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Third in our series on TJC Survey Management Strategies

Don’t think you can fly on auto-pilot for the TJC Medical Staff Credentialing & Privileging Session. Yes, it’s been a standard part of hospital surveys for a long time. Yet, we still see a significant number of survey findings in the Medical Staff chapter for many organizations. And, recently, even some Condition Level Deficiencies.

So, what are the current high focus areas for Medical Staff Credentialing & Privileging? And the common compliance challenges? Let’s review those and help you get prepared for this session.

TJC Medical Staff Credentialing & Privileging: Surveyor Focus

The goal of this one hour session is to evaluate your process for verifying credentials and granting privileges to licensed independent practitioners (LIPs.) Surveyors want to see that the process is consistently carried out.

They also want to see how you evaluate the performance of LIPs. So, they review your process for Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE.)

Who should Attend?

Your Medical Director, President of Medical Staff, and Medical Staff Coordinator are the key players for the TJC Medical Staff Credentialing & Privileging Session. We highly recommend you don’t let your Medical Staff Coordinator handle this session solo. Not having a physician involved sends the message that your physicians don’t take the process seriously.

Which Medical Staff Files Get Selected?

The surveyors will ask for specific credentials files to review. They typically ask for LIPs they’ve encountered during tracers – either in person or through the medical record. So, be sure to keep track of those names as tracers are conducted.

In addition, surveyors frequently request the following “high profile” files:

  • High risk specialties (e.g. ECT)
  • Non-physician LIPs (e.g. psychologists, APRNs))
  • “Moonlighters”
  • Unusual procedures (e.g. podiatry, dental)
  • Telemedicine practitioners

They’ll review these files to make sure every credential has been verified. This includes licensure, training, National Practitioner Data Bank query, peer recommendations, health attestation, and continuing medical education. They’ll also check that appropriate privileges have been granted.

What are the Compliance Challenges?

The most significant compliance challenges we see related to medical staff credentialing and privileging are around FPPE/OPPE and telemedicine practitioners. So, let’s take a look at those two topics.


Many organizations are still struggling with getting their FPPE/OPPE process fully implemented. At this point, TJC expects your FPPE/OPPE process to be data based.

You can use data on clinical documentation, patient outcomes, medication ordering patterns, committee meeting attendance, complaints, and other performance measures. If your FPPE/OPPE process is not data based, you will likely receive a Requirement for Improvement.

Also, we see frequent survey findings for lack of “triggers” defining when a practitioner who is on OPPE would be placed on FPPE. (This is called “for cause” FPPE to distinguish it from FPPE for new practitioners or new privileges.) The following are a few examples of triggers for FPPE:

  • 10% of medical records lacking complete documentation of MD in-person evaluation for restraint or seclusion
  • 10% of verbal orders not authenticated within 24 hours
  • Less than 90% compliance with documentation of mental status exam in psychiatric evaluations
  • 5 or more substantiated complaints from patients or families
  • Less than 75% attendance at required Medical Staff committees

For further guidance on criteria and triggers for FPPE, see the TJC FAQ Focused Professional Practice Evaluation – Performance Criteria vs Triggers.

Be aware that surveyors often test the validity of your FPPE process by asking how many LIPs were put on “for cause” FPPE in the last year. If you can show such a case, it’s obvious your process is working.

Lastly, remember if you privilege non-physician LIPs (such as APRNs or psychologists) you need to do FPPE and OPPE on those practitioners as well. Surveyors will definitely ask for those files to make sure that’s in place.

Looking for a good resource on FPPE/OPPE? Check out the TJC Standards BoosterPak on FPPE/OPPE. It’s available on your TJC Connect site.

Telemedicine Practitioners

Many organizations run into problems on survey around the credentialing and privileging of telemedicine practitioners. Be aware if you’re using contracted telemedicine practitioners, you’re still responsible for their credentialing and privileging. Essentially, you have three options:

  • Do all the credentialing and privileging of the telemedicine practitioners through your own medical staff OR
  • Use the credentialing information from the telemedicine organization and privilege those practitioners through your own medical staff OR
  • Use the credentialing and privileging decision from the telemedicine organization if they are TJC accredited and the practitioner is already privileged by that organization for the same privileges to be provided at your organization.

The details of these requirements are spelled out in in the Medical Staff chapter of the Hospital manual: MS.13.01.01. This standard is worth a very close reading to be sure you “cross all the t’s and dot all the i’s” when it comes to telemedicine practitioners.

Antimicrobial Stewardship

Many organizations are unaware they need to educate their LIPs on antimicrobial stewardship (AMS.) This requirement became effective in 2017. You can do this through written materials or presentations at medical staff meetings. We’ve seen surveyors score noncompliance when there’s no evidence that LIPs have been educated on AMS. (For more on the AMS requirements, see our recent post TJC Medication Management Tracer: Survey Management Strategies.

Continuing Medical Education

We sometimes see organizations struggling to keep up the documentation for continuing medical education (CME) for LIPs. Be aware you don’t need to collect copies of trainings attended. You can use an attestation by the LIP stating they’ve attended CME as required for their license. You just need to add the stipulation that the LIP will produce proof of attendance upon request. See the TJC FAQ Continuing Medical Education – Documentation.

Survey Management Take-Aways

The TJC Medical Staff Credentialing & Privileging Session is still an important part of your survey. So, review your Survey Activity Guide get ready to efficiently walk the surveyor through your files.

Be prepared to explain your FPPE/OPPE process and show how you’re implementing it. If you use telemedicine practitioners, make sure you’re getting them credentialed and privileging through one of the TJC approved mechanisms.

When we do our TJC mock surveys, we always include a detailed Medical Staff Credentialing & Privileging Session. Clients tell us that using our checklist to prepare their files helped them navigate this session with less stress and better results. That’s always a welcome outcome!