Credentialing and Privileging: A Board Guide
What Credentialing Means
Credentialing verifies a clinician’s education, training, licensure, certifications, and experience. It confirms the clinician is qualified to provide care in the organization. Physicians, physician assistants, advanced practice registered nurses, certified registered nurse anesthetists, and nurse midwives are among the licensed clinical staff typically credentialed.
What Privileging Means
Privileging defines what a credentialed clinician is authorized to do — which procedures they may perform and which conditions they may treat. Credentialing establishes that a clinician is qualified in general; privileging establishes what, specifically, they are qualified to do inside this organization.
Together, credentialing and privileging protect patient safety and reduce organizational risk.
Why This Matters
Healthcare organizations have a legal and moral obligation to confirm that any licensed care provider practicing within their walls is in fact qualified, has the necessary education and training, and has kept their license in good standing.
From a legal liability standpoint, the process matters more than any individual decision. Courts generally do not second-guess a hospital’s credentialing decision when the organization followed the standards in its own bylaws and applicable statutes, based the decision on legitimate, documented reasons connected to patient care or hospital operations, and did not act arbitrarily or on an improper motive such as discrimination, anti-competition, or retaliation. A credentialing process that is followed poorly — regardless of the outcome — can itself create liability and accreditation risk.
The Four-Step Process
Step | Typically Led By |
1. Establish policies and rules | Management, clinical leaders, and the board |
2. Collect and summarize information | Management and clinical leaders |
3. Evaluate and recommend membership and privileges | Management and clinical leaders |
4. Review, grant, deny, or approve privileges | The board |
The Board’s Role
- Ensure a strong, reliable credentialing process exists and is consistently followed.
- Rely on medical staff experts — typically through the Medical Executive Committee — to evaluate clinicians and make recommendations.
- Grant final approval of clinician appointments and privileges.
- Provide oversight of the process, not direct evaluation of individual clinicians.
The board retains ultimate responsibility for ensuring only qualified clinicians practice in the organization — even though it relies on others to do the underlying clinical evaluation.
What the Board Does Not Do
The board does not evaluate individual clinicians’ clinical competence directly, and it does not perform the credentialing verification work itself. That is management and medical staff work. The board’s job is to confirm the process was followed and the decision is reasonable and supported by facts — asking pertinent questions and being diligent that every step was completed before acting, not rubber-stamping medical staff recommendations.
Governance Questions
- Does the board receive enough documentation to confirm the credentialing process was followed, not just a list of names to approve?
- When was the credentialing process itself — not just individual files — last audited?
- Does the board understand the difference between what it is approving (the process and outcome) and what it is not evaluating (individual clinical competence)?
- Are credentialing matters that require closed session handled appropriately, with full board awareness of the outcome?
Witalis LLC is a national healthcare governance consulting firm specializing in governance design, board effectiveness, strategic planning, and board retreat facilitation for hospitals, health systems, medical groups, and other healthcare provider organizations.