Members Only | 10.23.25
Standing Firm: The Vital Role of Medical Staff Professionals in Credentialing and Privileging Competency Requirements
By Vicki Mash, MBA, CPMSM, CPCS
Have you ever been encouraged to move forward with credentialing despite incomplete or missing documentation? As Medical Staff Professionals (MSPs), we hold a vital responsibility in safeguarding the integrity of our healthcare organizations. Among our most critical duties is ensuring that every provider meets established baseline criteria and competency standards before being granted privileges.
It is essential to stand firm — these requirements are not optional or arbitrary. They are rooted in evidence-based practice, guided by accreditation standards, and, above all, designed to protect patient safety. Upholding these standards is not only a regulatory obligation but a professional and ethical imperative.
The Importance of Baseline Criteria
Baseline criteria are typically developed based on the standards set by accrediting bodies such as The Joint Commission (TJC), Det Norske Veritas (DNV), or Accreditation Commission for Health Care (ACHC), and are aligned with best practices. These criteria define the minimum qualifications a provider must meet to be considered for appointment and privileges.
When an applicant fails to meet the minimum threshold, the appropriate course of action is to deny or defer their application — not to lower the standard. Making exceptions, even in the face of staffing shortages or urgent clinical needs, sets a dangerous precedent and undermines the purpose of having a standardized, fair credentialing process.
The Purpose of Competency Requirements
Competency requirements are in place for one primary reason: to ensure that every provider is qualified and capable of delivering safe, effective care. These requirements help verify that a provider has the appropriate education, training, experience, and current clinical competence necessary to perform the privileges they are requesting.
Granting privileges to individuals who do not meet the competency criteria puts patients, the healthcare organization, and the individual provider at risk. It can also expose the institution to negligent credentialing claims and accrediting body citations.
Ongoing Monitoring: A Continuous Responsibility
Credentialing is not a one-time event. Ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE) are essential components of a comprehensive credentialing process. MSPs and Provider Enrollment professionals must continuously monitor provider performance, verify clinical activity, and ensure compliance with ongoing competency standards.
This monitoring helps identify issues before they escalate and provides data to support reappointment or privilege modification decisions. It also reinforces the organization’s commitment to delivering high-quality care.
Avoiding Exceptions: Fairness and Risk Mitigation
While there may be extenuating circumstances that tempt organizations to make exceptions — such as critical staffing shortages or pressure to onboard a high-profile recruit — granting privileges to a provider who does not meet established criteria can create significant legal and regulatory risks. Accrediting bodies expect all applicants to be treated consistently and equitably, regardless of their perceived importance or the organization’s staffing needs.
By maintaining consistency and adhering to established standards, MSPs and Provider Enrollment professionals protect both the integrity of the credentialing process and the safety of the patients served.
Credentialing Competency Quiz
Test your knowledge with the short quiz below:
- What is the primary reason competency requirements exist in the credentialing process?
a) To limit the number of applicants
b) To meet hospital budget goals
c) To ensure patient safety and care quality
d) To satisfy insurance requirements
- What are baseline criteria typically based on?
a) Provider availability
b) Hospital bylaws only
c) Accrediting body standards and best practices
d) Departmental preferences
- What is the risk of granting exceptions to providers who do not meet baseline credentialing criteria?
a) Improved staffing coverage
b) Reduced administrative workload
c) Increased likelihood of regulatory citations and negligent credentialing claims
d) Easier onboarding process
- Which of the following is a key component of ongoing provider monitoring?
a) Staff meetings
b) FPPE and OPPE processes
c) Annual holiday scheduling
d) Provider social media review
- Why is it important to treat all credentialing applicants the same?
a) To avoid complaints from staff
b) To ensure fairness and mitigate legal risk
c) To make the process faster
d) To please department chairs
Credentialing Competency Quiz — Answer Key and Explanations
- What is the primary reason competency requirements exist in the credentialing process?
✅ Correct Answer: c) To ensure patient safety and care quality
Explanation: Competency requirements are designed to ensure that providers have the necessary qualifications and current clinical competence to safely and effectively care for patients. It’s a patient safety measure, not an administrative or financial decision.
- What are baseline criteria typically based on?
✅ Correct Answer: c) Accrediting body standards and best practices
Explanation: Baseline criteria are generally established using standards set by accrediting bodies (like The Joint Commission or DNV) and industry best practices. They define the minimum qualifications needed for a provider to practice safely at an organization.
- What is the risk of granting exceptions to providers who do not meet baseline credentialing criteria?
✅ Correct Answer: c) Increased likelihood of regulatory citations and negligent credentialing claims
Explanation: Granting privileges to unqualified providers exposes the organization to significant risks, including accrediting body deficiencies and legal action for negligent credentialing if patient harm occurs.
- Which of the following is a key component of ongoing provider monitoring?
✅ Correct Answer: b) FPPE and OPPE processes
Explanation: Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) are standard components of continuous monitoring to ensure providers maintain their clinical competence and meet performance expectations over time.
- Why is it important to treat all credentialing applicants the same?
✅ Correct Answer: b) To ensure fairness and mitigate legal risk
Explanation: Consistently applying credentialing standards helps ensure a fair, unbiased process and protects the organization from claims of favoritism or discrimination. It also reduces the risk of regulatory scrutiny and legal liability.