Credentialing & Privileging

Reasons to deny privileges

Credentialing Resource Center Insider, July 10, 2008

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Sally J. Pelletier, CPMSM, CPCS, is a consultant with The Greeley Company, a division of HCPro, Inc., specializing in the areas of credentialing and privileging.

Dear credentialing colleague:

If you’re familiar with The Greeley Company’s guiding principles for credentialing and privileging, you’ll know that number 11 on the list states, “Because ‘there is no reason to deny’ is not a good enough reason to grant.” This prinicple often raises the eyebrows of medical staff leaders when they first hear it. If they are seasoned medical staff leaders or experienced credentials committee members, they soon will begin to nod their heads in agreement. Those with minimum experience in credentialing tend to ponder the statement with considerable uncertainty. Usually this uncertainty is out of a feeling of duty or sense of obligation to grant privileges to an applicant unless they are proven incompetent to perform the procedure and privileges requested.

However, when I discussed this principle recently with my colleague Carol Cairns, CPMSM, CPCS another senior consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, she enthusiastically said, “This is one of the principles that I actually like the most! This principle is one that nearly everyone--that is experienced--can relate to and is truly problematic.” Perhaps you can relate to one or both of the following scenarios based upon your own experiences. 

Scenario 1: The medical staff appointed a physician that just was not quite “right.” Throughout the information gathering, verification process, and assessment phase of processing this physician’s application those involved sensed something was amiss but was not “bad enough,” or not “obvious enough” to deny privileges. Department chairs or committee members perhaps even stated the following, “Well, there are not reasons enough not to appoint,” before recommending appointment and privileges. Subsequently the hospital spent the next five years:

  • Wondering why this individual had been appointed due to clinical mediocrity
  • Wishing (either due to quality of care issues or personality/behavior issues) that he or she had not been appointed
  • Attempting to get enough data to remove the person or spending considerable amounts of time managing poor performance 

Scenario 2: Dr. Jones, a gynecologist, has done occasional radical hysterectomies at your facility. The medical staff has recently implemented criteria-based core privileges that include eligibility requirements of fellowship training in gynecologic oncology with minimum volumes established for both initial appointment and maintenance of the privileges for radical hysterectomy. At reappointment, Dr Jones does not meet the established criteria but states emphatically, “The hospital has to prove I’m incompetent before they can take away my privileges for radical hysterectomy.” There are many credentialing principles that the credentials committee utilizes in their response to Dr. Jones including principle #11 that “no reason to deny” is not a good enough reason to grant.

How can medical staffs avoid these scenarios? Don’t allow yourself to enter them in the first place. You can accomplish this by adhering to the following tips that guide high functioning medical staff leaders when considering appointment and requests for privileges:

  • Use restraint; don’t feel obligated to recommend appointment and privileges.
  • Request any and all information needed to resolve all doubt about the applicant’s competence to perform the privileges requested.
  • Place the burden on the applicant to provide enough evidence.
  • Recognize that should the applicant fail to meet their burden, the application is considered incomplete and you will be unable to process it. If the applicant fails to meet his or her burden you should close the communication loop with proper written notification stating that, “the issue of ‘X’ is unresolved. Please provide us with specific evidence of ABC within the next 30 days. If we do not receive this information, we will consider your application incomplete.” Thus no action is taken regarding the applicant’s request for privileges. A report to the National Practitioner Data Bank report is not necessary because the medical staff did not deny membership or privileges. 
  • Actively, not passively, make a recommendation regarding appointment and privileges.

Remember, credentialing has no other master than the patient.

That’s all for this week.

All the best,

Sally J. Pelletier, CPMSM, CPCS

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