|Year : 2015 | Volume
| Issue : 2 | Page : 61-68
Criteria-based core privileging: Best form of privileging
Medical Processes, Fortis Healthcare Limited, Gurgaon, Haryana, India
|Date of Web Publication||19-Jan-2016|
Dr. Akash Sud
Fortis Healthcare Limited, Gurgaon, Haryana
Source of Support: None, Conflict of Interest: None
Hospitals are accountable and responsible for all activities & services provided by the individual healthcare providers within their premises. The primary objective of Credentialing & Privileging process is to ensure that hospital and healthcare providers provide services, which are appropriate in scope and quality of their practice. While credentialing involves obtaining, scrutinizing and verifying the qualifications, experience & professional standing of medical practitioners, to judge their competence, privileging is the right of a medical practitioner to provide specific medical care consistent with his/her training, experience and competency.
Of the various methods of privileging, Criteria-based core privileging incorporates predefined criteria in conjunction with clinically realistic, well-defined core privileges. This is a scientific approach to privileging in which the privileges for each specialty are predefined and divided into two categories:
a) Core Privileges: Privileges that a fully trained, entry-level medical practitioner is qualified to do in a particularly specialty on completing an approved training program.
b) Specific (Additional/Non-Core Privileges): Procedures that go beyond the core that would require additional training and/or experience are covered by additional specific privileges.
Practitioners who meet predefined criteria are eligible to apply for core privileges, and those who can document additional training and experience may request special (or noncore) privileges.
Advantages of Criteria Based Core Privileging are: scientific approach with clearly defined criteria, consistency, and practicality with ease of operationalization. High attrition rates & frequent hiring of medical staff also makes Criteria Based Core Privileging the most suitable form of privileging for Indian Healthcare scenario.
Keywords: Core privileges, credentialing, Credentialing and Privileging (C&P) Committee, privileging, specific privileges
|How to cite this article:|
Sud A. Criteria-based core privileging: Best form of privileging. J Nat Accred Board Hosp Healthcare Providers 2015;2:61-8
| Introduction|| |
Health services have a responsibility to ensure that all the services provided to patients are safe, appropriate, and within the capability and role of the service.  The hospital is accountable and responsible for all the activities and services provided by individual health care providers within its premises. Rapid advances in medical technology have resulted in the introduction of new procedures and techniques in medicine. Undue haste in applying and performing these techniques without adequate knowledge and training can result in unacceptable outcomes. With an increasingly well-informed and knowledgeable public, it is essential that there is a mechanism for hospitals and medical centers to ensure that all health care providers are competent in each procedure they perform.  Credentialing and privileging ensure that the services undertaken are within the scope of the doctor's practice.
The primary objective of this process is to ensure that hospital and health care providers provide services, which are appropriate in scope and quality. Therefore, there should be:
- Clear definition and review by the Credentialing and Privileging (C&P) Committee regarding training, experience, and competency required at each level of complexity of medical services and procedures.
- Formal definition and control by the C&P Committee of the medical services that the individual health care providers shall be permitted to provide, depending on their clinical competencies, the hospital service level consistent with the patient's needs, the availability of infrastructure and equipment, and the most efficient use of available resources.
- Monitoring of the quality and quantity of services being provided to permit regular review.
Every hospital must have a defined system for dealing with the process of credentialing and privileging, which must not only be fair, credible, and consistent but also flexible enough to address constraints such as the shortage of manpower in certain areas. Credentialing should also include the definition and delineation of the role of each medical personnel in the hospital.
While many people use the term credentialing to include privileging activities, the two processes are related but distinct. Credentialing is the process of obtaining and verifying the documents that support the doctor's qualifications to work at a hospital. Privileging is the process of obtaining the permission to practice in a hospital. 
Credentialing is the formal process used to verify the qualifications, experience, and professional standing of practitioners for the purpose of forming a view about their competence, performance, and professional suitability to provide safe, high-quality health care service.  The term "credentialing" refers to the systematic process of screening and evaluating qualifications and other credentials including but not limited to licensure, required education, relevant training and experience, and current competence and health status. The credentialing process informs the decisions to grant an appointment and clinical privileges, by providing information about whether the applicant has the education, training, experience, and professional attributes necessary to perform the clinical privileges requested. Credentialing verifies the education and training, which allows one's organization to grant privileges to a licensed independent provider to perform in his/her ambulatory environment. 
