Definitions:
- Credentialing: The process in which credentials are verified to ensure that practitioners meet the qualifications as determined in the DaVita Medical Staff Bylaws and the regulations as mandated by state and federal law.
- Credentialing Advisory Committee (CAC): An OCMO committee that provides the initial review and recommendations on medical staff appointment.
- eCred: DaVita’s online credentialing and privileging system.
- Privileging: The process in which the GB reviews credentials and votes to grant clinical privileges. Notifications of Privilege requests are sent to FAs and RODs. GBs review the practitioner’s credentialing packet in eCred, then the GB evaluates the scope and type of privileges at the facility and considers the request.
When is credentialing/privileging required?
- Initial appointment
- Reappointment (every 3 years, or every 2 years in MD, NY)
- When a practitioner requests privileges at an additional facility (clinic add)
What is the role of a Medical Director in the privileging process?
1. Thoughtfully review the applicant’s credentialing packet prior to making any decision on privilege requests.
- The FA/ROD will provide this packet for your review at the time of the meeting.
2. Consider the applicant’s qualifications when evaluating privileging decisions.
- Privileging decisions cannot be based solely on reputational concerns, allegations or hearsay, or competitive motives.
- Privileging requests sent to the GB for consideration have already been reviewed by DaVita’s Credentialing Advisory Committee, which confirms that the applicant satisfies the threshold criteria for medical staff membership.
3. Ensure the GB holds timely meetings.
- The GB is required to meet and vote on clinical privileges within 30 days of the request being received from credentialing. After 180 days, credentialing will have to re-verify the file.
- Never hold a vote on a practitioner’s privileges until you have received a vote request from Credentialing Services.
- You may be cited upon survey if the GB has not voted on clinical privileges.
4. Ensure compliance, confidentiality, and peer review privilege.
- Credentialing information and decisions must never be discussed with anyone outside of the Governing Body or the CPRC.
- A credentialing packet should never be distributed to anyone outside of the Facility GB; in addition, it should not be taken outside of the facility or distributed electronically.
- If you are considering a vote to deny an applicant’s privileges, you must contact the Peer Review coordinator. A majority vote to deny privileges must be supported by the DaVita medical staff bylaws.
CFC References
V750 > (Condition tag) Governance
V753 > (Standard tag)
V762 > (Standard tag)