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Affiliation certification vs. clinical evaluation: Save time by knowing the differences

Credentialing Resource Center Connection, January 17, 2008

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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 department.

Dear credentialing colleague:

While consulting and in day-to-day practice, I have noticed that some hospitals have been struggling with formatting and developing affiliation verification forms and clinical evaluation forms. In 2007, The Joint Commission (formerly JCAHO) implemented a new requirement for hospitals to incorporate the ACGME's six general competencies into their credentialing process. This new requirement is a great opportunity to clearly delineate the difference between these two very different forms.

An affiliation verification form should be sent directly to the medical staff office (MSO) and should NOT include clinical evaluation questions. This form should verify the applicant's status at the organization, for example, dates of affiliation, staff status, and the department of practice. Additionally, an affiliation verification form should ask questions specific to the applicant's practice at the organization, for example:

• Has the applicant ever been under any type of review and/or investigation or have they been the subject of any complaints or allegations of unprofessional or unethical behavior?
• Have there been any major health problems or substance abuse issues reported regarding this applicant?
• Has the applicant been derelict in their performance of medical staff duties, such as medical record documentation, meeting attendance, etc.?
• Has the applicant's membership or privileges ever been subject to review, restrictions, reduction, special oversight, or termination?

There are several other questions that MSPs can include in the form. These questions can be phrased in many different ways; however, the key is that they are specific to the affiliation.

A clinical evaluation is a separate form and MSPs should not combine its questions with the affiliation verification form's questions. The MSO should send the clinical evaluation form directly to the department chief or peer reference for completion, and you should not ask these individuals to verify dates of affiliation (this is the purpose of the affiliation verification form, as noted above). The clinical evaluation should ask the department chief or peer reference to evaluate the practitioner's competency and review the privileges that the applicant has requested. This form should include the ACGME's six general competencies, and the questionnaire can be broken out by each of the six sections.

Not only will ensuring that these forms are separate and specific help the MSP to obtain a more detailed, thorough response, but the turn around time is probably going to be quicker since the right people have the right form from the beginning. If you send the MSO a clinical evaluation, they can not complete it. If you send the department chief an affiliation verification, they simply have to turn around and send it to the MSO. Therefore, keeping the two processes and forms separate will help to improve the efficiency of the process and ensure that you receive the meaningful data to help your organization make a sound decision on whether to grant or renew medical staff membership and privileges.

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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