Credentials represent the formal qualifications, training, experience, and clinical competence of the health care provider providing the professional health service. They are evidenced by documentation such as university degrees, fellowships of professional colleges or associations, certificates of service, certificates of completion of specified courses, periods of verifiable formal instruction or supervised training, and information contained in confidential professional referee reports. 
The right of a medical practitioner is to provide specific medical care that is consistent with his/her training, experience, and competency. The clinical privileges represent the range and scope of clinical responsibility that a medical practitioner may exercise in the hospital. Clinical privileges are specific to the individual, usually in a single hospital and are not automatically transferable to another individual or hospital.
The oversight of an appropriately skilled and qualified medical administrator (Medical Superintendent or Medical Director) is essential for ensuring that systems for credentialing and privileging are effective. To have a pivotal role in the management of the process for credentialing and scope of clinical practice, medical administrators must themselves have the requisite qualifications, skills, and knowledge to complete this task. It is the responsibility of the medical administrator to convene the C&P committee at appropriate times. Members of these committees must have the relevant expertise for their roles and must not have a conflict of interest.
Approaches to privileging
The most commonly used methods of privileging  are:
- Laundry lists/privilege lists/privilege cards: Recommended by the American College of Surgeons in the 1950s, laundry lists are detailed checklists that itemize the procedures/conditions that applicants can specifically request to perform/treat. Hospitals often use such lists for surgical specialties. Laundry lists have many drawbacks:
- Laundry lists are usually not associated with predefined criteria and practitioners while applying for privileges simply check off the procedures they would like to perform or the conditions they would like to treat, as there are no defined criteria that must be met for each requested privilege. As applicants are not routinely required to provide specific documentation of training and experience to show that they are qualified for all requested privileges, practitioners tend to apply for "all privileges listed" because they do not want to take the time to request each procedure or condition.
- Laundry lists are most often procedurally focused but often the cognitive areas of practice are not addressed.
- Laundry lists are often not inclusive because of which many hospitals are tempted to write "others" at the bottom of the request form, which enables practitioners to request to perform procedures or treat conditions for which the hospital has no predefined privileging criteria or that are outside the scope of the services of the hospital.
- There are legal issues associated with laundry lists as hospitals cannot demonstrate that they critically reviewed a practitioner's request when the request was for a large number of check marks on a form. How does a hospital demonstrate that it has reviewed the applicant's prior education, training, and experience for each privilege requested?
- Maintaining laundry lists is very difficult as new procedures or new conditions are identified, thus requiring that hospitals update and maintain these laundry lists on an almost continuous basis.
- Categorization: Also referred to as "categories or levels of privileges," categorization identifies major treatment areas or procedures that are classified based on the degree of complexity of the procedure or illness to be treated. Typically, categories are based on the level of a practitioner's training and experience. Categorization seems to be more applicable to medical (i.e., cognitive) areas than to surgical (i.e., procedural) areas. These categories are many a time vague categories that do not specify the required education, training, and experience, and may fail to specify the privileges that may be requested/granted. The hospital must state clearly the standards that the applicant must meet for each category, which is lacking most of the times.
- Descriptive approach: In the descriptive approach, the practitioner is not required to complete a checklist or use categories but instead is asked to describe in a narrative format in his or her own words those areas in which he or she possesses clinical competence. These are usually not objective and a practitioner might only write that his or her clinical privileges "shall be defined as those standard and customary activities appropriate to the diagnosis and treatment of any and all diseases covered in the specialty of, say, Pediatrics."
- Combination approach: A combination approach combines various features of the laundry list, categorization, and descriptive approaches.
- Delineation by codes: This is done using the International Classification of Diseases (ICD) codes, Current Procedural Terminology (CPT) codes, and diagnosis-related group (DRG) codes. If an individual meets the predefined criteria for a particular clinical area, he or she would be granted privileges based on the ICD, Ninth Revision, Clinical Modification (ICD-9-CM), CPT, or DRG codes for those procedures. Unfortunately, delineating by codes often results in rather extensive privilege lists that can consist of 18-20 pages for one surgical specialty (e.g., general surgery).
