NCPG: Issue 02 2013

Nursing Credentialing and Privileging Guideline

1.0 Policy Statement

Credentialing and privileging are processes that are used by the hospital to ensure
that customers and the public are treated by licensed professionals who have been
educated, trained, certified and/or licensed to perform certain medical, nursing and
health care tasks. These two processes also provide a measure of confidence by the
facility that the health care professionals are able to provide a high level of care and
avoid malpractice.
Basic Life Support (BLS) programs are to be attended by all trained nurses and &
Advance Life Support (ALS) are to be attended by trained nurses in the critical areas.
Both programs requires recertification every 2 yearly.
Trained Nurses nursing certificate.

2. Definition:-
2.1 Credentialing

a. Credentialing enables the organization to evaluate a professionals

qualifications in order to determine appropriateness for a position.
b. The credentialing process involves confirming a healthcare providers licensure
and authorization to practice in the state, and any relevant certifications,
education, and training.
c. Credentialing requires primary source verification and it means the hospital,
must verify credentials the applicant claims to have with the agency or
institution that granted the license, degree or certification. Validation from the
applicants/employees previous employment is also required.
d. Credentialing is done prior to the appointment of the staff.

2.2 Privileging
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a. Privileging is the process through which the health care professional is granted
authority to provide certain care and services to patients within the organization.
b. Privileging requires performance assessment of the staffs education,
experience, training, etc, in order to determine whether she/he can be granted
the privilege to perform the required procedure.
c. A privileging system/process has been formulated to minimize risk to the
organization and maximize patient safety.
d. State Registered Nurses (SRN) with certificate in nursing are assessed for
competency in 3 procedures namely, IV Cannulation, administrating IV injection
and blood taking. They are awarded the privileges to practice and their
competency shall be assessed 3 yearly.

2.3 Competency Assessment

a. New nursing graduates/ Trained staff are attached to the preceptor / Unit
Manager / appointed staff for a minimum of 6 months to perform procedures
under the scope of their qualification.
b. During this duration the preceptor / Unit Manager / appointed staff shall assess
the competency level of the staff.
c. The staff shall be given periodic feedback on a 3 monthly basis till their
confirmation.
d. Upon completion of the 6 months period, the competency level of the staff shall
be summarized based on the training records and competency records.
e. In specialized areas where staff has undergone Post Basic course the staff shall
be assessed for her competency as well.
f. Core procedures of the services shall be identified for annual competency
assessment.
g. Basic Life Support (BLS) & Advance Life Support (ALS) programs are to be
attended by Trained nurses and need to be recertified every 3 yearly.
h. Since it is difficult to get placing for ALS/ACLS, PAL & NRP as majority are
conducted by the MOH, trained nurses without the post basic qualification in the

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respective critical areas will be trained within 6 months 1 year of their

attachment.
i. Annual core competency assessment includes the 4 NNA elements,
Administration of oral medication, Administration of I/V infusion, Aseptic wound
dressing and Blood transfusion.

3.0 Privileging Purpose

This guideline outlines the process for nursing privileging, by which an individual
Registered Nurse is granted privileges to perform a particular nursing procedure or
service that is outside their identified scope of qualification.

4.0 Assessment Tool

a. A structured checklist is used to serve as a guide for the Consultant/ Nurse

Instructor/UM /Preceptor/Appointed Staff to assess staffs level of competency.
b. This enables a structured methodology of evaluating and assessing staffs
competency.
c. Assessment tools are maintained as record of the staffs practical competency
in the clinical area.

