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Board approval of credentialing and privileging policies

Credentialing Resource Center Connection, July 8, 2004

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Dear credentialing colleagues:

Recently I have received a number of requests for advice concerning board review and approval of medical staff credentialing and privileging policies. The following six recommendations may be of use to your credentials committee and administration:
 
1. Your board (or appropriate subcommittee) must approve the medical staff bylaws and associated credentialing manuals prior to their use. Without board approval, these documents simply constitute medical executive committee (MEC) recommendations and are not authorized for use. It is vital that all such policies -- including criteria for clinical privileges, appointment criteria, investigation procedures, and any other issue that could adversely affect a physician's ability to practice at the hospital -- be constituted as board policy through the review and adoption process. There are many reasons for this recommendation, including state and federal laws and regulations, accreditation requirements, legal protection, and corporate bylaws.

2. The board should review and reapprove all of the above documents at a frequency established by the board. The board should approve the bylaws at least every two years or as needed when changes are recommended. The board should approve any of the various credentialing or privileging policies whenever change is recommended. Upon periodic review, any policies and procedures not subject to change need not go to the board, but should be reauthorized by the chief executive officer (CEO).

3. You should annually archive copies of all documents with their effective dates that are material to the appointment, privileges, reappointment, or disciplinary process. Maintain the documents in a secure location/form.

4. In some facilities, authority for approval of previously mentioned documents is granted by the board to the CEO.

5. Review your state laws and regulations to determine which documents must be approved by the board prior to use.

6.  Hospitals interested in establishing an appropriate policy concerning the above should consult with experienced healthcare attorneys for advice and review.
 

The documents that govern the appointment and privileging process are important and often form the basis for scrutiny of hospital and medical staff practices. Plaintiff attorneys will search diligently for signs indicating that the board may have acted negligently by letting the medical staff assume responsibility for credentialing policies or decisions.
 
That's it for today.

All the best,
Hugh Greeley
www.greeley.com/seminars

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