Credentialing & Privileging

Tips for preparing for a survey

Credentialing Resource Center Connection, November 6, 2008

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

Dear credentialing colleague:

Preparing for a survey by an accrediting body can be stressful because the information you need to gather can be unpredictable. There is no guarantee a surveyor won’t ask for something you had not anticipated or prepared for. However, putting together as much information in advance will not only ensure that you have the most recent documents available, but will also ensure that if you are out of the office when a surveyor arrives, your backup support person has the information needed readily available.

Regardless of which accrediting body you use, putting together the basic information in a binder or making it available electronically will help to ensure that the credentialing session runs smoothly. Below is a sample of information to include in your binder:

  • Copy of your bylaws, rules and regulations, and hearing policy. Flag and/or highlight any sections you expect the surveyor to look for, such as the section indicating the bylaws can not be unilaterally amended.
  • Copy of policies and procedures.
  • Copy of your application and supporting documents. Flag and/or highlight key sections such as the area where the applicant discloses any health issues that may impact their ability to perform requested procedures, or the section of the attestation where the applicant pledges to provide continuous care for his or her patients.
  • Copy of your clinical evaluation templates showing that you have incorporated the six general competencies into your evaluation process (this applies to Joint Commission-accredited facilities).
  • Copy of any key forms used (such as focused review forms, ongoing practitioner profiles and review forms, identity verification forms, proctor evaluation forms, etc.).

    Considering that some accrediting bodies have moved to unannounced surveys—and considering you deserve a vacation—you need to ensure that you have a backup staff member fully oriented on which steps to take should a survey occur when you are out of the office or unavailable. Developing speaking points for all key processes and issues will assist your backup during a survey. For example, develop a bulleted list summary of the steps that your organization takes when reviewing a request for a procedure that is not currently offered (such as new technology or equipment procedures). Make a checklist for items to pull to ensure that all elements are in order, for example:

  • Upon notice that a surveyor is on site, notify the members of the credentials committee via the paging system and via e-mail
  • Check the online privilege portal to ensure that there are no access issues
  • When pulling a credentials file for a surveyor, ensure that the quality file is also pulled. Check to ensure that all documents have been filed and that the file is in order for easy navigation
  • Pull regulatory binder and review speaking points

    Ensuring that you are well prepared for a survey not only helps to alleviate stress, it is a reflection on your department. Preparation helps convey to the surveyor that you are well organized and detailed oriented – skills required for all successful MSP’s!

    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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