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Conflicts among governing documents

Credentialing Resource Center Connection, July 23, 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:

By the calendar, summer has arrived in New Hampshire. We’ve had some beautiful sunny and hot days intermingled with dreary, stormy, and humid days full of rain. Summer is also a very busy time in many healthcare organizations driven by an increase in new applicants and often a decrease in staff due to vacations. However, there is no time like the present to review your medical staff bylaws, medical staff rules and regulations, delineation of privilege forms, and departmental rules and regulations to make sure they are not in conflict about defining qualifications for privileges.

Quite often as I review governance documents from healthcare organizations across the country, I find conflicts within their documents related to eligibility requirements or criteria for privileges. These inconsistencies are typically within the areas of education and board certification requirements but may manifest themselves in other areas as well. The following are examples:

• The medical staff bylaws require completion of an ACGME or AOA-accredited post graduate training program. In contrast, the department of radiology has defined that post graduate training may be completed at an ACGME, AOA, or The Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited program.
• The medical staff bylaws require board certification within a practitioner’s primary area of specialty within five years of completion of post graduate training. In contrast, the department of medicine delineation of privilege form states that board certification or board “eligibility” is required, but says nothing about the requirement to obtain board certification within a defined time period.

An MSP’s role in helping an organization develop these governing documents reminds me of the game many of us as children played called “red light, green light.” If you’re not familiar with the game, let me explain it. The premise is that one person plays the “stop light” or “red light” and the rest try to touch him or her. The players would form a line and move toward the red light facing the other way. At a given point the “red light” would turn around and yell “red light” – catching any of the green lights in motion and making them “out” of the game. Play continues in this fashion until all the players are out or a player touches the red light and wins.

If you are an MSP, or a member of the credentials committee it is your role to be the “red light” for your organization. As criteria for privileges is developed and recommended by departments or clinical services lines, it is your job to yell “red light” if you see clear discrepancies or inconsistencies with standards established within your medical staff bylaws. Give the green light to move the recommendations forward when you know that there are no areas of contradiction or conflict with existing documents.

Remember, credentialing has no other master than the patient.

That’s all for this week.

All the best,

Sally J. Pelletier, CPMSM, CPCS
http://www.greeley.com/consulting.cfm

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