CHAPTER - I

INTRODUCTION

CREDENTIALING

Credentials are documented evidence of licensure, education, training, experience, or

other qualifications. Credentials are the process of obtaining, verifying, and assessing the
qualifications of a health care practitioner to provide patient care services in or for a
health care organization.

Credentialing of doctors and nurses is a process of verifying the qualifications, expertise,

and experience of healthcare professionals. It plays an important role in ensuring quality
patient care and safety. Credentialing involves a comprehensive evaluation of various
aspects of a healthcare provider's professional background, such as education, training,
licenses, certifications, and work experience.

Credentialing is critical for ensuring that only qualified and competent healthcare
providers are allowed to practice in their respective fields. It is a crucial component of the
healthcare system, as it helps to maintain the highest standards of patient care and safety.
Credentialing also helps healthcare organizations to comply with regulatory requirements
and accreditation standards.

In addition to credentialing, healthcare professionals may also undergo periodic re-

credentialing or re-validation to ensure that they maintain their skills and knowledge, and
are up-to-date with the latest developments in their field. This ongoing evaluation helps
to ensure that healthcare professionals are providing the best possible care to their
patients.

Overall, credentialing is an essential process that ensures that healthcare professionals are
qualified .

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PRIVILEGING

Privilege is a process whereby the individual nurses credentials is evaluated based on

their performance in the competency test, further issued by the Nursing credentialing
committee on regular basis.

Healthcare professionals have been playing a critical role in the healthcare industry,
providing care and treatment to patients with various health conditions. Among the
healthcare professionals, doctors and nurses take center stage in providing care and
treatment to patients, and their role cannot be ignored.

The society perceives doctors and nurses as professionals that possess the highest levels
of knowledge, and their opinions carry much weight in healthcare decision-making. They
are considered the most privileged healthcare professionals due to the critical nature of
their work and the complexity of the issues they handle. As a result, their pay, benefits,
and working conditions have often been better compared to other healthcare
professionals, such as pharmacists and laboratory professionals.

This privileged position of doctors and nurses has led to some challenges, including high
levels of burnout, increased pressure, and lack of appreciation among other healthcare
professionals. Furthermore, this privileged position leads to the over-reliance on their
input in certain critical healthcare decision-making ventures, thus putting unnecessary
pressure on them.

This paper explores the privileging of doctors and nurses and its impact on the healthcare
industry.

Competency is the process whereby the specific scope and content of patient care
services are authorized for a health care provider by a health care organization based on
evaluation of the individual’s credentials and performance.

2
1.1 INDUSTRY PROFILE

The Healthcare Industry comprises medical facilities that provide care and services to
individuals who require medical attention. Hospitals are equipped with trained medical
professionals, model equipment, and facilities catering to patients' diverse medical needs.
The industry includes private and public hospitals and outpatients clinics, rehabilitation
centers, and diagnostics laboratories.

The scope of hospitals includes general and speciality care, emergency care, intensive
care, and long term care. Hospitals also offer a broad range of supportive services such as
diagnostics imaging, laboratory testing, and pharmacy services. It is a vital component of
the healthcare system and plays a critical role in the communities they serve. It
employees a large workforce, including allied health professionals, nursing staff,
physicians and administrative staff. Due to the complexity of healthcare delivery and
rapidly evolving medical technology, hospitals require significant capital investment and
on-going operating expenses.

The healthcare industry is highly regulated with strict licensing and accreditation
standards enforced by government agencies. In addition, most hospitals are subject to
reimbursement regulations from the private and public payers, including Medicare and
Medicaid. These regulations have a massive impact on hospital and finances and create
challenges for healthcare providers to provide quality care while maintaining
sustainability. It is crucial in providing comprehensive healthcare services to the public.
Keeping up with advances in medical technology and adapting to regulatory changes
while balancing financial sustainability remains a significant challenge for the industry.

There has experienced significant changes over time, including the shift towards value
based care and an emphasis on patient-centred approaches to health care. Economic
factors, such as changing reimbursement models, electronic health records, and advances
in medical technology, have also had a significant impact on the industry. Hospital faces
several challenges, including rising costs, varying insurance coverage, staffing shortages,

3
and the need to maintain quality in patients care. In response, hospitals are leveraging
technology and data analytics to reduce costs, improve patients outcomes and
experiences, and manage resources more efficiently.

It remains an essential component of the overall healthcare system, providing critical care
to patients who require hospitalization for their illnesses and medical conditions. Despite
the challenges, hospitals continue to serve as a backbone of healthcare and delivery and
are essential to maintaining the overall health of populations.

1.2 INSTITUTIONAL PROFILE

Scudder Memorial Hospital is providing quality healthcare for the past 152 years in and
around Ranipet. The history of the hospital dates back to the middle of the 19th century
when Dr. Silas Downer Scudder started the hospital in Ranipet on 17th march 1866. He
was the son of Rev. Dr John Scudder, the first Medical Missionary from America to the
east / India. The name and fame of the hospital spread rapidly all over Ranipet.in
popularity so that the number of patients in the third year was double that in the second
year. Crowd of sick and suffering people began to pour in from all towns and villages.
From the start the Gospel was regularly preached and religious tracts and books freely
distributed. The new hospital building was completed and occupied in 1928. Over the
years, several committed and dedicated servants of God rendered their selfless service to
the hospital and glorified our Lord’s name.

Scudder Memorial Hospital is a pioneering multispecialty charitable health care

Institution in the heart of Ranipet, strongly built on the foundation of grace, compassion
and service towards the sick.

