Guideline text:
(Rev. 122, Issued: 09-26-14, Effective: 09-26-14, Implementation: 09-26-14)

§482.22(a)(2) - The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations.  A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section.

## Interpretive Guidelines §482.22(a)(2)

There must be a mechanism established to examine credentials of individual prospective members (new appointments or reappointments) by the medical staff.  The individual's credentials to be examined must include at least:

- A request for clinical privileges;
- Evidence of current licensure;
- Evidence of training and professional education;
- Documented experience; and
- Supporting references of competence.

The medical staff may not make its recommendation solely on the basis of the presence or absence of board certification, but must consider all of the elements above.  However, this does not mean that the medical staff is prohibited from requiring in its bylaws board certification when considering a MD/DO for medical staff membership or privileges; only that such certification may not be the only factor that the medical staff considers.

The medical staff makes recommendations to the governing body for each candidate for medical staff membership/privileges that are specific to type of appointment and extent of the individual practitioner's specific clinical privileges, and then the governing body takes final appropriate action.

Each practitioner who is a member of the medical staff or who holds medical staff privileges is subject to the medical staff's bylaws, rules, and regulations, in addition to all the requirements of the Medical Staff Condition of Participation.  The medical staff and the governing body must enforce its medical staff requirements and take appropriate actions when individual members or other practitioners with privileges do not adhere to the medical staff's bylaws, regulations, and rules.  They must likewise afford all members/practitioners who hold privileges the protections and due process rights provided for in the bylaws, rules and regulations.

A separate credentials file must be maintained for each individual medical staff member or applicant.  The hospital must ensure that the practitioner and appropriate hospital patient care areas/departments are informed of the privileges granted to the practitioner.

## Survey Procedures §482.22(a)(2)

- Determine whether the medical staff bylaws identify the process and criteria to be used for the evaluation of candidates for medical staff membership/privileges.
- Determine whether the criteria used for evaluation comply with the requirements of this section, State law, and hospital bylaws, rules, and regulations.
- Determine whether the medical staff has a system to ensure that practitioners seek approval to expand their privileges for tasks/activities/procedures that go beyond the specified list of privileges for their category of practitioner.

Ask the leadership of the medical staff what methods are used to ensure that all medical staff members and non-member practitioners who hold privileges adhere to the medical staff bylaws, rules and regulations and are afforded the protections and due process rights provided for under the bylaws, rules and regulations.  Ask for specific examples of actions taken.

When interviewing practitioners during the survey, ask how they are made aware of their rights and responsibilities with respect to medical staff bylaws, rules and regulations.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"context_event": "medical staff credentialing", "required_artifact": ["request for clinical privileges", "evidence of current licensure", "evidence of training and professional education", "documented experience", "supporting references of competence"]}, "rule_type": "existence", "scope_tags": ["clinical", "facility", "legal"]}