and has become more prescriptive regarding the scope of practice limits in many jurisdictions. In addition, it has been tied in recent years to continuing education requirements, proof of competence, and both sanctions and supervision in instances in which impairment is established. Licensing of facilities has likewise become a major state function, involving monitoring of numerous and varying requirements established by state legislatures and regulatory agencies.
Health care programs provide risk and quality management through a number of approaches. They and accreditation organizations have established standards of practitioner competence based on such factors as training in accredited health professional programs, possession of a current state license, professional certification, demonstration of specific technical skills under expert supervision, evidence of liability coverage and acceptable prior malpractice experience, and attestation to the existence of no current health conditions that would expose patients to risks. Programs now commonly have dedicated resources to establish primary source verification of practitioners ' qualifications, to conduct initial and ongoing peer review of practitioners ' skills, and to restrict a clinician's practice and to report defined infractions to various state agencies and national data banks.
The complexities and multiple requirements imposed on providers to account to many agencies and managed care organizations and managed behavioral health care organizations has caused credentialing-privileging to become a costly and time-consuming enterprise for both organizations and individual practitioners. The evolution of integrated credentialing systems could substantially reduce these burdens and maintain protection for the public.
Physicians who have contracts with multiple organizations tell us that they can have as many as 20 or 30 reviews in a year, each of which looks at similar but just a little bit different criteria.
American Medical Association
Public Workshop, April 18, 1996, Washington, DC
A number of quality-focused activities have evolved from purchasers ' needs to account for costs and regulators' needs to account for risks. The Health Care