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Credentialing Residents and Fellows

Credentialing Residents and Fellows

February 22nd, 2022
February 22nd, 2022

Over the years that I’ve been involved in consulting, I’ve noticed a number of hospitals that engage in work that is not required by accreditation/regulatory agencies. Because there is so much work that IS required, let’s discuss one area that is often misunderstood and may result in performing unnecessary work: Credentialing Residents and Fellows.

If your healthcare organization is involved in the teaching of residents/fellows, you are either a sponsoring institution, a primary clinical site or a rotation site.


What Does Credentialing Mean?

Credentialing (in the hospital world) means the process of obtaining, verifying and assessing the qualifications of a physician to provide patient care services. Initial appointment and reappointment are terms used to describe the timing of credentialing. Privileging is a subset of credentialing in the hospital and is the method used to define those patient care activities (including procedures) that the physician can perform. Privileging decisions (made by the Board of the organization) are based on the following factors, as applicable: license, education, training, experience, competence, health status and judgment.

Credentialing (in the GME – Graduate Medical Education - world) means the process that other organizations require (i.e., hospitals, licensing boards, etc.) that the GME Residency Coordinator helps to facilitate. The Residency Coordinator coordinates getting residents “credentialed” to work in hospitals where they will be rotating or to obtain appropriate licensure.

Additionally, GME Residency Coordinators provide training verifications to outside entities and facilitate completion of peer reference forms required by hospitals that perform privileging.

Additional definitions that are important in GME are included at the end of this article.

Joint Commission standards do not require that residents be credentialed and privileged by the hospital medical staff organization unless the resident is acting outside of the residency program. Examples:


  • A resident is moonlighting;
  • A resident is doing an “unofficial rotation” (sometimes referred to by hospitals as a preceptorship) – these are often of short duration and occur during a residents’ vacation.
  • A fellow is acting outside of the fellowship program. Here is an example: Let’s say that you have a fellow who has completed residency training in internal medicine and is now in an infectious disease fellowship program. The fellow might be privileged to provide internal medicine services while in the infectious disease program (if permitted to do so by the program director and the organization). In this case, the fellow would need to be privileged for the internal medicine services he/she would be providing.

Joint Commission standards are focused on supervision of residents and the communication between the sponsoring organization and rotation sites.

However, residents must be “authorized” to provide patient care services in the hospital setting. They can’t just show up and start a rotation without any administrative oversight. How can this authorization be most expeditiously handled?

The agreement between the sponsoring institution/program and the site that provides a rotation should specify each organization’s responsibilities and what type of documentation should be provided by the sponsoring organization to the rotation site. Typically, the rotation site provides an orientation specifically related to the rotation site, but is not required to “credential” the resident. The “credentialing” that is required has already been performed by the sponsoring organization. The agreement will specify responsibility for provision of liability insurance.

The aforementioned agreement provides details related to the methods used by the sponsoring institution to “credential” the residents (i.e., assure that residents continuously meet the requirements of residency program). For example, the sponsoring organization may have performed the following types of verifications:


  • Evidence of completion of Medical School
  • Licensure
  • Background check
  • Health screening requirements (which would not need to be done at the rotation site, unless there were some unique health screening requirement at the rotation site not covered by the sponsoring institution)
  • And more...

Sponsoring institution should transmit to the site rotation a summary sheet (preferable this will be transmitted electronically) on each resident that will be available at the rotation site that includes demographic information as well as information related to education/training, each resident’s picture, etc.

Additionally, the sponsoring institution should provide information related to each resident’s ability to provide patient care services (i.e., what can the resident do with/without direct supervision?). This information should be updated annually.

This must provide sufficient details for hospital staff so that they would be able to check if a resident is attempting to do something without supervision that he/she has not been granted authority to do.


Example: Lumbar Puncture


  • Level 1 – the individual can perform the procedure only under direct supervision
  • Level 2 – the individual can perform the procedure under indirect supervision, i.e. under the specific written descriptions of lines of responsibility for the care of patients on each type of teaching service
  • Level 3 – The individual can perform the procedure under indirect supervision and can supervise others performing the procedure

The rotation site must have the ability to communicate to the patient care staff what the various residents are able to do with/without supervision. In many organizations, this is communicated electronically via the “privilege inquiry” software system or through some type of intranet where the information is posted and available to patient care staff.

Remember that if your organization uses residents that are functioning outside of their sponsoring program (i.e., they are “moonlighting”) the sponsoring program must be aware of the fact that the resident is moonlighting (the hospital should obtain permission from the Program Director for the resident to moonlight). The organization where a resident is moonlighting must credential/privileging the moonlighting resident because when they are moonlighting they are functioning as a licensed independent practitioner.


Additional Definitions:

Master Affiliation Agreement: A written document that addresses GME responsibilities between a sponsoring institution and a major participating site.

Moonlighting: Patient care activities external to the educational program that residents/fellows engage in at sites used by the educational program (internal moonlighting) and other healthcare sites.

Primary Clinical Site: If the sponsoring institution is a hospital, it is by definition the principal or primary teaching hospital for the residency/fellowship program. If the sponsoring institution is a medical school, university, or consortium of hospitals, the hospital that is used most commonly in the residency/fellowship program is recognized as the primary clinical site.

Program Letter of Agreement (PLA): A written document that addresses GME responsibilities between an individual accredited program and a site other than the sponsoring institution at which residents receive a required part of their education.

Residency: A program accredited to provide a structured educational experience designed to conform to the program requirements of a particular specialty.

Rotation: An educational experience of planned activities in selected settings, over a specific time period, developed to meet goals and objectives of the program.

Site: An organization providing educational experiences or educational assignments/rotations for residents/fellows (e.g., a university, a medical school, a hospital, a private medical practice, a nursing home, a school of public health, a health department, a public health agency, an organized health care delivery system, a medical examiner’s office, a consortium, an educational foundation).

Sponsoring Institution: The organization (or entity) that assumes the ultimate financial and academic responsibility for a program of GME. The sponsoring institution has the primary purpose of providing educational programs and/or health care services.

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