Credentialing and privileging: Five tips for ASCs

Over the last few years, the number of ambulatory surgery centers (ASCs) owned or managed by surgeons has substantially increased. Furthermore, some health care professionals and administrators now assert that certain operations that can be done in ambulatory centers should not be performed in hospitals. With that in mind, this column highlights key elements of the credentialing process for ASCs.

Understanding the credentialing process—defined as the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a health care organization—is essential to ensure that the properly credentialed and privileged practitioners are providing the best possible care to those patients who require outpatient surgery. The following are five tips to better understand this process.

Tip 1: Use the elements of performance as a guide

The Joint Commission standard for the credentialing and privileging process for an accredited ASC is HR 02.01.03, which states that the facility “grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the [ASC] to practice independently.”*

The standard has 34 elements of performance (EPs), which include the following measurable actions:

  • Review of the practitioner’s credentials, including evidence of current licensure
  • Evaluation of relevant training and education specific to the requested privileges
  • Evidence of competence or ability to perform the specific procedure requested (including the applicant’s written statement that no health problems exist that could affect his or her ability to perform the requested privileges, as stipulated by EP 10)
  • Ability to comply with the ASC’s requirements for granting, renewing, revising, and denying privileges
  • Verification of current license from primary source
  • Primary source verification documenting training specific to the privileges requested
  • Evaluation of challenges to licensure or registration
  • Documentation of current evidence, including peer and/or faculty recommendations, of the individual’s ability to perform the privileges requested

Tip 2: Obtain key verification

One of the chief responsibilities of a freestanding ASC facility is to determine whether licensed, independent practitioners are capable and competent to provide high-quality and safe care to patients. Before a practitioner can be considered for this privilege, however, necessary credentialing must be verified.

Key verification can come from the following sources:

  • Primary source verification, which centers on the practitioner’s qualifications by an original source or approved agent of that source. This form of verification may include direct correspondence, telephone, or electronic communication
  • Reports from credentials verification organizations that meet Joint Commission requirements

Tip 3: Use peer reviews

EP 8 of the standard states, in part, that before granting initial renewed or revised privileges to a licensed, independent practitioner, the organization should evaluate the results of any peer review of the individual’s clinical performance.

Peer recommendations must come from practitioners who are in the same professional discipline. Peer review is important because it can meet requirements to review professional performance, judgment, and clinical or technical skills before granting initial, renewed, or revised privileges.

Tip 4: Understand the risks of inaction, expectations of implementation

Neglecting the credentialing and privileging process increases the risk of negatively affecting the following:

  • Quality of care
  • Patient safety
  • Risk management
  • Compliance with Joint Commission standards and the Centers for Medicare & Medicaid Services Conditions of Participation or Conditions of Coverage
  • Public reputation
  • Financial health

In addition, privileges should be site-specific to ensure the staff is competent in that area and the equipment and environment are appropriate for the requested operation.

Tip 5: Ask for help if you need it

Questions on credentialing and privileging, including requests for a conference call, should be directed to The Joint Commission’s Standards Interpretation Group at 630-792-5900. Questions also can be submitted via an online form. More information also is available online.


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily represent the official views of The Joint Commission or the American College of Surgeons.

*The Joint Commission. Standards changes for deemed status ambulatory surgical centers. Joint Commission Perspectives. September 2014. Available at: Accessed December 28, 2015.

The Joint Commission. Revisions to requirements for ambulatory care organizations. Joint Commission Perspectives. 2013;33(7):5-7.

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