Credentialing and Privileging Practices at Choctaw Nation

EXECUTIVE SUMMARY:

This final report addresses credentialing, privileging, and personnel suitability practices at the Choctaw Nation Health Care Center (Choctaw Hospital), which is accredited by the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission).  The hospital completed credentialing and privileging reviews for all 42 practitioners in our review, as required by Joint Commission standards.  However, Choctaw Hospital did not complete personnel suitability reviews for these practitioners, as required by the Indian Child Protection and Family Violence Prevention Act of 1990.  Hospital officials told us that they were unaware of the Act and its requirements for personnel suitability reviews through background investigations.  During our review, the hospital began to conduct background investigations of practitioners.  We recommended that Choctaw Hospital continue its efforts to establish written procedures and controls to ensure that background investigations are performed on all medical staff in accordance with the Indian Child Protection and Family Violence Prevention Act.  Hospital officials agreed with our recommendation.