Key Excerpts from AAAHC Core Standards
Governance: The governing body addresses and is fully and legally responsible
for the operation andperformance of the organization. This can be done directly or by appropriate professional delegation.
The governing body must meet at least annually and keep minutes or other records as may be required for the orderly conduct of the organization.
Credentialing
Credentials must be verified according to the procedures established in bylaws, rules and regulations. There must be processes for expeditious processing of applications for
clinical privileges.
There must be a procedure for obtaining primary or secondary source information.
Credentials files are maintained for each healthcare professional and include initial application, reapplications, verifications, privileges granted, and other pertinent information.
In a solo practice, a peer must review the physician’s credentials file at least every three years to assure currency, accuracy, and completeness.
Credentialing is a three-phase process to assess can validate qualifications to provide services.
- Establish minimum training, experience, and other requirements for physicians and other healthcare professionals
- Establish a process to review, assess, and validate an individual’s qualifications, including education, training, experience, certification, licensure, and any other competence-enhancing activities against the organization’s established minimum requirements
- Carries out review, assessment, and validation outlined in the organization’s description of the process
The governing body must:
- establish and is responsible for a credentialing and reappointment process and applying criteria uniformly to all individuals who provide patient care
- approve mechanisms for credentialing, reappointment, and granting of privileges, suspending or terminating clinical privileges, including provisions for appeal of such decisions
- either directly or by delegation, make initial appointment, reappointment, and assignment or curtailment of clinical privileges based on peer evaluation (must be consistent with state law)
- have specific criteria for initial appointment and reappointment of physicians and dentists
- make provisions for expeditious processing of clinical privileges applications
Initial application PSV
- education, training, experience verified with primary source,
- experience reviewed for continuity and relevance with documentation of any interruptions
- peer evaluation for current competency by an individual who can address clinical, ethical, and professional performance and, when available, by data regarding treatment outcomes
- current state license
- DEA, if applicable
- Proof of current medical liability coverage meeting governing body requirements
- NPDB
Credentials Verification Organization
The organization must perform an assessment of the capability and quality of the CVO’s work.
Reappointment
Every 3 years unless state law requires otherwise.
Must verify
- Current state license
- DEA if applicable
- Status of board certification
- NPDB
- Peer review activities
- Solo practitioner offices will be reviewed by a peer every 3 years to assure currency, accuracy and completeness
Information the organization must require and review for both initial and reappointment:
- Professional liability claims history
- Information on licensure revocation, suspension, voluntary relinquishment, probationary status, or other conditions/limitations
- Complaints or adverse action reports from professional society or licensure board
- Refusal or cancellation of professional liability coverage
- Denial, suspension, limitation, termination or non-renewal of professional privileges at any clinic, hospital, health plan, or other institution
- DEA and state license action
- Disclosure of any Medicare or Medicaid sanctions
- Conviction of criminal offense (excluding minor traffic violations)
- Current physical, mental health, or chemical dependency problems that would interfere with the ability to provide high-quality patient care or services
- Signed release and attestation statement
Information that must be monitored on an ongoing basis (at expiration, appointment,
and re-appointment, at minimum.):
The organization monitors and document the currency of datesensitiveinformation such as licensure, professional liability insurance(if required), certifications, DEA registrations, and other such items,where applicable, on an ongoing basis.
Privileging
Privileging is a three-phase process to determine the specific procedures and treatments that may be performed. The organization must:
- Determine clinical procedures and treatments offered to patients
- Determine qualifications related to training and experience that are required to authorize an applicant to obtain each privilege
- Establish a process for evaluating the applicant’s qualifications using appropriate criteria and approving, modifying, any and all of the request privileges in a non-arbitrary manner.
Privileges for specific procedures are granted for a specified period of time based on the applicant’s qualifications within the services provided by the organization.
The organization has its own independent process of credentialing and privileging that includes review and approval by the governing body.
Appointment or privileges may not be approved solely on the basis that another organization, such as a hospital, took such action, although this information can be used in consideration of the application.
The governing body provides a process for the initial appointment, reappointment, assignment or curtailment of privileges and practice for allied health care professionals (based on state law and evidence of education, training, experience and competency).
In following list of resources has been developed to help organizations identify primary and secondary sources for verifying credentials of health care professionals. If you have any questions regarding primary or secondary source verification, please contact the Accreditation Association at 847/853.6060 or .
Primary Source Verification: Primary Source Verification is documented verification by an entity that issued a credential, such as a medical school or residency program, indicating that an individual's statement of possession of a credential is true. Verification can be done by mail, fax, telephone, or electronically, provided the means by which it is obtained are documented and measures are taken to demonstrate there was no interference in the communication by an outside party. Primary sources include:
Certifying Boards*
- Chiropractic Colleges Association of Chiropractic Colleges
- American Dental Association's (ADA)List of Dental Schools
- Drug Enforcement Agency (DEA) database
- Medical Schools - Association of American Medical Colleges
- Nursing Schools -American Association of Colleges of Nursing
- Physician Assistant Schools - American Academy of Physician Assistants
- Podiatry Schools - American Association of Colleges of Podiatric Medicine
- Residency and Fellowship Programs GME programs accredited by the Accreditation Council on Graduate Medical Education
- State Licensing Agencies - Federation of State Medical Boards
- Federation of State Medical Boards
*These sources are for verification of Board Certification only, not education or training.
Secondary Source Verification: Acceptable secondary source verification is documented verification of a credential through obtaining a verification report from an entity listed below as acceptable on the basis of that entity having performed the primary source verification. Information received from any of these sources must meet the same transmission and documentation requirements as outlined above for primary sources. Currently acceptable secondary sources include:
- American Association of Nurse Anesthetists
Specialty boards of the American Board of Medical Specialties - Specialty boards recognized by the American Dental Association
- American Medical Association Physician Master Profile
American Osteopathic Association Master Profile - American Nurses Credentialing Center
College of Nurse-Midwives
Educational Commission for Foreign Medical Graduates
Commission on Certification of Physician Assistants - CVO is okay if you have proper assessment of capability and quality of CVO
- Another health care organization, such as a hospital or group practice, that has carried out primary source or acceptable secondary source verification, provided it supplies directly, without transmission or involvement by the applicant or other third party, original documents or photocopies of the verification reports it has relied upon. A statement that it has performed verification is not sufficient.
Documents, diplomas, certificates or transcripts provided directly by the applicant rather than by the primary or secondary source are not acceptable.
9/2014