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Ensure confidentiality during the application process

Credentialing & Verification Update, May 21, 2008

Confidentiality plays a key role in credentialing. Information obtained during the credentialing process should be kept in confidential credentials files with strict policies regarding where the files are kept and which individuals have access to the information.

Policies should be clear about access
Policies should also include details about the information to which the applicant has access. For example, if your organization indicates to professional references that their replies will be confidential, the hospital must ensure that any physician who requests to review his or her credentials file should not be allowed to review questionnaires submitted to the organization from peer references or department chairs. These letters are sent to the references and are completed under the pretenses that they are confidential. If individuals do not feel that the information will be kept confidential, they may not be as willing to be candid about the information provided.  

Keep confidential information separate
A process for maintaining confidential committee minutes should also be outlined. Minutes are not verbatim documentation of meetings, but rather are a summary of important points and actions taken. Only individuals who participate in the committee, or others specifically approved by the organization, such as legal counsel and the board of directors, should have access to the minutes. Regulatory agencies that come in to do audits can review minutes if approved by legal counsel, but the organization should ensure that the review occurs in a secure location where the minute books are kept under the supervision of designated hospital personnel.

Releasing confidential information to outside organizations should be done with caution.

Complaints that your organization receives regarding the applicant should also be handled with strict confidentiality. Disruptive policies should detail processes for the reporting and escalation of complaints. Once investigations are closed, a clear process that outlines where the documentation is stored must be in place, whether that is in the credentialing file, quality file, or another location. The organization must determine what information to store in which location, who has access to the information, and how long that information should be kept on file for future reference.

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