Credentialing & Privileging

Acting on negative peer or clinical evaluations

Credentialing Resource Center Connection, December 3, 2009

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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, continuing medical education, research administration, and medical staff services departments.

Dear credentialing colleague:

I recently received the following question: What happens when a department chief and credentials committee disagree on whether or not to grant privileges to an applicant with a negative peer reference or clinical evaluation? Before I was able to answer the question, I needed to gather a bit more information regarding the situation.

At one time or another during the credentialing process, an MSP may process a file in which a peer reference or a clinical evaluation submitted on behalf of the applicant is negative or has unacceptable performance noted as a part of the evaluation. When this situation occurs, there are several elements that one must consider. The applicable department chief should be made aware of negative evaluations and review them to determine if the remarks are related to interpersonal relationships, professionalism or quality of patient care. Often times it is best that the chief contact the evaluator who submitted the negative response. This ensures that the chief receives all of the answers and information needed to make an informed decision prior to granting membership and/or clinical privileges.

Additionally, the chief should, conduct a thorough review of all other information contained in the credentialing file, as he or she does for every applicant. The chief should look for any other negative information, trends, or red flags pertaining to the applicant and determine whether any additional information is needed either from the applicant or other sources.

To further explore the red flags raised, the chief may consider meeting with the applicant to discuss the concern. The negative evaluation should not be shown to the applicant; however, its content can be discussed. Remember, it is best practice for the requesting hospital to have a release signed by the  applicant stating that the evaluator will not be held liable for damages so long as he or she is providing information in good faith and without malice.

Once the chief deems there is sufficient information to make an informed recommendation, the chief should clearly document how he or she reached the final decision based on the information available. Typically, it is best to ask the chief to write a detailed letter to the credentials committee for inclusion in the file. The credentials committee can then review the recommendation from the chief and proceed with their review – all pertinent information regarding the evaluation should be provided to the credentials committee.

If the chief’s recommends not to grant membership and clinical privileges to the applicant, the next step is to refer to your policies. What do your medical staff bylaws or associated documents indicate should occur if the chief recommends that the applicant be denied membership and privileges?

Typically, the recommendation and supporting documentation is forwarded to the credentials committee, which can accept the recommendation, send the file back to the chief and medical staff services for further information and clarification, or they can disagree with the chief and make their own recommendation to the medical executive committee (MEC).

When the chief and the credentials committee disagree, as I have seen happen, you should always ensure that you are following the steps outlined in your bylaws or associated documents. Recently, I reviewed a situation where the credentials committee at a hospital disagreed with the negative recommendation from the chief as they felt that the chief was basing his/her decision on a negative recommendation from a prior business associate of the applicant. There were no other red flags noted in the file, all other clinical evaluations submitted on behalf of the applicant were satisfactory and the applicant otherwise met all criteria for membership and the requested clinical privileges. The committee gathered additional information, requested a specific focused professional practice evaluation to monitor the concerns expressed by the business partner and submitted their recommendation to the MEC to consider.

Disagreements between chiefs and committees can and do occur, however, as always remember The Greeley Company's five P’s:

It is our Policy to follow our Policy. In the absence of a Policy, it is our Policy to create a Policy.

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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