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Annual Review of Credentialing Documents

Credentialing Resource Center Connection, December 20, 2007

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Anne Roberts, CPMSM, CPCS, is the director of medical affairs at Children's Medical Center in Dallas, where she oversees the medical administration, graduate medical education, and medical staff services departments.

Dear credentialing colleague:

As the year end approaches, we are all scanning our "to-do" lists to ensure that we have not forgotten any part of our year-end processing. Sending out committee appointments for the upcoming year, appointing new officers, and running annual reports are likely atop your lists. However, one of the most crucial steps this time of year for MSPs is to ensure that their organization conducts, at minimum, an annual review of all medical staff governing documents and privilege delineations.

One of the most common reasons that regulators such as The Joint Commission (formerly JCAHO) and the National Committee for Quality Assurance (NCQA) cite organizations for noncompliance with standards is because the organizations have implemented a policy and then failed to follow it. If your practice does not mirror your policy, then one of the two must change quickly. Your organization should determine which is best-the policy or the practice-and then adjust accordingly. However, if your organization does not have the staffing or resources to mirror in practice what is in the policy, it may have to meet the minimum standard for the time being. Then, when the staffing or resources becomes available, the policy and/or practice can be revised to exceed the minimum.

With regard to privilege delineation, it is important to ensure that all procedures listed on your privileging forms continue to be available at your organization. Privilege delineations are developed by taking into consideration not only the requesting practitioner's training, education, and experience-but also the currently available equipment, staffing, and resources. In particular, any significant changes in staffing and resources during the past year may affect what clinical services are offered. Additionally, as healthcare organizations grow, they must update their privileges to reflect the new services and the minimum threshold criteria required by practitioners to request those new privileges.

Regulatory standards and legislature continue to change and evolve annually as well. For example, there continues to be controversy surrounding the revisions to Joint Commission standard MS.1.20, which is currently scheduled to take effect in July 2009. Many organizations may have to significantly revise the structure of their medical staff bylaws to comply with the new standards. Certain elements that are currently in documents that supplement the bylaws (i.e., policy and procedure documents) may be required to be moved into the bylaws themselves. As a result, MSPs must be familiar with state, federal, and regulatory requirements, and stay abreast of all changes to ensure that their governing documents and processes comply.

Remember, clear, effective communication is the key to success!

That's all for this week.

All the best,

Anne Roberts, CPMSM, CPCS

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