- Criteria-based core privileging: Criteria-based core privileging incorporates predefined criteria in conjunction with clinically realistic, well-defined core privileges. This is a scientific approach to privileging in which the privileges for each specialty are predefined and divided into two categories: Core privileges and specific (additional/noncore) privileges:
- Core privileges: Privileges that a fully trained, entry-level medical practitioner is qualified to do in a particularly specialty on completing an approved training program.  These are those basic clinical activities within a specialty or subspecialty that any appropriately trained, actively practicing practitioner would be competent to perform. These can be accorded to any practitioner possessing the basic qualification in the concerned specialty. Thus, a newly qualified specialist would be granted core privileges.
- Specific (additional/noncore) privileges: Procedures that go beyond the core that would require additional training and/or experience are covered by additional specific privileges.  Apart from the core clinical activities, medical practitioners sometimes perform procedures that require a higher level of training and experience to avoid poor outcome. Specific privileges nearly always correspond to one or more of the following:
- New advances in technology.
- High-risk/problem-prone, volume-sensitive diagnoses or procedures that would not be automatically incorporated within the core.
- Issues that occasionally cross specialty lines.
In the criteria-based core privileging approach, practitioners who meet the predefined criteria are eligible to apply for core privileges, and those who can document additional training and experience may request special (or noncore) privileges. As a first step, each medical discipline must identify core and specific procedures.
Why criteria-based core privileging? 
The core privileging approach has several other advantages that help make it effective:
- Practical and easy to operationalize: All the previous approaches to privileging essentially require holding a session of the C&P Committee each time a new medical staff joins so that the staff gets privileged and can start working. This is a major challenge in the present health care scenario with high attrition rates. However, in case of core privileging this is not needed as both the core privileges as well as the criteria for qualifying for these core privileges are defined and approved by the C&P Committee; so for each new appointment convening C&P Committee is not required. Also, the easy-to-use format increases productivity because nonclinicians can complete much of the initial research.
- Scientific approach with clearly defined criteria: When looking at a laundry list of privileges for a particular specialty, a few procedures are likely to cause a department head to hesitate and question as to whether to recommend those privileges to the practitioner, which is not the case here.
- Consistency: Consistency is one of the key factors as all practitioners in a clinical area are asked to meet the same minimum threshold criteria covering education, training, experience, and demonstrated current competence. Consistency is also a significant part of risk management because consistent criteria help minimize the risk by ensuring that only practitioners with the proper education, training, experience, and demonstrated current competence perform certain procedures and treat specific conditions.
- Objective prescreening: The biggest advantage of the criteria-based core privileging system is that it clearly defines the minimum threshold criteria, providing an objective way to prescreen applicants for clinical privileges. Those practitioners who do not meet the predefined criteria for core privileges or special requests are not eligible to apply for those privileges.
Mandatory requirements for privileging
- For any medical practitioner practicing in the country, registration of his/her qualification(s) with the Medical Council of India or a State Medical Council is mandatory.
- Individuals who do not clear the credentialing process are not allowed to apply for privileging.
- The credentialing process for health care providers should be completed prior to an individual being allowed to provide patient care services.  Privileging process must be completed on or before the day of joining or assigning duties (i.e., prior to joining duty).
Process flow for criteria-based core privileging
The process of criteria-based core privileging has the following steps:
- Defining the core privileges and the criteria for qualification: This is the single most important step in the entire process of core privileging. For each specialty or clinical practice area, the medical staff form the concerned specialty (or an appropriate subcommittee) determines:
- Core privileges (a list of all clinical activities within the specialty, which a freshly qualified and trained specialist can perform); once approved, this list shall be the "core privileges" for the concerned specialty.
- Defined criteria, i.e., the requisite qualifications (and training, experience, etc.) required for attaining the core privileges. Once approved, these shall be the "defined criteria" for granting core privileges.
Both the core privileges and the defined criteria are then presented before the C&P Committee for approval. Once approved, these core privileges can be delineated to any medical staff who is newly joining, and who meets the defined criteria by the Head of the Department (HOD) and the Medical Administrator, as defined in the methodology. As both the core privileges and the defined criteria are approved by the C&P Committee, it is accepted that the core privileges so granted have the approval of the C&P Committee.
- Guiding principles for privileging: Once the core privileges and the defined criteria are defined and approved, the C&P Committee needs to define the guiding principles to be followed for privileging. The guiding principles for privileging are:
- Residents: Resident doctors are only granted privileges under supervision. The privileges shall be predefined and specific to the department.
