Exhibit M-2 - Credentials Management Policy (2018).pdf
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- Solicitation number
- HT001524R0030
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Defense Health Agency
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This document outlines the credentials management policy for Fort Belvoir Community Hospital. The policy establishes roles and responsibilities for managing credentials for all healthcare providers who diagnose, treat, or manage patient care within their licensed scope of practice. This includes physicians, nurses, pharmacists, psychologists, social workers, and other clinical staff. All providers must have privileges granted by the hospital before performing any patient care. The policy defines procedures for initial credentialing and recredentialing, monitoring ongoing performance, and taking corrective actions if needed to ensure quality of care and patient safety.
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Fort Belvoir Community Hospital
ADMINISTRATIVE
INSTRUCTION
NUMBER 6055.03
Incorporated Changes June 15, 2018
SUBJECT: Credentials Management Policy
References: See Enclosure I
DHO
1. PURPOSE. This Instruction, in accordance with the authority in Reference (a) through (e), cancels and reissues Reference (f) to update formatting and review references of authority. In accordance with References (g) through (o), this Instruction establishes Fort Belvoir Community Hospital (FBCH) policy to outline roles and responsibilities for the management of the credentials function throughout the FBCH. This relates to whether in the direct care system, under preferred provider agreements, or other means established in support of managed care.
2. APPLICABILITY. This Instruction applies to all staff and services within FBCH, assigned or attached, and all other organizational entities assigned within the FBCH.
3. DEFINITIONS. See Glossary
4. POLICY. It is the policy of FBCH that clinical privileges be delineated for all health care providers who diagnose, initiate, alter, or terminate health care treatment regimens within the scope of his or her license, certification, or registration. This category includes audiologists, behavioral health practitioners, chiropractors, clinical and staff pharmacists, clinical psychologists, clinical social workers, dentists, dietitians, nurse anesthetists, nurse midwives, nurse practitioners, occupational therapists, optometrists, physical therapists, physician assistants, physicians, podiatrists, psychological associates, social workers, and speech therapists. Health care providers may not perform any patient care in FBCH care facilities unless the practitioner has current privileges granted by FBCH.
5. RESPONSIBILITIES. See Enclosure 2
6. PROCEDURES. See Enclosure 3
ATAMMC PWS Exhibit M-2 Credentials Management Policy (2018)
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