How Well Do You Know These Credentialing, Privileging and Peer Review Requirements?


Avoiding the common errors that derail surgery centers’ compliance efforts

Recently I was asked to put together a presentation on avoiding common mistakes in credentialing, privileging and peer review.

As luck would have it, these are some of my favorite subjects. I enjoy connecting the dots in the processes, so I was eager to uncover the areas in which leaders were currently struggling. To do it right, I had to dust off my regulatory hat, open my accreditation resources and dive into the research. I was surprised how many of the most common mistakes haven’t changed much over the years.

In regulatory compliance, “loop closure” means completing tasks with documentation that each step was done according to policy. This requires a meticulous attention to detail — an ability to find and check off each requirement to avoid gaps. For instance, even if you have a great policy and are following it to the letter, if you don’t have the documentation, it doesn’t count. Lack of loop closure was a contributing factor in the most common errors leading to deficiencies.

Provider-to-provider evaluations

The purpose of the credentialing and privileging process is to ensure applicants are legally and professionally qualified to perform the procedures requested. With the Peer Review process, the performance of providers on key patient outcome indicators is evaluated by other providers. These processes must follow established requirements which vary depending on the accrediting agency the facility uses. Most agencies require the policy to clearly define each step in the process from application to approval or denial of privileges. The process should be efficient and carried out in a timely manner and the specific privileges should be requested and approved as individual line items. Meticulous documentation should take place at every step in the process. Instead of including every specific mistake, I’ve identified the most common themes of the errors that facilities tend to commit:

  • Policy or process element errors: With these types of errors, a required portion of the policy or process wasn’t present, wasn’t completed or simply wasn’t documented.
  • Timeline errors: These include expiration dates of privileges and credentials, or failure to meet policy deadlines.
  • Documentation: The omission of signatures, dates, and the failure to document Governing Body approval are common documentation errors.
  • Credentialing and Privileging: The most common errors include failure to perform Primary Source Verification, list specific privileges requested as line items and include oversight of moderate sedation and privileges related to fluoroscopy, ultrasound, and lasers.
  • Peer Review: These include failure to perform a peer review, failure to include important aspects of care and failure to include the peer review in the re-appointment process.

For additional help

Credentialing, privileging, and peer review are integrated processes, and loop closure to prevent deficiencies is best achieved through knowing your policy, having an organized plan to carry out responsibilities and documenting every step of the way.

If you want to learn more about how to avoid common mistakes in credentialing, privileging and peer review process, be sure to check out my recorded webinar, which can be accessed through this link: OSM

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