Scudder Memorial Hospital caters to the healthcare needs of over 65 villages around
Ranipet. The treatment provided at SMH is highly subsidized and less expensive
compared to the private clinics & hospitals. Most of our patients are poor and on many
occasions the very poor patients are treated free of cost at SMH.

4
VISION STATEMENT: "To continue the Healing Ministry of Jesus Christ by providing
quality and accessible health care to all"

The vision for the hospital was a seed planted by Dr. John Scudder, a medical missionary
from the United States of America in 1819 which after years of hard work and
determination, was established as Scudder Memorial Hospital by Dr. Silas Scudder in
1866.

Scudder Memorial Hospital has been providing quality healthcare for the past 150 years
in and around Ranipet. The History of the hospital dates back to the middle of 19th
century when Dr. Silas Downer Scudder started the hospital in Ranipet on March 17,
1866.

Silas was the son of Rev. Dr. John Scudder the first Medical Missionary from America to
to India. The name and fame of the hospital spread rapidly all over Ranipet The hospital
grew rapidly in popularity so that the number of patients in the third year was double that
in the second year.

Today, SMH serves over 150 inpatients and 250 outpatients daily, with over 8 wards, 15
clinics each day and 20 other departments / sections.

John Scudder was born in Freehold, New Jersey, and was educated at the College of New
Jersey (1811) and the College of Physicians and Surgeons, New York (1813).

He established a successful medical practice in New York, and in 1816 married Harriet
Waterbury. He sailed for Ceylon in 1819 as the first medical missionary of the American
Board of Commissioners for Foreign Missions (ABCFM).

Stationed among the Tamils of Jaffna peninsula, he was ordained by fellow missionaries
in 1821 and launched a ministry of intensive evangelism together with a hospital, day and
boarding schools, and training of medical students.

5
Rev. Dr. John Scudder and his descendants have established a Medical Missionary
Service in Vellore District of Tamil Nadu State, which has resulted in the establishment
of the two outstanding Medical Institutions.

Firstly, it is the Scudder Memorial Hospital in Ranipet, standing in the city where
Dr.Silas Scudder began the medical services of the Scudder family, itself a memorial to
Dr.John Scudder and his seven sons, who all became missionaries.

Secondly, it is the Christian Medical College and Hospital by Dr. Ida Scudder in Vellore.
The hospital grew rapidly in popularity so that the number of patients were increasing
year by year. The new hospital building was started in 1919 and completed and occupied
in 1928.

As Sir William Wanless has said, ―After all mission hospital is not to be regarded, on
the one hand as an institution established nearly for the preaching of the gospel or solely
as method of evangelism. It is a part of the gospel; it is evangelism‖.

Like many other Mission Hospitals in India, SMH also faced its ups and downs in its
long journey. . During the years 2000 to 2010, the SM hospital faced a very critical time
in its history and was about to close down. But by God’s mercy, new administration
headed by,

Dr. Anbu Suresh Rao and the valuable partnership of CMC & Hospital, Vellore brought
back the past glory and started shining.

Currently the Hospital is a 164 bedded multi-specialty hospital with all the specialties
like, General Surgery and Medicine, Orthopedic & Spine Surgery, Arthroplasty,
Pediatrics, Pulmonary Medicine, Dental & Maxillofacial Surgery, Ophthalmology, ENT
Surgery, Obstetrics & Gynecology, Dermatology, Family Medicine, Physiotherapy and
Psychiatry.

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God has provided a team of 40 dedicated doctors under the leadership of Dr. Anbu
Suresh Rao to SMH, Ranipet. All these doctors are full time and reside within the campus
and have chosen to serve the poor and needy people through this mission hospital. The
dedication of these medical personnel has surely been sustained by self-sacrifice and
ideals.

Scudder Memorial Hospital will stand as a beacon light guiding the people of its
community to the Great Physician, the savior of the World.‖

Owned by: Church of South India Trust Association (CSITA) Synod, Chennai

Governed by: Church of South India Vellore Diocese, Diocesan Medical Board

By the grace of God, Scudder Memorial Hospital Ranipet continues to grow in every
aspects of life and in its contribution to the physical and spiritual welfare of all the people
who enter its premises. Scudder Memorial Hospital continues to witness his presence and
to be an instrument of his healing ministry since 1866.

7
1.3 PROBLEM IDENTIFICATION

 No proper communication with the relevant department staff members

 Frequently Transferring the staff members to various departments
 Problems by the observers in the specific departments.

1.4 NEED FOR THE STUDY

1. To observe a properly integrated function of HR with Doctors and Nurses.

2. To maintain the updated information of the healthcare professionals such as licensing
and certifications.
3. To clearly define the roles and responsibilities on each staff with regard to their
clinical areas.
The purpose of the Credentialing, Competency Assessment & Appraisal policy is to
ensure that the patients shall receive care from individuals who reflect the highest levels
of qualifications and competencies in their respective professional disciplines.

1.5 AIM OF THE STUDY

To assess the credentialing and privileging in the healthcare sector to improve the quality
of patient care especially in the following departments this has a significant effect
towards the same.

 Medical Service
 Nursing Service

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 CHAPTER-2

REVIEW OF LITERATURE

Medical recruiters who lack the necessary knowledge and abilities have resulted in
compliance with company XYZ's quality control criteria for credentialing and
privileging. The organisation is exposed to risk and potential legal issues when quality
control criteria are not met, and employing healthcare providers will take longer to
complete. Understanding the extant research in the fields of credentialing, privileging,
adult learning theories, instructional design systems, and organisational change is the aim
of this overview of the literature.

