Every licence in date. Every person ready.
Behind every licence is a person who earned it. A lapse is rarely their failure. It is a record nobody watched. This register watches it with them.
A copy is not a check. A date is not a reminder.
Credentials lapse a few days at a time: a card that ends with the month, a renewal that never reaches the file. The standards are clear about whose job it is to know.
Primary-source verification means checking a qualification “by the original source or an approved agent of that source”. It is the organisation’s responsibility, not the licensed individual’s.
The Joint CommissionAmerican Heart Association course cards, including BLS and ACLS, are valid for two years and expire on the last day of the month the course was taken. Online renewal opens 90 days before.
Vanderbilt University Medical CenterAustralian national guidance recommends re-credentialing at intervals of three to five years, and sooner when concerns arise or registration changes.
Australian Commission on Safety and Quality in Health CareNCQA’s 2025 standards cut the time allowed between verification and the credentialing decision to 120 days, from 180, and ask organisations to audit how updates are documented.
Horty, Springer & MatternOne register. One row per credential.
Not one row per person. A nurse with a registration, a BLS card and a fire-safety course has three rows, each with its own date, owner and proof.
| Staff ID | Role | Credential | Type | Expires | Verified with source | Renewal owner | Days left | Window |
|---|---|---|---|---|---|---|---|---|
| MD-007 | Consultant physician | ACLS | Certification | 2026-12-09 | Yes | Head of internal medicine | 27 | 30 days |
| LB-011 | Laboratory technician | Professional registration | Registration | 2026-11-09 | Yes | Laboratory manager | -3 | Expired |
| RN-014 | Registered nurse | Basic Life Support (BLS) | Certification | 2027-01-09 | Yes | Ward 3 manager | 58 | 60 days |
| TR-019 | Ambulance driver | Emergency vehicle licence | Licence | 2027-02-09 | Yes | Transport supervisor | 89 | 90 days |
| PH-003 | Pharmacist | Pharmacist licence | Licence | 2027-07-09 | Pending | Chief pharmacist | 239 | Not verified |
| FM-002 | Electrician | Electrical installation licence | Licence | 2027-10-09 | Yes | Facilities manager | 331 | In date |
Rose columns calculate themselves in the XLSX. The files also hold the department, issuing body, issue date, who verified and when, the evidence file and notes.
Usually the line manager. The person renews; the owner makes sure it happens.
Yes only after you checked with the issuing body. Pending until then.
Expired comes first, then Not verified, then 30, 60, 90 days, then In date.
Six steps. Then every Monday.
Gather every credential
Licences, registrations, certifications and mandatory courses, for every role that needs them. Clinical, technical and support roles alike.
Check each with its source
Contact the board, university or certifying body. Record the date and who checked. Leave Pending until then.
Name an owner per row
A role, not a department. A credentialing officer is the backup.
Act on the windows
At 90 days the person books renewal. At 60 the owner confirms the date. At 30 the item is escalated and rostering is told.
Filter every Monday
Filter the Window column. Three questions: who is out of date, who will be within 90 days, what has no verified proof.
Never overwrite a date
When a credential renews, add the new dates and keep the old in Notes, with who changed it and why.
Where registers usually break.
Locums, floaters and shared staff fall between them. Keep one register.
A scan shows what was handed in, not what the board holds today.
Two-year cards on staggered cycles fall due almost every month. They slip first.
HR assumes the department chases it; the department assumes HR does.
The old value and the reason vanish. An auditor can’t tell a renewal from a correction.
Activity, location or messages say nothing about who is qualified, and cost trust.
When the register outgrows one person.
A spreadsheet works until it depends on whoever keeps it. These are the signs it is time to move.
- Reminders depend on someone opening the file.
- You can’t say which roles require which credentials, and who is missing one.
- An auditor asks for the history of a date, and there is none.
- Rosters are built without knowing whose card has lapsed.
ROADYOM REFRACTION
Credentials beside people, rosters and onboarding.
Refraction is Roadyom’s people system. Each licence and certification has an expiry date, an owner, an evidence file and a full history of changes. Records are checked against your own framework rules, such as which roles require which credentials. Refraction doesn’t track activity. People make the decisions.
Questions, answered.
What is the difference between credentialing and privileging?
Credentialing confirms what a person holds. Privileging decides what they may do in your facility. This register covers the first; record privileges decided by your committee alongside it.
Why 90, 60 and 30 days?
Each window has a job: book, confirm, escalate. Ninety days also matches when online renewal opens for AHA cards at Vanderbilt, for example.
Does it work outside healthcare?
Yes. Teaching licences, safeguarding checks, regulatory certifications in banking, engineering and electrical licences, driving permits. Change the Type list to match.
Should we store licence numbers?
Store what your regulator requires and no more. The template uses an evidence reference instead, pointing to the verification record kept securely.
Can staff see their own row?
They should. People renew on time when they can see what is held about them and when it ends.
Why doesn’t the CSV show the window?
A CSV can’t hold formulas reliably across programs. It carries the data columns. The XLSX adds Days left and Window, calculated from today’s date.
Sources (5)
- Verification - Primary Source Verification - Definition (Ambulatory Health Care). The Joint Commission, 2026.
- Resuscitation Program FAQs. Vanderbilt University Medical Center, 2026.
- Credentialing and defining scope of practice: Guidance for health services and clinicians. Australian Commission on Safety and Quality in Health Care, 2026.
- Question of the Week, February 27, 2025: NCQA credentialing standard changes. Horty, Springer & Mattern, 2025.
- 42 CFR § 482.22 – Condition of participation: Medical staff. Legal Information Institute, Cornell Law School, 2026.
Know who is ready. Every morning.
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