Credentialing and Privileging - Peer References

Who can provide a peer reference for independent or non-independent practitioners such as nurse practitioners, physician assistants, and psychologists, midwives, and social workers when there is no other similar practitioner on staff?  

The definition of a peer (see MS.06.01.05 EP 2, 8) is someone from the same discipline. For example, physicians for physicians, dentists for dentists, podiatrists for podiatrists, etc. It does not have to be someone in the same specialty (orthopedist, etc.). To be able to provide a reference the peer must be familiar with the individual's actual performance.  For the nurse practitioner, physician assistant, and psychologist, or social worker ideally this should be another individual from the same discipline and the organization should attempt to obtain such references. This could be someone within the same organization or someone from outside the organization.

In situations where there is no nurse practitioner, physician assistant, psychologist, or social worker who could provide a peer reference it is acceptable for a physician or D.O with essentially equal qualifications, who is familiar with the allied health practitioner's performance, to provide the reference. For example, an internist could provide a reference for a physician assistant, an anesthesiologist could provide a reference for a nurse anesthetist, and a psychiatrist could provide a reference for a psychologist and a psychologist with similar responsibilities could provide a reference for a social worker.

Last updated on January 17, 2019
Manual: Hospital and Hospital Clinics
Chapter: Medical Staff MS

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