INTERNATIONAL STUDIES

(Me kruk, 2009), Similar to credentialing, granting privileges involves a number of

steps, including application, evaluation, interview, decision, and renewal processes.
Among other things, privileging can entail confirming a provider's current licence,
making sure they have training and expertise that is pertinent.

Forster et al. (2011), The Joint Commission established that verification of credentials
must come from a prime source, or from the source itself, in order to be completed. Until
the credentialing procedure is finished, no healthcare provider is allowed to offer
services. Healthcare facilities should have legislation that directs the administrative
credentialing process, A person needs to have the appropriate credentials in order to
practise medicine, which is a privilege. The pre-application process should be covered in
organisational bylaws, along with steps to restrict the practise of medicine for providers
who are deemed unsatisfactory.Provide criteria for temporary rights and set conduct
standards. Every healthcare facility that creates administrative standards for credentials
should align their practises with applicable state and federal legislation.

9
Patrick M. Campbell, Vanessa K. Barone, and Carmelo A. Milano (2015), The
function of credentials in emergency department personnel is examined in this article.
The authors talk about the particular difficulties in certifying emergency medicine
specialists, namely the requirement for quick assessment and hasty judgement. They also
offer suggestions for setting up efficient emergency medicine credentialing systems.

Reames et al. (2016), The significance of credentials and privileges in ensuring patient
safety and high-quality care has been stressed in numerous research. Credentialing and
privileging are important parts of a bigger framework for assuring patient safety and the
quality of care, according to a systematic evaluation of the literature that the authors
conducted. The report provides numerous instances of adverse occurrences and patient
harm brought on by insufficient credentialing and privileging processes, emphasising the
significance of comprehensive analysis of healthcare professional credentials and
abilities.

Smith and others (2017), According to the literature, credentialing and privileging
procedures can differ greatly amongst healthcare institutions or jurisdictions, resulting in
inconsistent standards, inefficiencies, and perhaps harmful patient outcomes. hospitals in
Australia, Canada, the UK, and the US were compared for their credentialing and
privileging procedures, and significant differences in procedures' timeliness, policies, and
practises were found. To increase the consistency and effectiveness of the credentialing
and privileging procedures, the authors advise the creation of standardised, evidence-
based methods and guidelines.

Meghan N. Stawicki, Susan D. Moffatt-Bruce, and Michael Rosen (Anesthesiology

News 2018), The significance of competence evaluation and certification in perioperative
care is covered in this article. The authors outline the difficulties in upholding
credentialing requirements in a healthcare setting that is rapidly changing and offer
tactics that healthcare professionals can employ to preserve competence and guarantee
patient safety.

10
NATIONAL STUDIES

Dr. Elsheeba (Indian Journal of Critical Care Medicine, 2010): The article
"Credentialing and privileging of intensive care unit practitioners: Indian perspective"
emphasises the significance of doctor and nurse privileges and credentials in Indian
intensive care units (ICUs). It emphasises the necessity of developing uniform procedures
for credentialing and privileging, defining competency-based criteria for ICU
practitioners, and assuring continuing monitoring and evaluation of their performance.

Dr. Roshan Immanuel (published in Indian Journal of Anaesthesia, 2013)The

process of granting credentials and privileges to doctors in India is described in this
article in general terms, along with the legal and regulatory frameworks, certification
requirements, and difficulties in putting such systems into practise. In supporting
standardised credentialing and privileging methods, it also analyses the function of
medical societies and professional bodies.

Dr. Raman Kumar and Dr. Supten Sarbadhikari (2015), In order to guarantee patient
safety and a high standard of care in the Indian healthcare system, this article examines
the significance of credentialing and privileging. It gives a brief review of the regulations
and norms that are already in place in India for credentialing and privileging, and it
emphasises the necessity for uniform procedures and standards for determining the
proficiency of healthcare providers.

Dr. Jeetha D'Lima and Dr. Sujatha Shanmugam (2016), In specific, the credentialing
and privileging of nurses in the Indian context is the topic of this literature review. It
presents a summary of the existing literature on the subject in the Indian context and
analyses the various facets of credentialing and privileging, including education, training,
experience, and competency evaluation.

11
Dr. John Wesley (published in Indian Journal of Public Health, 2016):This review
summarises the existing research on the subject and focuses primarily on the certification
and privileges of nurses in India. It covers the significance of certification and privileging
in nursing practise, the realities of current nursing certification procedures, their
difficulties, and the requirement for uniform certification and privileging procedures for
nurses in India.

Dr. Vivek Chouksey and Dr. Madhuri Chouksey (2017): The obstacles faced
throughout the credentialing and privileging procedure for physicians and nurses in India
are covered in this article. It draws attention to problems including the absence of
uniform recommendations, the wide range of evaluation standards, and the requirement
for effective systems for credentialing and privileging in the Indian healthcare system.

Dr. Sourav prasad (published in Indian Journal of Medical Sciences, 2018) The
regulatory structure in India for credentialing and privileging healthcare professionals,
including doctors and nurses, is thoroughly analysed in this article. It analyses the issues
with and shortcomings in the existing regulatory system while reviewing the pertinent
laws, rules, and regulations. Additionally, it makes suggestions for improving India's
systems for granting credentials and privileges.

Dr. Suresh K Sharma and Dr. Devesh Kumar (2019): A Comparative Study between
India and the United States In this study, the nurse credentialing and privilege processes
in India and in the United States are compared. It emphasises the need for standard
procedures in India based on global best practises and illustrates the contrasts and
similarities between the two systems.

