Physician Credentialing and Delineation of Clinical Privileges in Emergency Medicine
Revised April 2017, October 2014, June 2006 and June 2004
Reaffirmed October 1999
Revised with current title September 1995, June 1991
Originally approved with the title "Guidelines for Delineation of Clinical Privileges in Emergency Medicine" April 1985.
As an adjunct to this policy statement, ACEP has created a Policy Resource and Education Paper (PREP) 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 those specific services and procedures that a physician is deemed
qualified to provide or perform. The specific processes 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
- 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
the proficiency of each physician will be monitored.
For the purposes of specialty recognition, an emergency physician is defined as one who is certified (or eligible to be certified) by the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM) or an equivalent international certifying body recognized by ABEM or AOBEM in emergency medicine or pediatric emergency medicine, or who is eligible for active membership in the American College of Emergency Physicians.1
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 providers of emergency care 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 ABEM or AOBEM, or pediatric emergency medicine subspecialty
certification by the American Board of Pediatrics is an excellent, but not the
sole benchmark for decisions regarding an individual’s ability to practice
emergency medicine. Especially in rural areas, physicians who trained in other
specialties may provide emergency care and be granted privileges by an
objective measurement of care provided, sufficient experience, prior training,
and evidence of continuing medical education.
*ED medical director refers to the
chair, medical director or their designee.
1. American College of Emergency
Physicians policy statement titled "Definition of an Emergency
Physician" revised April 2017.