Credentialing and Privileging Practices at Muscogee (Creek) Nation

EXECUTIVE SUMMARY:

This final report addresses credentialing, privileging, and personnel suitability practices at the Creek Nation Community Hospital (Creek Hospital).  Tribally operated hospitals, including Creek Hospital, are not required to follow Indian Health Service (IHS) credentialing, privileging, and accreditation requirements.  Although the Creek Hospital is not required to comply with the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) standards, the hospital's bylaws require hospital management to follow a standardized credentialing and privileging process consistent with Joint Commission standards. The hospital completed credentialing and privileging reviews for all 17 practitioners in our review, as required by their bylaws.  However, Creek Hospital did not complete personnel suitability reviews for any of its contract practitioners, as required by the Indian Child Protection and Family Violence Prevention Act of 1990.  Hospital officials told us that they were unaware the Act required tribes or tribal organizations to conduct personnel suitability reviews through background investigations.  Subsequently, the hospital began to develop procedures to conduct background investigations on all practitioners.  We recommended that Creek 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.