Dr. Abhinav Bassi, Dr. Shashi Bhushan, and Dr. Sudhir Kumar (2020): This
systematic review offers a thorough overview of the body of knowledge regarding the
recognition and privileges accorded to healthcare providers in India. It talks about the
difficulties, ideal methods, and suggestions for enhancing the credentialing and
privileging procedures in India.

12
(Patel & Sharma, 2020), Since credentialing verification is a crucial component of the
provider recruiting process, credentialing is a crucial topic for every business that hires
healthcare professionals. According to Patel and Sharma (2020), health care facilities
require regulations to set the minimal requirements for credentialing and privileging to
ensure provider competency, even though recruiting exceptional medical personnel is
essential for successful businesses. This section will explain healthcare credentialing,
give a general overview of the procedure, and talk about current healthcare credentialing
difficulties. In order to assure consistency and that healthcare providers are qualified to
deliver clinical services, it is crucial to verify their credentials, including licences,
schooling, certificates, and records of malpractice. Generally speaking, any licenced
provider subject to licencing requirements and authorised by law to provide.

13
 CHAPTER - III

RESERACH METHODOLOGY

3.1 Research Methodology

Research Methodology is used to collect data, to identify and to analyse the collected
information. In this chapter the researcher explains about the methods for the study on
Credentialing and privileging of Doctors and Nurses in Scudder Memorial Hospital,
Ranipet.it defines about the theoretical analysis of the method which is appropriate for
the study. It also with research design, sampling, theoretical model, etc.

3.2 Statement of the Problem

The process of credentialing and privileging of doctors and nurses is often complex and
varies greatly between healthcare institutions. This can create inconsistencies in the
quality and safety of patient care, as well as potential legal liabilities for healthcare
organizations. Additionally, poor communication and documentation of the credentialing
and privileging process can result in delays or disruptions in healthcare delivery, leading
to negative patient outcomes. Therefore, there is a need to establish standardized and
transparent credentialing and privileging procedures that ensure patient safety and high-
quality care delivery, while protecting healthcare organizations from legal and financial
risks.

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3.3 OBJECTIVES OF THE STUDY

CREDENTIALING

1. To establish and maintain a standard of competence and professionalism among

healthcare providers.
2. To prevent unqualified or incompetent individuals from providing healthcare
services.
3. To ensure that healthcare providers have the necessary licenses and certifications
required by law.
4. To protect patients from harm by ensuring that healthcare providers are appropriately
screened for past conduct, criminal history and malpractice claims.
PRIVILEGING

1. To ensure that healthcare providers are continuously evaluated for their clinical
knowledge, skill and competency.
2. To ensure that healthcare providers are aware of current medical knowledge and
practice guidelines.
3. To enable healthcare providers to realize their full potential through continuing
education, training and professional development.
3.3.1 Primary Objective

 Study on credentialing and privileging among doctors and nurses in Scudder

Memorial Hospital, Ranipet.
3.3.2 Secondary Objective

 Professional development
 Team building
 Career advancement
 Liability protection

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3.4 Study Process:

 Documentation Review (various policies relevant to the study)

 Credentialing and Privileging policy according to NABH Standards
 HR policies on recruitment, training and development
 Semi-structured interview with staff, Observation, Usage of checklist

3.5 SCOPE OF THE STUDY

In general, the scope of credentialing and privileging for doctors and nurses includes the
following:

1. Verification of education, licensure, certification, and/or training.

2. Evaluation of clinical competence and judgment.
3. Review of previous healthcare practice and any disciplinary actions taken against the
healthcare professional.
4. Assessment of the healthcare professional's knowledge and experience in a particular
area of practice.
Determining the appropriate clinical privileges based on the healthcare
professional's qualifications and experience.

Overall, credentialing and privileging are important processes that help ensure patient
safety and quality of care. By verifying a healthcare professional's qualifications and
granting them specific clinical privileges, healthcare organizations can ensure that
patients receive safe and effective care.

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 3.6 LIMITATIONS

1. May struggle to capture the full range of skills and knowledge that a doctor or nurse
possesses, and may not reflect their on-going learning or evolving skillset.
2. Process can vary across different organizations and jurisdictions, leading to discrepancies
in the requirements and expectations for doctors and nurses.
3. May not adequately recognize the qualifications and experiences of doctors and nurses
trained outside the country, leading to difficulties in gaining certification and approval to
practice.

3.7 RESEARCH DESIGN

The research design for studying the credentialing and privileging of doctors and nurses
will involve a mixed-methods approach, combining both quantitative and qualitative data.
The quantitative approach will involve analyzing data collected from administrative
databases and surveys, while the qualitative approach will involve conducting interviews
and focus groups with healthcare providers and administrators.

3.8 DESCRIPTIVE RESEARCH

The descriptive method has to be used in this study like survey, data’s was collected
through Credentialing forms and Privileging forms from the Doctors and Nurses in
Scudder Memorial Hospital.

3.9 Instrument Design

The design for this case is framed for the Checklist as


Credentialing Form

Privileging Form

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3.10 Data Collected Methods

Secondary Data

The data has been collected by various methods such as


Gathering information from administration

Verification

Evaluation

Documentation

Review and re-credentialing.

3.11 Sampling

Purposive sapling method is used by the researcher

3.12 Sampling Method

The Researcher has used the Convenience sampling technique to identify the
respondents.

3.13 Sample Size

The data was collected from the Doctors and Nurses of Scudder Memorial Hospital,

Ranipet. The sample size is 150.

