Credentialing & Privileging

Use root-cause analysis to improve credentialing

Credentialing Resource Center Insider, January 20, 2003

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Dear Credentialing Colleague:

Many industries recognize the value of conducting root-cause analyses (RCAs) when a major failure is identified. RCAs are conducted in the nuclear power industry, the commercial airline industry, the United States military, health care organizations, and many more.

Credentials committees might benefit significantly from conducting a careful RCA whenever a failure or near miss is identified in the credentialing process. The following "sentinel events" are worthy of an RCA:

  1. Any fair hearing, termination, or denial of medical staff appointment or clinical privileges
  2. A corporate negligence suit alleging improper or inadequate credentialing
  3. A nasty privileging turf battle
  4. Any time it takes more than 100 days to process a medical staff application/reapplication
Each of the above scenarios might be considered a sentinel event, thus prompting the formation of an RCA team composed of individuals familiar with such analyses. It's not necessary for all members of the team to be thoroughly experienced in the art of "credentialing;" it's perhaps better to have others at the table willing and able to constantly ask "Why?" for the fifth time when attempting to determine the actual root cause of a breakdown or near miss.

If you would like to download a copy of an RCA checklist to use as a template for analyzing credentialing failures, please click here. Then click on the first bulleted item.

That's all for this week.

All the best,

Hugh Greeley
www.greeley.com/seminars/



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