- Senior Residents: The Senior Residents are granted:
- Core privileges based on the predefined criteria.
- Specific privileges may be granted only under exceptional circumstances by the C&P Committee only.
- Preliminary specific privileges shall not be granted.
- Consultants (any level from Junior Consultant and above) - consultants are granted:
- Core privileges based on the requisite qualifications.
- Preliminary specific privileges are granted as defined in the methodology.
The steps A and B above are more or less a one-time activity.
- Methodology - Actual process of delineation of privileges.
- The Human Resource (HR) Department is responsible for ensuring that each applicant for medical staff appointment receives the appropriate privileges request forms. The privileges request forms should accompany the application and should include:
- Overview of the hospital's privileges process.
- Instructions for completing the privileges request forms.
- Privileging criteria.
- The appropriate requested section (e.g., a gynecologist receives gynecology forms).
- List of core privileges of the specialty.
- A special procedures section (if applicable).
- Privileges requests: Each applicant must include in his or her application for appointment or reappointment to the medical staff a request for the specific clinical privileges that he or she seeks. All requests for clinical privileges are to be submitted, with supporting material, to the HR Department, which will:
- Verify the supporting material (qualification, training, and experience).
- Submit the application package, with supporting material, to the applicable department head.
- Departmental Head - shall recommend the grant of privileges as follows:
- Core privileging: Based on the successful completion of credentialing, the Departmental HOD shall recommend to the Medical Administrator who shall grant the core privileges specific to the specialty. These shall be granted at the time of joining, along with the credentialing.
Applications of all new joinees (since the last committee meeting) will be tabled by the Secretariat to the next Credentialing and Privileging Committee for verification and formal approval.
- Preliminary specific privileging: In addition to the core privileges, the new joiner (consultants only) can request preliminary specific privileges. The onus is on the applicant to prove that she/he has the requisite qualification/experience for each of the privileges requested for. He shall substantiate the application with the requisite certificates/experience certificates/references.
The requests for grant of preliminary specific privileges are made to the Departmental HOD for recommendation. The Departmental Head will:
- Review the request and all supporting material for granting clinical privileges and, where necessary, conduct a personal clinical interview with the requester
- Formulate a written report and forward it to the Medical Administrator
- The Medical Administrator will:
- Review the request and the report of the Departmental Head.
- Based on the patient care needs, the facility's capability to support the type of privileges being requested, and the availability of qualified coverage in the applicant's absence, record his observations and forward to the Chairman of the Credentialing and Privileging Committee for decision.
- Chairman of the Credentialing and Privileging Committee:
Based on the privileges requested, the department head's report and the Medical Head's recommendation, shall either approve or disapprove the preliminary specific privileges.
The preliminary privileging shall be valid for a maximum period of 120 days, within which they shall have to be formally presented before the Credentialing and Privileging Committee for final approval.
The structure of the Privileging Committee is as follows:
Chairman - Senior clinician of repute
Convener - Medical Administrator
Essential Member - Head of the hospital, if different from Medical Administrator
Members (four to six) - Mix of medical and surgical specialists
Coopted member(s) - Departmental Heads of the concerned department(s)
Member Secretariat - Head of HR
Terms of reference
- Members are appointed by the Medical Administrator/Head of the hospital.
- Members are appointed for a minimum period of 2 years.
- Members must be at least a Senior Consultant.
- Quorum: At least 50% members (excluding coopted members) must be present to complete the quorum. The presence of the Chairman, Convener, and Essential Member is mandatory.
- An agenda shall accompany a notice for all scheduled meetings.
- The committee shall meet at least four times per year or at even frequency.
- Matters coming before the committee shall be decided by a consensus. In case consensus is not achieved, the matter will be decided by a simple majority vote of the members present. The chairperson has a casting vote in the case of tied vote. Proxy voting is not permitted.
- Verify information pertaining to the C&P process.
- Coordinate C&P process.
- Recommend credentialing and privileging of specialists on application.
- Maintain a database of specialists who have been credentialed and privileged.
- Prepare reports as required.
Custody: HR personnel shall be the custodian of all privileging documents. They shall be filed in the employee's personal file.
Exercise of privileges
Any practitioner who provides clinical services at the hospital shall exercise only those privileges that have been granted to him or her and emergency privileges as described herein.
