Credentialing and Privileging Practices at Northern Navajo Medical Center

EXECUTIVE SUMMARY:

The objective of this audit was to determine whether Shiprock Hospital had completed the credentialing, privileging, and personnel suitability reviews for its medical practitioners (practitioners).  Shiprock Hospital did not routinely complete required credentialing, privileging, or personnel suitability reviews for its practitioners.  Shiprock Hospital did not routinely complete required credentialing, privileging, or personnel suitability reviews for its practitioners.  For the 84 practitioners we reviewed, Shiprock Hospital did not (1) verify the credentials for 32, or 38 percent, before the practitioners provided patient care; (2) ensure that 67, or 80 percent, had current privileges, with lapsed period ranging from 3 days to over 3 years; or (3) request the Office of Personnel Management to perform a background investigation of 41, or 49 percent.  As a result, the hospital's management could not assert full assurance that its practitioners had the appropriate qualifications, authorizations, and personnel history to provide patient care.  Among other things, we recommended that IHS ensure that Shiprock Hospital has a sufficient number of staff assigned to adequacy perform the credentialing and privileging processes before the practitioners provide patient care, has fully implement credentialing and privileging computer software to track and monitor the status of its practitioners, and reports privileging problems and associated corrective actions to the Joint Commission, as appropriate.