Healthcare Safety Toolkit Library

Healthcare providers and facility administrators can use this sample credentials file chart audit to ensure compliance with hospital standards and policy. The downloadable form provides a comprehensive checklist field including necessary elements of review to ensure credentialing documentation is in place for physicians on staff.

Through thorough assessment using this form, you can determine which physician files at your own facility are out of compliance with proper credentialing procedures, helping to safeguard against accidental oversights and room for liability.

The credentialing process is information-intensive, often requiring a multitude of components for completion. Staying organized and updated on what details you need is important in the successful implementation of the credentialing process.

To stay on target with your assessment process, use our Comprehensive Credentialing Checklist to ensure that all needed information has been verified prior to presenting for next level of approval or review.

While licenses offer a benchmark for the training of an employee, these hardly gauge how competent the physician may be at a particular skill. When onboarding new medical staff members, it’s essential to evaluate their individual competencies and professionalism to ensure it’s streamlined with your facility’s quality of care.

Use the sample Focused Professional Practice Evaluation (FPPE) form provided to quickly assess your new staff members.

Letter and form to be sent for reference of the applicant.

A request for peer review of a new applicant should include the following indicators: evaluation of the applicant’s experience, ability and current competence in the areas of medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills and professionalism.

Provided is a sample peer review request letter and evaluation form that you may use to quickly send and request assessments for new applicants to your facility. The download provides an introductory letter followed by an evaluation form to be completed by the selected peer.

The Governing Board is ultimately responsible for credentialing and privileging activities of the hospital. It’s best practice to provide them with a yearly report of all credentialing activities that occurred in order to sustain continued process oversight.

The downloadable document provided is a sample credentialing audit that can be performed and presented to the governing board of your facility. New applicant activity and medical staff roster counts are included within the audit to provide a broad overview of the department or facility for review.

Healthcare organizations should take the possiblity of an active shooter event occuring in their facility very seriously. These resources provide key tactics on managing violent and disruptive behavior as a risk reduction process.

Active shooter training is vital for all staff in a healthcare organization as they are the eyes and ears of the facility. These resources help ensure staff are trained and prepared to address violent/aggressive behavior/situations.