Upon written agreement of the HOD in which the privileges will be exercised, the Medical Administrator (in consultation with the Chairman of the C&P Committee) may grant temporary privileges in the following circumstances:
- To fulfill an important patient care, treatment, and service need, which shall not get fulfilled if the temporary privileges under consideration are not granted (e.g., a patient requiring an urgent surgery who would not be able to undergo the surgery in a timely manner).
- A situation in which the institution will be placed at risk of not adequately meeting the needs of patients who seek care from the institution if the temporary privileges under consideration are not granted (e.g., the institution will not be able to provide adequate round-the-clock coverage in the provider's specialty for lack of specialty residents, a locum resident may be granted temporary privileges).
Temporary privileges could be granted to a new applicant (who is currently not working in the hospital) or specific privileges to an existing medical staff. Before granting temporary privileges to a new applicant, the hospital must obtain and verify the following information:
- The practitioner's qualification and training for the privilege being granted.
- The practitioner's valid registration with the Medical Council of India (MCI).
- One positive reference from a responsible medical peer regarding the applicant's competence, training, and ability to perform the requested privileges.
Temporary privileges are granted for no more than 120 days.
Termination of temporary privileges
The Medical Administrator and Chairman of the C&P Committee after consultation with the appropriate department head (or designee) may terminate a practitioner's temporary privileges at any time and must terminate a practitioner's temporary privileges upon the discovery of information or the occurrence of an event that raises questions about the practitioner's professional qualifications or the ability to exercise any or all of his or her temporary privileges.
In an emergency situation, a medical staff member is authorized to do everything possible to the degree permitted by his or her license but regardless of his or her departmental affiliation, staff category, or level of privileges, to save a patient's life or to save a patient from serious harm.
Any practitioner who exercises emergency privileges is obligated to summon all consultative assistance deemed necessary and to arrange appropriate follow-up. When an emergency situation no longer exists, the practitioner must request the privileges that he or she needs to continue to treat the patient.
Cross specialty privileges
Procedures that may be performed by more than one specialty are called cross specialty privileges. It is the responsibility of the medical staff to ensure that a single level of care is provided regardless of which specialty is performing the procedure. In most cases, criteria may have to be developed to ensure this single level of care. Depending on the procedure, it may be "core' for one specialty but not for another.
Reduction/revocation of privileges
Reduction of privileges refers to restricting and/or prohibiting performance of specific procedures. Reduction of privileges may be time-limited.  Revocation of privileges refers to the permanent loss of clinical privileges. 
Reprivileging is the process of reevaluating the professional credentials and clinical competence of health care providers who have been granted clinical privileges and will include the evaluation of professional performance, clinical judgment, technical competence, and skills. Reprivileging should be conducted at least every 3 years. The decision to grant privileges at reappointment or while reprivileging must be based upon:
- Observed clinical performance.
- Documented results of the staff's quality improvement program activities.
- Pertinent information.
The medical staff must request the renewal of privileges in a timely manner prior to the expiry of current privileges. The HOD should verify and assess professional performance, peer recommendation, clinical judgments, and/or technical skills. Peer recommendations are part of the basis of recommendation for approval of clinical privileges.
Additional clinical privileges
With change in hospital practice and clinical techniques over time, it is normal that clinical privileges will also change. The health care provider may submit a specific request for modification of clinical privileges at any time. Requests must be accompanied by explanatory statements and appropriate documentation, which supports the health care provider's claim. The hospital will evaluate valid requests for clinical privileges on the basis of prior education and continuing education, training, experience, utilization practice patterns, current ability to perform the privileges requested, and demonstrated current competence, ability, and judgment.
The HOD will consider the additional information in the entire credentialing and privileging folder before making a recommendation to the Credentialing and Privileging Committee for final decision.
Clinical privileges in case of new technology/equipment 
Whenever a privileging question arises pertaining to the use of new technology or a new treatment protocol, the committee shall gather necessary details to arrive at a decision:
- The onus is on the interested practitioner to provide information about the device, technology, or protocol. The practitioner should be requested to provide a full briefing concerning the new technique or procedure, including:
- What clinical conditions it can be used for? How are those conditions being treated presently?
- What will be the significant difference in patient outcome if this technology is used?
- Which all specialties/staff might use this technology?
- How often might it be used in this hospital in 1 year?
- At which facilities/hospitals, is this technology being used?
- Will this technology require additional training for nursing/operation theater (OT) staff or the doctors who would use the technology?