Doctors - 30

Nurses - 120

3.14 Semi Structure review

The semi-structured review is a critical step in the credentialing and privileging process,
which is typically conducted by a peer review committee consisting of medical

18
 professionals, nurses, and administrators. This review is essential because it evaluates the
qualifications of the healthcare professional, including their education, training, work
history, and clinical competence. The review committee also examines their compliance
with the organization's medical staff bylaws, policies, and procedures, as well as their
medical liability insurance and criminal background.

 Education and training

 Professional Licensure and Certification
 Work Experience
 Clinical Competence
 Adherence to Medical Staff Bylaws
 Medical Liability Insurance

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 CHAPTER - IV

DATA ANALYSIS AND INTERPRETATION

Responsibilities

The Credentialing Committee shall meet to assess the credentials and qualifications of
Nursing Staff. This committee shall be authorized to do the Competency for Nursing
Staff based on qualifications, experience and area specific skills. This shall be duly
recommended after conducting knowledge and skills assessment by the respective area
In-charge and Nursing Supervisors and the same shall be forwarded by the Deputy
Nursing Superintendent to the credentialing committee.

It shall be the responsibility of this committee to assess the credentials before recruiting a
new nursing staff. The committee shall meet once in 2 months.

Credentialing Policy:

4.1.1 Process of Credentialing of Care Providers

Step 1: The Care Providers shall be made to complete a credentialing Performance

developed by the hospital for the purpose of credentialing.

Step 2: All relevant document copies of the Care Providers shall be collected along with
the credentialing form. List of relevant document copies –

1. Copy of all degree or Diploma

2. Copy of State Registration
3. Two Passport size photo
4. Work Experience Certificates
Apart from verifying the certificate copies with the originals, the copies shall also be sent
to the issuing authorities for verification.

20
Step 3: The completed application material shall be circulated through the credentialing
committee members who shall give their comments on the column provided for their
remarks on the applicant and their recommendations.

Step4: An acceptance letter shall be collected from the applicant if the terms and
conditions in the offer letter are acceptable to him / her.

Step 5: After the collection of acceptance letter from the applicant, an (Provisional)
appointment letter shall be given by the Medical Director (or) HRD to the care provider
and the intimation of which shall go to nursing office.

4.2 Competency Assessment Policy:

4.2.1 Protocol of the Competency process:

Step 1: The credentialing committee shall review the recommendations of the care
providers, take into account their credentials, years of experience, competence and other
such factors and shall finally decide regarding the competencies to be allocated to the
respective care provider as follows.

S.NO CREDENTIALS & COMPETENCY PERIOD

CRITERIA

Category I – Recruits 0 - 1yr 3Months

Category II – Recruits 1yr & Above 1 ½ Month (45days)

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 Step 2: Summary of Competency Assessment

1. First one month of the period of Competency Assessment

 Initial Meeting postings placed.
 Nurse and Preceptor/Assessor discuss and plan how the competencies are to be
achieved.
 A learning period is agreed by nurse
 Nurse participate the Induction and Orientation program to be conducted by SREE
and In-service Education.
 Competency assessment form filled then & there.
2.Second month of the period of area specific Competency Assessment

 Nurse observes work with Preceptor/Assessor and /or other nursing staff for the
achievement of competencies.

· Area specific knowledge assessment test to be conducted end of the month.

3. Age Competency Assessment

 Pediatric & Neonatal assessments are conducted to the nurses posted to these specific
areas.
3. Third month of the period of Competency Assessment
 Nurse, Preceptor/Assessor and Verifier (if applicable) hold a final meeting and
conduct a written test and practical skill test.
 Nurse shall be qualified if he/she shall score >75% after conducting the skill
assessment test. If scored <75%, his/her competency period shall be extended for
another one month.
 Final assessment is carried out and documentation is completed, signed and submitted
to the Credential committee for authorization and the same shall be forwarded to the
Nursing Superintendent.
 Nursing Superintendent submits a report to HR Department that recommends or does
not recommend his/her competencies

22
PROCESS FLOW FOR RECRUITMENT / CREDENTIALING

If the nurse shall not be qualified during the extended competency period, the committee
shall forward a letter through the Nursing Superintendent to the Medical Director for
further action.

23
Summary of assessment category – II

1. 0 to 15days – Orientation, Departmental Orientation

2. 15 to 30days – Area specific orientation & Knowledge assessment test
3. 30 to 45days – Skill assessment
Step 3: A copy of the approved competency assessment form of each care provider shall
be disseminated the information the information with the following:


Medical Superintendent

Deputy Medical Superintendent

HRD

Respective Wards
Step 4: The competencies allocated to nursing staff shall be reviewed periodically.
Category I – 0 to 3rd month, then 6th month and 12th month and subsequently once in a
year.

Category II – 11/2 months, 6months, 12months and subsequently once in a year

Area specific Competency for shifting nurses to other area : Ward seniors – 15days
area specific assessment according to Job description and Scope of Service


ICU to Ward – 15 days

Ward and ICU to Procedure area – one month competency

Speciality nurses fresher – 3months competency

Speciality nurses seniors – 1 month competency

Training for Nurses – Culture of Safety, RCA, FMEA, Why Why Analysis and its
incident report closure.

24
 4.3 Appraisal Policy

This committee shall also oversee the appraisal of Nursing Staff on an annual basis. The
appraisal process shall be transparent and will involve the concerned Healthcare
Professional. The staff shall be expected to participate in the hospitals quality improvement
program.

4.4.Verification of credentials

Original verification of credentials of all Nurses shall be done and documented prior to
assignment patients independently.

