Credentialing and Privileging
The institutes and centers appoint medical staff members (1) to further their medical or surgical specialty/subspecialty training in a research setting or (2) to conduct clinical research after having completed training. For the candidate’s initial appointment, after nomination for medical staff membership by senior faculty of the NIH institute or center, the Clinical Center follows established procedures for verifying completion of medical education, postgraduate training, and licensure, and for identification of possible adverse occurrences at other institutions.
The nomination process for initial credentialing generally requests clinical privileges commensurate with the potential medical staff member's training and anticipated Clinical Center activities. Factors to support credentialing decision-making include verification of competence from the applicant's prior program director, letters of recommendation, and a search, using national databases, for adverse occurrences during previous medical staff appointments.
Following initial credentialing and awarding of privileges to a medical staff member, the supervisory senior medical staff should be vigilant to assure the medical staff member's sustained cognitive and technical competence.
The medical staff member's clinical supervisor (section head, branch chief or clinical director) will use the Ongoing Professional Practice Evaluation (OPPE) to document continued competence at the time of recredentialing. The medical staff member's clinical supervisor must review and sign the OPPE before its submission to the Credentials Committee.
Objective data to be considered may include inpatient and outpatient activity, numbers of procedures performed, complications associated with procedures, participation in quality assurance meetings, professional education (including attendance at IC or Clinical Center grand rounds presentations), and adherence to clinical administrative requirements (e.g., completion and timeliness of procedure notes, consult notes, and admission/transfer of service/discharge notes).
If the clinical supervisor determines that the medical staff member under consideration for recredentialing needs monitoring or specialized training elsewhere, this indication must accompany the OPPE as a memo, and must be approved by the clinical director. Clinical supervisors are encouraged to review the OPPE with their medical staff members at intervals between credentialing cycles because these reviews can be a valuable mentoring and performance improvement tool.