on chart review as sole means of peer review
  • Failure to include allied healthcare providers
  • Insufficient primary/secondary source verification
  • Insufficient or no documentation of key processes or information

If any of these deficiencies sound familiar to your organization, consider taking these actions to improve its compliance rates:

Conduct reappointment activities at least every three years and include peer review results in the reappointment process. The peer review process should not be limited to a review of clinical records but should also incorporate other items – such as infection rates, patient satisfaction survey results, and compliance with medical staff rules and regulations – and providers should be involved in determining the criteria for peer review.

Ensure the documentation of specific privileges. For example, with anesthesia, fluoroscopy, laser, and supervision, supporting documents should include the organization’s privileging form and approved privileging list. Incorporate detailed documentation during the initial privileging and reappointment processes, including time period for privileges granted, what privileges are requested and what are granted.

Also keep in mind that it’s important for privileging and reappointment procedures to be consistent and not reliant on another organization’s results. When new services are added or no longer provided, a formal adjustment of privileges should occur. The governing body and credentialing committee of the organization need to review and approve a formal list of privileges used by the organization.

To download the full report, please visit:

Naomi Kuznets
Naomi Kuznets, PhD, is the senior director at AAAHC Institute for Quality Improvement where she currently oversees development and implementation of ambulatory healthcare performance measures and benchmarking. She has extensive experience and expertise in healthcare-services-research within both medical society and association settings. Naomi is a member of the Board of the ASC Quality Collaboration and is the AAAHC/Institute liaison to the National Quality Forum, Physician Consortium for Performance Improvement and U.S. Department of Health and Human Services "Eliminating Healthcare Acquired Infections (HAIs)" effort. Previous experience also includes working as a senior policy associate and a senior policy analyst at the American Medical Association.


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