References:

1. Area Specific Competencies

2. Area Specific Appraisal

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CREDENTIALING OF DOCTORS

4.1 Table- Designation of Doctors

S.NO DESIGNATION RESPONDENTS PERCENTAGE(%)

1 Consultants 10 33.3
2 Medical Officer 20 66.7
TOTAL 30 100

INTERPRETATION

From the table, designation of Doctors was identified that Medical Officer are in highest
number of equipment (66.7%) when compared to Consultants (33.3%).

4.1Chart - Designation of Doctors

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4.2 Table - Qualification of Doctors

S.NO QUALIFICATION RESPONDENTS PERCENTAGE(%)

1 PG Degree 10 33.3
2 UG Degree 20 66.7
TOTAL 30 100

INTERPRETATION

From the table, qualification of doctors was identified that UG Degree (66.7%)
qualification has the highest number when compared to PG Degree (33.3%).

4.2 Chart - Qualification of Doctors

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4.3 Table - Count of Licensing of Doctors

S.NO LICENSING RESPONDENTS PERCENTAGE

(%)
1 TNMC 28 93.3

2 APMC 02 6.7

TOTAL 30 100

INTERPRETATION

From the table, Count of Licensing of Doctors was identified that TNMC has the highest
number of licensed (93.3%) when compared to APMC (6.7%).

4.3 Chart - Count of Licensing of Doctors

28
4.4 Table - Experience Verification of Doctors

S.NO EXPERIENCE RESPONDENTS PERCENTAGE(%)

VERIFICATION
1 Verified 21 70
2 Not Verified 09 30
TOTAL 30 100

INTERPRETATION

From the table, Experience Verification Of Doctors was verified in the highest number
(70%) when compared to not verified (30%).

4.4 Chart - Experience Verification of Doctors

29
4.5 Table - Credentialing Forms of Doctors

S.NO CREDENTIALING RESPONDENTS PERCENTAGE(%)

FORM
1 Available 27 90
2 Not Available 03 10
TOTAL 30 100

INTERPRETATION

From the table, the credentialing forms of doctors was available (90%) when compared to
Not Available of Credentialing forms(10%).

4.5 Chart - Credentialing Forms of Doctors

30
4.6 Table - Count of JD Based Training Given for Doctors

S.NO JD BASED TRAINING RESPONDENTS PERCENTAGE(%)

1 Yes 30 100
2 No 0 0
TOTAL 30 100

INTERPRETATION

From the table , The count of JD Based Training Given was identified that training given
has the highest number (100%) when compared to training not given (0%).

31
4.7 Table - Count of CME Credit Hours of Doctors

S.NO CME CREDIT HOURS RESPONDENTS PERCENTAGE(%)

1 Yes 30 100
2 No 0 0
TOTAL 30 100

INTERPRETATION

From the table , the count of CME Credit hours of Doctors was identified that CME
credit hours was given to the Doctors has highest number (100%) when compared to not
given (0%).

32
PRIVILEGING OF DOCTORS

4.8 Table - Privileging of Consultants

CONSULTANTS [SAMPLE SIZE - 10]

PRIVILEGED
PRIVILEGING NOT WITH
CRITERIAS PRIVILEGED PRIVILEGED SUPERVISION TOTAL %

GENERAL
PROCEDURES 7 0 3 10 17.9

CLINICAL
PROCEDURES 10 0 0 10 25.6

TECHNICAL
ASPECTS 6 0 4 10 15.4

ADMINISTRATIVE 7 3 0 10 17.9

TEACHING 4 6 0 10 10.3

SPECIAL
PROCEDURES 5 3 2 10 12.8

INTERPRETATION

From the table, Privileging of Consultant was identified that privileged criteria for
Clinical procedure has highest (25.6%) when compared to General procedure (17.9%),
Administrative (17.9%), technical aspects (15.4%), Special Procedures(12.8%) and
teaching(10.3%).

33
4.8 Chart - Privileging of Consultants

34
4.9 Table - Privileging of Medical Officers

MEDICAL OFFICERS [SAMPLE SIZE - 20]

PRIVILEGED
PRIVILEGING NOT WITH
CRITERIAS PRIVILEGED PRIVILEGED SUPERVISION TOTAL %

GENERAL
PROCEDURES 15 2 3 20 40.5

CLINICAL
PROCEDURES 10 3 7 20 27

TECHNICAL
ASPECTS 6 5 9 20 16.2

ADMINISTRATIVE 4 12 4 20 10.8

TEACHING 0 20 0 20 0.1

SPECIAL
PROCEDURES 2 9 9 20 5.4

INTERPRETATION

From the table, Privileging of Medical Officers was identified that privileged criteria for
General Procedures has the highest (40.5%) when compared to Clinical
Procedures(27%), Technical Aspects(16.2%), Administrative (10.8%) and Special
Procedures(5.4%).

35
4.9 Chart - Privileging of Medical Officers

36
CREDENTIALING OF NURSES

4.10 Table - Designation of Nurses

S.NO DESIGNATION RESPONDENTS PERCENTAGE(%)

1 Staff Nurse 100 83.3
2 Auxiliary Nurse 20 16.7
TOTAL 120 100

INTERPRETATION

From the table, Designation of Nurses was identified that Staff Nurse has the highest
number (83.3%) when compared to Auxiliary Nurse (16.7%).

4.10 Chart- Designation of Nurses

37
4.11 Table - Qualifications of Nurses

S.NO QUALIFICATION RESPONDENTS PERCENTAGE(%)

1 Diploma 80 66.6
2 UG Degree 20 16.7
3 Training Course 20 16.7
TOTAL 30 100

INTERPRETATION

From the Qualification of Nurses was identified that Diploma has the number (66.6%)
when compared to UG Degree (16.7%) and Training Course (16.7%).

