Credentialing and Privileging Practices at Lawton Indian Hospital

We found that Lawton 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 34 practitioners we reviewed, the hospital did not: (1) verify the credentials for 11, or 32 percent, before the practitioners provided patient care; or (2) ensure that 25, or 74 percent, had current privileges, with lapsed periods ranging from 3 days to 4 years. Lawton 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 Lawton Hospital: (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, (2) assign a sufficient number of staff to adequately perform the credentialing and privileging processes before the practitioners provide patient care, and (3) provide sufficient training to staff assigned to perform the credentialing and privileging processes. In its written response to our draft report, IHS agreed with all recommendations and stated that such actions were underway or complete.