- Is this technology approved for the intended purpose?
- Which manufacturers sell or distribute it? Can they provide
- Research concerning the proposed technology procedure?
- Manufacturers equipment/technology manuals?
- Approvals as necessary?
- The Privileging Committee will review the issue and will determine whether the institution is interested in the technology or not, depending upon the institution's current plan of care, whether the new technology/procedure is of proven clinical efficacy and effectiveness, and whether the new procedure/technology carries a greater risk than the existing conventional therapy.
- If it is determined that the institution is interested in the new technology, the committee shall find out the possible specialty/subspecialties that may be interested in the issue, the positions held by specialty societies or academies concerning the issue (if any), and the type of practitioner(s) that already perform(s)/treat(s) the issue in other similar hospitals.
- The committee shall determine from the subject matter experts:
- The type of basic education and, if necessary, continuing education required to exercise the privileges safely and effectively.
- The number of years of formal training, and in which field(s) (and, if applicable, continuing training - either didactic or hands-on).
- The committee will submit the results based on the above.
Procedure for appeals
An appeals process must be available and managed independently of the credentialing and scope of practice committee and the appointments committee.  A formal mechanism needs to be established to allow a practitioner to appeal against any decision of the Credentialing and Privileges Committee, which may include:
- Denial of privileges as requested.
- Enforcement of conditions to the granting of privileges.
- Withdrawal of privileges.
The appeal process is intended to allow for reconsideration of any adverse decision and for new information to be brought forward if available. All appeals shall be made to the Credentialing and Privileges Appeals Committee.
Credentialing and privileging (C&P) is an integral component of clinical risk management and clinical governance as well as hospital accreditation. The task of delineating privileges is complex and demanding.  Most hospitals find operationalizing privileging very challenging. Criteria-based core privileging is the best form of privileging as it is based on defined criteria, which are not only fair, credible, and consistent but also flexible enough to address the constraints such as the shortage of manpower and attrition. Frequent hiring of medical staff also makes criteria-based core privileging the most suitable form of privileging for Indian health care scenario. A well-defined credentialing and privileging system while maintaining impartiality ensures the delivery of quality and safety patient care by health professionals.
The effectiveness of processes of credentialing and defining the scope of clinical practice depends on the contribution of professional peers who must verify credentials, evaluate competence and performance, and recommend the appropriate scope of clinical practice in the context of the organization's needs and capability. 
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Credentialing and defining the scope of clinical practice for medical practitioners in Victorian health services - A policy handbook. Quality, Safety and Patient Experience Branch, Victorian Government, Department of Health, Melbourne, Victoria. 2011. p. 6.
Guidelines for credentialing and medical privileges, University Kebangsaan Malaysia Medical Centre (UKMMC), 2010. p. 1-22.
Morgan W. DC Hospital Credentials and Privileges: Knowing what to expect can help expedite the process.
Publication of American Chiropractic Association: 3270.
Credentialing and Defining Scope of Clinical Practice for Country Health SA Health Services for Medical and Dental Practitioners; National Library of Australia Cataloguing-in-Publication; 2009. p. 5-6.
Ambulatory Care Program: The Who, What, When, and Where′s of Credentialing and Privileging; Joint Commission Accreditation. Booklet; 2014: p. 1-8.
Guidelines for credentialing and medical privileges, University Kebangsaan Malaysia Medical Centre (UKMMC), 2010. p. 5.
Smith MA, Smith M, Pelletier SJ, Pelletier S, Searcy VL, Crimp W. Core Privileges for Physicians: A Practical Approach to Developing and Implementing Criteria-based Privileges. 4 ed. Marblehead: HCPro Inc.; 2007. p. 23.
Guidelines for credentialing and medical privileges, University Kebangsaan Malaysia Medical Centre (UKMMC). 2010. p. 5.
Credentialing and Privileging; Medical Protective Clinical Risk Management Department, The Medical Protective Company; 2014. p. 4.
Guidelines for credentialing and medical privileges, University Kebangsaan Malaysia Medical Centre (UKMMC). 2010. p. 19.
Standard for Credentialing and Defining the Scope of Clinical Practice Australian Council for Safety and Quality in Health Care 2004.
Guidelines for credentialing and medical privileges, University Kebangsaan Malaysia Medical Centre (UKMMC). 2010. p. 4.