5.0 Privileging Process

a. It is the responsibility of the Unit Manager to identify preceptor, plan and assign
clinical experiences for the staff to acquire proficiency in the identified nursing
procedure using the structured check list.
b. Staff are required to be attached to the preceptor or Unit Manager or appointed
staff to perform procedures that are not in the scope of their qualification.
c. During this duration the Preceptor / Unit Manager / Appointed staff shall initially
guide and facilitate the staff and gradually assess the competency level of the
staff.
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d. Upon completion of the 10 number of the stipulated procedures, the

competency level of the staff shall be summarized based on the training records
and competency records.
e. For rare procedures, if the staff had performed the task competently 3 or more
times the competency level can also be summarized for privileging
recommendation.
f. Core procedures of the services shall be identified for re privileging prior
completion of the 3 years privileges of the staff.
g. Staff competency shall be rated using the rating standard as per the In-Service
Record book
Rating Scale
90 % 100% 5 Excellent
80% - 89% 4 Superior
70% - 79% 3 Competent
51% - 69% 2 Fair
50% below 1 Poor

h. The total competency rating is compared to the weightage provided and is

converted to percentage.
i. The percentage is then graded within 1 to 5, where 1 is poor and 5 is excellent.
5. Comments of the assessment shall be documented progressively into the
structured checklist.

4.0 Privileging Responsibility

a. The Unit Manager/ Consultant/Nurse Instructor /Preceptor/Appointed Staff are
to facilitate to assess the individual for the required competency.
b. Competency assessment of the individual are to be documented using
appropriate checklist to determine the level of competency and maximum of 10
procedures are to be logged into the In-service record book.
c. Upon completion of the competency assessment the Unit Manager /
Representative shall present the competency assessment status of the

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privileged procedures to the Hospital Medical Education Committee for

privileging recommendation.
d. The recommendation for privileging will be presented minimum twice a year and
when required.
e. Privileging Committee comprises of the Hospital Medical Education Committee
(MEC) that recommends privileging and the Hospital Credentialing Committee
endorses the recommended privileges of the staff.

5.0 Privileges Recommendation

a) If the competency level is at 3 and above, the committee may recommend the
privileges for 3 years.
b) The privileges of the procedures recommended for the staff is then brought to
the Credentialing Committee for endorsement.
c) Upon endorsement by the Credentialing Committee, the staff will be granted the
privileges of doing the procedures in the related specified setting for duration of
three years.
d) The performance of the staff is monitored yearly along with the SPAR and
privileging is to be reviewed after 3 years or whenever necessary.
e. If upon awarding the privileges, the staff failed in performing the specified
privileges in accordance to the requirement, the privileges are denied and
recommended for retraining and the process shall be repeated.

5.2 Privileges Not Recommended

a) If the competency level is below 3, the privileges are denied and

recommended for retraining and the process shall be repeated.

Flow Chart: Credentialing & Privileging Process

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Credentialing & Privileging Process Flow

New Graduate / Staff Certificate Credential

Attach to Preceptor
In-service
Record Book
Assess competency
level
Competency
Summarize record
Competency (Checklist of
level Procedure)
Upon
completion
of no. of
procedures

Competency
Competency level
Level of 3 & more
of less than 3 Propose
Privileging

Recommendatio
n
at
MEC

Privileging Not Privileging

Recommended Recommended

Endorsemen
t by
Credentialin
g Committee
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Awarded 3 years privileges
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Appendix : Letter of Credentialing and Privileging Award

(Logo & Name of Hospital)

Reference No:
Date

Designation
Ward / Unit

Dear (Name of Staff)

Re : Credentialing and Privileging Award

This is to certify that I as a (designation) has been duly assessed and found to be
clinically competent. The Clinical Committee has endorsed your credential.

We are hereby accorded the privilege of performing the following procedures:

(eg)
1. IV Cannulation
2. Iv Injection
3. Blood Taking

This credentialing and privileging is only valid for the period of three (3) years from 1st
Date, Month & Year to Date , Month & Year.

We look forward to your continuous support and contribution towards further growth
and success in the hospital performance and the years ahead.

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DECLARATION
I, _____________________hereby acknowledge that I have been declared clinically
competent to perform the above mentioned procedures. I therefore accept these
credentials and the responsibilities entailed with it.

Signature: Date:

APPROVED BY
Name: Name: Name:

Signature :. Signature :. Signature :

.
(CNO/DCNO): (CEO / General Manager) (Medical Director:)

Date : Date : Date:

c.c. Personal file

Registration No