Physician Credentialing and Delineation of Clinical Privileges in Emergency Medicine

Revised and approved by the ACEP Board of Directors June 2006
This policy statement replaces one with the same title revised by the ACEP Board of Directors June 2004; reaffirmed and approved in October 1999 with the same title; revised and approved in September 1995 with new title "Physician Credentialing and Delineation of Clinical Privileges in Emergency Medicine"; revised in June 1991 with the same title; and originally approved in April 1985 titled "Guidelines for Delineation of Clinical Privileges in Emergency Medicine"

As an adjunct to this policy statement, a Policy Resource Education Paper (PREP) has been developed titled "Guidelines for Credentialing and Delineation of Clinical Privileges in Emergency Medicine".

Physician credentialing is the process of gathering information regarding a physician's qualifications for appointment to the medical staff, whereas delineation of clinical privileges denotes approval to provide specific services or perform specific procedures by a physician. The specific process for physician credentialing and delineation of clinical privileges must be defined by medical staff and department bylaws, policy, rules, or regulations. Each member of the medical staff must be subject to periodic review as part of the performance improvement activities of the organization.

The American College of Emergency Physicians (ACEP) believes that:

  • The exercise of clinical privileges in the emergency department is governed by the rules and regulations of the department;
  • The ED medical director is responsible for periodic assessment of clinical privileges of emergency physicians;
  • When a physician applies for reappointment to the medical staff and for clinical privileges, including renewal, addition, or rescission of privileges, the reappraisal process must include assessment of current competence by the ED medical director;
  • The ED medical director will, with the input of department members, determine the means by which each emergency physician will maintain competence and skills and the mechanism by which to monitor the proficiency of each physician.

A qualified emergency physician is defined as one who possesses emergency medicine training or sufficient experience in emergency medicine to evaluate and manage all patients who seek emergency care. ACEP believes that the ED medical director should be responsible for assessing and making recommendations to the hospital's credentialing body related to the qualifications of emergency physicians with respect to the clinical privileges granted to them. At a minimum, those applying for privileges as emergency physicians should be eligible for ACEP membership. Board certification by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine is an excellent but not the sole benchmark for decisions regarding an individual's ability to practice emergency medicine. Other qualifications may include objective measurement of care provided; sufficient experience; prior training; and evidence of continuing medical education.

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