Credentialing & Privileging

JCAHO calls for positive identification of applicants

Credentialing Resource Center Connection, July 14, 2003

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Dear Credentialing Colleague:

An application is delivered to your desk. A quick review shows nothing out of the ordinary, so credentials verification begins. Letters and electronic inquiries are prepared and sent out via mail and the Internet. The American Medical Association responds promptly with a Physician Masterfile Report, as do all other sources. Miraculously, next week's mail brings completed reference questionnaires--each with glowing comments and notations concerning the applicant's past accomplishments and competence.

You sit back and think to yourself, "This one is a piece of cake." The department chair and credentials committee quickly determine that the applicant is both qualified and competent. Recommendations go to the medical executive committee and then to the governing body. John Smith, MD, is formally appointed to the medical staff and awarded privileges in internal medicine.

But when this physician begins his work at the hospital, disaster strikes. Nurses notice inconsistencies in his orders, other physicians wonder why they're consulted on such simple cases, and radiologists scratch their heads in search of pathology. Shortly, it becomes obvious that John Smith is not a competent doctor. But before action can be taken, he goes missing--along with hospital equipment and drugs.

What happened here? It could have been a case of stolen identity. Various estimates suggest that there are many health care impostors roaming the land from bogus chief executive officers to would-be surgeons.

JCAHO to the rescue! Under its new 2004 Medical Staff standards, positive identification is now required for all applicants (see the Elements of Performance for MS.4.10). Specifically, MS.4.10 says that hospitals' credentialing processes must "include a mechanism to ensure that the individual requesting approval is the same individual identified in the credentialing documents."

To meet this new requirement, you could require physicians to submit a photo with their applications. Copy and send that photo to past practices or training programs, along with a request to verify that the applicant pictured is indeed the person known to the reference. This new standard will require you to tweak your credentialing procedures and perhaps purchase a scanner and digital camera.

As I've pointed out before, credentialing is a moving target. Just when we think we've got it down to a science, we find that our complex society presents us with yet another challenge.

That's all for this week.

All the best,

Hugh Greeley



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