Implementation of healthcare professional credentials in hospitals: A scoping literature review
DOI: https://doi.org/10.56922/mhc.v4i6.2419
Credentialing Clinical Privileges Clinical Governance Healthcare Professionals Hospital
Abstract
Background: Credentialing implementation is a fundamental pillar of clinical governance in hospitals, ensuring that healthcare professionals possess competencies aligned with the clinical privileges granted to them. Despite its critical role in patient safety, the implementation of credentialing processes often encounters various administrative and regulatory challenges.
Purpose: To map the existing literature on credentialing implementation processes, regulatory frameworks, barriers, and success factors for healthcare professional credentialing in hospital settings through a scoping review approach.
Method: A scoping review design following the PRISMA-ScR guidelines. Article searches were conducted using the Wiley Online Library, PubMed, and ScienceDirect databases, covering publications from 2015 to 2025. After the screening process, 12 articles met the inclusion criteria and were included in the review.
Results: A total of 12 articles were analyzed in this review. The findings indicate that the digitalization of credentialing systems and the implementation of Primary Source Verification (PSV) significantly improve the accuracy of competency verification and reduce the risk of malpractice. Regulatory frameworks, such as Medical Staff Bylaws, serve as the primary foundation for accountability in granting clinical privileges. However, barriers including staff resistance to recredentialing, lack of data integration, and limited resources in rural areas remain major challenges. Key success factors were identified as strong hospital leadership commitment and the independence of medical committees in conducting peer review.
Conclusion: Effective credentialing implementation requires the integration of transparent policies, robust health information technology infrastructure, and a strong patient safety culture. The findings of this scoping review are expected to serve as a reference for hospital management in optimizing credentialing systems to ensure the quality of healthcare services.
Keywords: Credentialing; Clinical Privileges; Clinical Governance; Healthcare Professionals; Hospital.
Downloads
References
Audrain, R. L., Weinberg, A. E., Bennett, A., O’Reilly, J., & Basile, C. G. (2022). Ambitious and sustainable post-pandemic workplace design for teachers: A portrait of the Arizona teacher workforce. Primary and secondary education during Covid-19. Springer, 353-381.
Covell, C. L., Neiterman, E., & Bourgeault, I. L. (2016). Scoping review about the professional integration of internationally educated health professionals. Human resources for health, 14(1), 38.
Dharmagunawardene, D., Bowman, P., Avery, M., Greenfield, D., & Hinchcliff, R. (2025). Factors influencing the establishment of hospital accreditation programs in low-and middle-income countries: a scoping review. Health Policy and Planning, 40(4), 496-517.
El-Sappagh, S. H., Nazih, W., Alharbi, M., & AbuHmed, T. (2025). Responsible Artificial Intelligence for Mental Health Disorders: Current Applications and Future Challenges. Journal of Disability Research, 4(1), 20240101.
Gershuni, O., Orr, J. M., Vogel, A., Park, K., Leider, J. P., Resnick, B. A., & Czabanowska, K. (2023). A systematic review on professional regulation and credentialing of public health workforce. International journal of environmental research and public health, 20(5), 4101.
Haskins, S. C., Bronshteyn, Y., Perlas, A., El-Boghdadly, K., Zimmerman, J., Silva, M., & Narouze, S. (2021). American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians—part I: clinical indications. Regional Anesthesia & Pain Medicine, 46(12), 1031-1047.
Hussein, M., Pavlova, M., Ghalwash, M., & Groot, W. (2021). The impact of hospital accreditation on the quality of healthcare: a systematic literature review. BMC health services research, 21(1), 1057.
Innis, J., Dryden-Palmer, K., Perreira, T., & Berta, W. (2025). How do health care organizations take on best practices? A scoping literature review. JBI Evidence Implementation, 13(4), 254-272.
Jose, A., Tortorella, G. L., Vassolo, R., Kumar, M., & Mac Cawley, A. F. (2022). Professional competence and its effect on the implementation of healthcare 4.0 technologies: scoping review and future research directions. International Journal of Environmental Research and Public Health, 20(1), 478.
Khan, K. (2021). Investigation of Wnt Signaling in the Biopathogenesis of Myocardial Infarction. McGill University (Canada).
Menon, S., Krallman, K. A., Arikan, A. A., Fuhrman, D. Y., Gorga, S. M., Mottes, T., & Zangla, E. E. (2023). Worldwide exploration of renal replacement outcomes collaborative in kidney disease (WE-ROCK). Kidney international reports, 8(8), 1542-1552.
Merry, L., Castiglione, S. A., Rouleau, G., Létourneau, D., Larue, C., Deschênes, M. F., & Ahmed, L. (2023). Continuing professional development (CPD) system development, implementation, evaluation and sustainability for healthcare professionals in low-and lower-middle-income countries: a rapid scoping review. BMC medical education, 23(1), 498.
Nemenqani, D. M., Tekian, A., & Park, Y. S. (2017). Competency assessment in laboratory medicine: Standardization and utility for technical staff assessment and recertification in Saudi Arabia. Medical teacher, 39(sup1), S63-S74.
Rice, M. K., Hodges, J. C., Bellon, J., Borrebach, J., Al Abbas, A. I., Hamad, A., & Hogg, M. E. (2020). Association of mentorship and a formal robotic proficiency skills curriculum with subsequent generations’ learning curve and safety for robotic pancreaticoduodenectomy. JAMA surgery, 155(7), 607-615.
Sarwar, A., Khan, J., Muhammad, L., Mubarak, N., & Jaafar, M. (2021). Relationship between organisational dehumanization and nurses' deviant behaviours: A moderated mediation model. Journal of nursing management, 29(5), 1036-1045.
Shorey, S., Lau, T. C., Lau, S. T., & Ang, E. (2019). Entrustable professional activities in health care education: a scoping review. Medical Education, 53(8), 766-777.
Slenter, D. N., Kutmon, M., Hanspers, K., Riutta, A., Windsor, J., Nunes, N., & Willighagen, E. L. (2018). WikiPathways: a multifaceted pathway database bridging metabolomics to other omics research. Nucleic acids research, 46(D1), D661-D667.
West-Oram, P. G. (2020). Benjamin M. Meier and Lawrence O. Gostin, Human Rights in Global Health: Rights Based Governance for a Globalizing World.
Wilson, D., Crengle, S., & Cram, F. (2020). Improving the quality of mortality review equity reporting: Development of an indigenous Māori responsiveness rubric. International Journal for Quality in Health Care, 32(8), 517-521.
Zgambo, M., Arabiat, D., & Ireson, D. (2021). Uptake of health services by youth living with HIV: a focused ethnography. International Nursing Review, 68(3), 299-307.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 JOURNAL OF Mental Health Concerns
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
