Action Alerts

JCAHO "Expedited Credentialing" Standard, MS.4.30 for Hospitals
October 2004

JCAHO CAMH (Hospital) standard MS.4.30 states, “An organized medical staff may use an expedited process for appointing to the medical staff and when granting privileges when criteria for that process are met*”. 

*To expedite initial appointments to membership and granting of privileges, reappointment to membership, or renewal or modification of privileges, the governing body may delegate the authority to render those decisions to a committee of at least two voting members of the governing body.

There are Elements of Performance (EP) to be met for the expedited credentialing process of the governing body. In essence, these requirements are:

• The application must be complete as provided by the applicant
• The process must be criteria based
• The criteria should include fact patterns that would exclude an application from the process (including not only adverse information regarding the applicant, but also, less than favorable reports from medical staff leadership such as a department chair or credentials committee chair), and must be applied on a case-by-case basis
• The application can not eligible for expedited processing if medical executive committee makes an adverse recommendation

Should a new or renewal completed application meet the various elements, have a positive recommendation by the medical executive committee, then use of the expedited processing by the governing body may be in order.

The governing body may delegate authority to two or more governing body members to constitute an ad hoc committee (provided the governing body’s code of regulations authorizes committees of this size and permits the governing body to delegate this authority) and render a decision on an application on behalf of the governing body. [If the code of regulations does not authorize this action, discussion should be held with hospital legal counsel to see if amendments to the code of regulations may be appropriate.]

This board ad hoc committee can then attend a medical executive committee meeting at the appropriate time in the agenda and “sign-off” on the recommended applications. The ad hoc committee should do so after it has reviewed the applications as a “board ad hoc committee” meeting with its own set of minutes separate and apart from those of the medical executive committee. This ad hoc committee then reports its decision to the governing body at the next regularly scheduled governing body meeting. The effective date of the appointment is the date of the ad hoc committee’s action.

QMCG Tips for Success:

1. Expedited credentialing is a governing body function NOT a medical executive committee function
2. Expedited credentialing should only be used when there is a completed application which has had all credentials and competencies verified and reflects no quality of care or professional behavior concerns
3. If the application reveals any of the “ineligible criteria” do NOT use the expedited process

Questions? Please call QMCG at (614) 227-4848 or visit www.qmcg.com to review your special situation regarding this standard.