Credentialing & Privileging

The reluctant department chair

Credentialing Resource Center Connection, September 23, 2004

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Dear credentialing colleague:

What's a credentials committee to do when a department chair simply refuses to make a recommendation on an applicant?
 
Here are the facts: Dr. Smith has been a department chair for nearly two years and has another year to go before reelection. Dr. Smith is part of a single specialty general surgical group and will not make an appointment recommendation for a physician joining the "other group" in town. 
 
The file seems to be a "no brainer" except for a few special procedure requests. The candidate submitted an application almost four months ago. When Dr. Smith is asked to complete the recommendation his response has been, "I'll try to get to it later this week but my surgical schedule is killing me."
 
The credentials committee chair has personally spoken to Dr. Smith and speculates that he will never complete this application review.
 
The medical staff bylaws state that "the file, with all supporting information, will be forwarded to the credentials committee only after review and recommendation by the applicable department chair."
 
This situation is easy to solve. The credentials comittee should immediately review the file, despite the bylaws' stipulation. Minutes should indicate that the credentials committee evaluated the file after providing the applicable department chair with multiple opportunities to formulate a recommendation. The credentials committee's recommendation should then be forward for immediate review by the medical executive committee (MEC) with or without the reluctant chair's recommendation. 
 
A recommendation should then be forwarded directly to the board for final action.
 
To avoid confusion in the future, the MEC should propose an amendment to the bylaws permitting the credentials committee to review applications when a department chairperson has not acted within a reasonable period of time. 
 
And the reluctant department chair should not be reelected.

That's it for this week.

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



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