4.11 CHART - Qualifications of Nurses

38
4.12 Table - Licensing of Nurses

S.NO LICENSING(TNNMC) RESPONDENTS PERCENTAGE

(%)
1 Yes 120 100

2 No 0 0

TOTAL 120 100

INTERPRETATION

From the table, Licensing of Nurses was identified that TNNMC license has Large in
number (100%) when compared to Absence of license (0%).

39
4.13 Table - Experience Verification of Nurses

S.NO EXPERIENCE RESPONDENTS PERCENTAGE(%)

VERIFICATION
1 Verified 106 88.3
2 Not Verified 14 11.7
TOTAL 120 100

INTERPRETATION

From the table, Experience of Nurses was identified that the experience certificate
verified has the highest number (88.3%) when compared to not verified (11.7%).

4.13 Chart - Experience Verification of Nurses

40
4.14 Table - Credentialing Forms of Nurses

S.NO CREDENTIALING RESPONDENTS PERCENTAGE(%)

FORM
1 Available 100 83.3
2 Not Available 20 16.7
TOTAL 120 100

INTERPRETATION

From the table, Credentialing Forms of Nurses was identified that Available Forms has
the highest number (83.3%) when compared to Not Available of credentialing form
(16.7%).

4.14 Chart - Credentialing Forms of Nurses

41
4.15 Table - Count of CNE Credit Hours of Nurses

S.NO CNE CREDIT HOURS RESPONDENTS PERCENTAGE(%)

1 Yes 120 100
2 No 0 0
TOTAL 120 100

INTERPRETATION

From the table, the count of CNE Credit Hours of Nurses was identified that CNE Credit
hours was given to the Nurses has highest number (100%) when compared to not given
(0%).

42
4.16 Table - JD Based Training Given to Nurses

S.NO JD BASED TRAINING RESPONDENTS PERCENTAGE(%)

1 Yes 100 83.3
2 No 20 16.7
TOTAL 120 100

INTERPRETATION

From the table, The Count of JD Based Training Given to Nurses was identified that
Training given has highest number (83.3%) when compared to Training not given
(16.7%).

4.16 Chart - JD Based Training Given to Nurses

43
PRIVILEGING OF NURSES

4.17 Table - Privileging of Nurses for UG Degree

UG DEGREE - STAFF NURSE [SAMPLE SIZE - 20]

PRIVILEGED %
PRIVILEGING NOT WITH
CRITERIAS PRIVILEGED PRIVILEGED SUPERVISION TOTAL

GENERAL 30.8
PROCEDURES 20 0 0 20

CLINICAL 27.7
PROCEDURES 18 1 1 20

TECHNICAL 20
ASPECTS 13 2 5 20

03
ADMINISTRATIVE 2 18 0 20

7.7
TEACHING 5 15 0 20

SPECIAL 10.8
PROCEDURES 7 13 0 20
INTERPRETATION

From the table, Privileging of Nurses for UG Degree was identified that Privileged staff
nurse of General Procedure has the highest number (30.8%)when compared to Clinical
Procedures (27.7%), Technical Aspects (20%), Special Procedures (10.8%) , Teaching
(7.7%) and Administrative (3%).

44
4.17 Chart - Privileging of Nurses for UG Degree

45
4.18 Table - Privileging of Nurses for Diploma

UG DIPLOMA - STAFF NURSE [SAMPLE SIZE - 80]

PRIVILEGED
PRIVILEGING NOT WITH
CRITERIAS PRIVILEGED PRIVILEGED SUPERVISION TOTAL %

GENERAL
PROCEDURES 73 4 3 80 27.8

CLINICAL
PROCEDURES 69 7 4 80 26.2

TECHNICAL
ASPECTS 65 12 3 80 24.7

ADMINISTRATIVE 5 75 0 80 1.9

TEACHING 7 73 0 80 2.7

SPECIAL
PROCEDURES 44 16 20 80 16.7

INTERPRETATION

From the table, Privileging of Nurses for Diploma Degree was identified that Privilege
Staff Nurse of General Procedure has the highest number (27.8%) when compared to
Clinical procedure (26.2%), Technical Aspects (24.7%), Special Procedure (16.7%),
Teaching (2.7%) and Administrative (1.9%).

46
4.18 Chart - Privileging of Nurses for Diploma

47
4.19 Table - Privileging of Nurses for Training Course

PRIVILEGED
PRIVILEGING NOT WITH
CRITERIAS PRIVILEGED PRIVILEGED SUPERVISION TOTAL %

GENERAL
PROCEDURES 0 0 20 20 0

CLINICAL
PROCEDURES 15 0 5 20 83.3

TECHNICAL
ASPECTS 0 20 0 20 0

ADMINISTRATIVE 1 19 0 20 5.6

TEACHING 0 19 1 20 0

SPECIAL
PROCEDURES 2 18 0 20 11.1

INTERPRETATION

From the table, Privileging of Nurses for Training Course was identified that privileging
Criteria for Clinical procedure has the highest number (83.3%) when compared to
Administrative (5.6%) and Special Procedure (11.1%).

