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Audit (A-06-04-00038)

11-22-2004
Credentialing and Privileging Practices at Clinton Indian Hospital

Executive Summary

We found that Clinton Hospital did not routinely complete required credentialing and privileging reviews for its practitioners. The credentialing and privileging reviews are generally required by industry-wide standards and specifically by IHS Circular 95-16. For the 23 practitioners we reviewed, the hospital did not: (1) verify the credentials for 7, or 30 percent, to determine their current competence; or (2) ensure that 17, or 74 percent, had current privileges, with lapsed periods ranging from 2 days to 34 months.

Clinton Hospital's management had not ensured that the credentialing and privileging review processes received the necessary level of priority in terms of management attention and other resources. As a result, the hospital's management could not assert its full assurance that its practitioners had the appropriate qualifications and authorizations to provide patient care.

We recommended that IHS ensure that Clinton Hospital's management establishes a system to routinely perform credentialing and privileging reviews. The hospital should: (1) establish controls to complete credentialing and privileging reviews in a timely manner, such as a computerized credentialing system to track and monitor the status of its practitioners, and (2) assign staff exclusively to perform the credentialing and privileging processes before the practitioners provide patient care. In a written response to our draft report, IHS stated that all recommended corrective actions had been taken.

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