Physician Credentialing and Delineation of Clinical Privileges in Emergency Medicine

Revised April 2017, October 2014, June 2006 and June 2004

Reaffirmed October 1999

Revised September 1995 with current title, June 1991

Originally approved April 1985 titled "Guidelines for Delineation of Clinical Privileges in Emergency Medicine"

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 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 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.

Reference

1. American College of Emergency Physicians policy statement titled "Definition of an Emergency Physician" revised April 2017.