48
4.19 Chart - Privileging of Nurses for Training Course

49
 CHAPTER – V

FINDINGS

 From the table, designation of Doctors was identified that Medical Officer are in highest
number of equipment (66.7%) when compared to Consultants (33.3%).
 From the table, qualification of doctors was identified that UG Degree (66.7%)
qualification has the highest number when compared to PG Degree (33.3%).
 From the table, Count of Licensing of Doctors was identified that TNMC has the highest
number of licensed (93.3%) when compared to APMC (6.7%).
 From the table, Experience Verification Of Doctors was verified in the highest number
(70%) when compared to not verified (30%).
 From the table, the credentialing forms of doctors was available (90%) when compared to
Not Available of Credentialing forms(10%).
 From the table , The count of JD Based Training Given was identified that training given
has the highest number (100%) when compared to training not given (0%).
 From the table , the count of CME Credit hours of Doctors was identified that CME
credit hours was given to the Doctors has highest number (100%) when compared to not
given (0%).
 From the table, Privileging of Consultant was identified that privileged criteria for
Clinical procedure has highest (25.6%) when compared to General procedure (17.9%),
Administrative (17.9%), technical aspects (15.4%), Special Procedures(12.8%) and
teaching(10.3%).
 From the table, Privileging of Medical Officers was identified that privileged criteria for
General Procedures has the highest (40.5%) when compared to Clinical
Procedures(27%), Technical Aspects(16.2%), Administrative (10.8%) and Special
Procedures(5.4%).
 From the table, Designation of Nurses was identified that Staff Nurse has the highest
number (83.3%) when compared to Auxiliary Nurse (16.7%).

50
 From the table, Qualification of Nurses was identified that Diploma has the number
(66.6%) when compared to UG Degree (16.7%) and Training Course (16.7%).
 From the table, Licensing of Nurses was identified that TNNMC license has Large in
number (100%) when compared to Absence of license (0%).
 From the table, Experience of Nurses was identified that the experience certificate
verified has the highest number (88.3%) when compared to not verified (11.7%).
 From the table, Credentialing Forms of Nurses was identified that Available Forms has
the highest number (83.3%) when compared to Not Available of credentialing form
(16.7%).
 From the table, the count of CNE Credit Hours of Nurses was identified that CNE Credit
hours was given to the Nurses has highest number (100%) when compared to not given
(0%).
 From the table, The Count of JD Based Training Given to Nurses was identified that
Training given has highest number (83.3%) when compared to Training not given
(16.7%).
 From the table, Privileging of Nurses for UG Degree was identified that Privileged staff
nurse of General Procedure has the highest number (30.8%)when compared to Clinical
Procedures (27.7%), Technical Aspects (20%), Special Procedures (10.8%) , Teaching
(7.7%) and Administrative (3%)
 From the table, Privileging of Nurses for Diploma Degree was identified that Privilege
Staff Nurse of General Procedure has the highest number (27.8%) when compared to
Clinical procedure (26.2%), Technical Aspects (24.7%), Special Procedure (16.7%),
Teaching (2.7%) and Administrative (1.9%).
From the table, Privileging of Nurses for Training Course was identified that privileging
Criteria for Clinical procedure has the highest number (83.3%) when compared to
Administrative (5.6%) and Special Procedure (11.1%)

51
SUGGESTIONS


Establishing standardized criteria and guidelines for credentialing and
privileging across healthcare organizations, specialties and states.

Enhancing the collaboration and communication between healthcare
organizations and professionals to streamline the credentialing and privileging
process.

Implementing an ongoing evaluation and monitoring process to ensure that
healthcare professionals are maintaining their competence and meeting
established standards.

Offering ongoing education and training opportunities for healthcare
professionals to improve the quality of care provided to patients.

Ensure that healthcare professionals are adequately trained and experienced
before granting them privileges to practice.

Implement evaluation mechanisms to assess healthcare professionals'
competency and qualifications.

CONCLUSION

Credentialing and Privileging of doctors and nurses helps to protect patients and
organization from the risks associated with unqualified, incompetent, or fraudulent
practitioners. It also helps to ensure that healthcare professionals maintain their
competencies and adhere to the ethical standards in their practice. Therefore,
healthcare institutions should develop a robust credentialing and privileging process
to maintain quality care and patient-centred services while also complying with
regulatory bodies' requirements. These processes facilitate the establishment of a
qualified and capable healthcare workforce which is essential for improving patient
outcomes and enhancing healthcare quality. They also contribute to the protection of
public health by ensuring that healthcare professionals are proficient, competent, and
maintain high standards of practice.

52
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54
ANNEXURE

CREDENTIALING AND PRIVILEGING CHECKLIST FOR

DOCTORS AND NURSES

EMPLOYEE NAME: EMPLOYMENT NUMBER:

RESPONDENT NUMBER:

DESIGNATION:

□ Consultant □ Medical Officers □ Staff Nurse □ Auxiliary Nurse

QUALIFICATION: (10th, 12th, Provisional Certificate)

□ PG Degree □ UG Degree □ Diploma □ Training Course

STATE REGISTRATION COUNCIL: (Tamilnadu registration is mandatory, Registration Number,

Validity)

□ TNMC □ TNNMC □ Others

TRACK OF CNE/CME CREDIT HOURS:

□ Yes □ No

VERIFICATION OF EXPERIENCE CERTIFICATES SUBMITTED:

(Total No. of Experience and authenticity of the certificates submitted)

□ Verified □ Not Verified

CREDENTIALING FORMS AVAILABLE IN THE PERSONAL FILE:

(with the necessary documents attached and properly filled)

□ Available □ Not Available

PRIVILEGING FORMS AVAILABLE IN THE PERSONAL FILE:

(Employees are aware of their privileges allotted by their immediate supervisors - approved by the
Nursing Superintendent/Medical Superintendent and duly signed by them all.)

□ Available □ Not Available

RECORD JD-BASED TRAINING GIVEN TO THE EMPLOYEES: (for privileging purposes)

□ Yes □ No

55
56