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Consider a 'credentials file review' policy

Credentialing Resource Center Connection, May 22, 2003

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Dear credentialing colleague:

At a hospital I once visited, medical staff members grew increasingly suspicious about the contents of credentials files because one physician circulated a rumor that they were actually maintained by administration to use against physicians.

The issue became so serious that it was even discussed at a medical executive committee (MEC) meeting. The chief executive officer, baffled by the situation, suggested that the MEC might be able to reverse the suspicion if it announced that any physician could make an appointment with the medical staff services professional (MSSP) to review the contents of his or her file.

After some discussion and a quick consultation with legal counsel, a policy was drafted that authorized the review of credentials files by individual physicians under the watchful eye of the MSSP and after the removal of confidential reference letters from the initial application stage. It also indicated that a physician could not actually view any incident reports that might be present, but the department chair or chief of staff could read them to the physician without identifiers.

While some physicians grumbled over not being able to review actual incident reports, the policy was approved and communicated to all medical staff members. Almost immediately, three or four physicians asked to review their files. These reviews took place without serious incident, and the chief of staff reported at the next general staff meeting that he sincerely hopes making credentials files accessible would bolster trust between the medical staff and management.

It turns out that the desired result was attained, and the "suspicious physician" had to look elsewhere for signs of conspiracy. You might take a moment at the next credentials committee meeting to determine how your medical staff office would respond to a physician who requests access to his or her credentials file. In most instances, you can take a lead from human resources. All employees are generally free to review the contents of their personnel files. They are not permitted to remove any information, but they may add personal notations if they so choose. And they may review the file only while under supervision.

That's all for this week.

All the best,

Hugh Greeley

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