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Develop a year end report on credentialing activities

Credentialing Resource Center Connection, October 7, 2004

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Dear credentialing colleague:
 
Now that autumn has arrived-- a time of year when there are typically slightly diminished numbers of new applicants and the medical staff begins to focus on the expectation of new faces at the table next year -- your credentials committee (CC) might begin to develop your annual report.

If you have never completed such a report, now is the time to begin the tradition. The medical executive committee (MEC) and the board would be interested in a concise report that summarizes the CC's activities during the past 12 months. The report may also suggest changes in the way the CC conducts its own business.

You should consider including the following in your report:

A. A narrative by the CC chair expressing his or her appreciation for the trust and support of the MEC and board. This introduction might also express in narrative format what is shown in the graphs and tables that follow.

B. Numerical data indicating the interest of new physicians to join the medical staff, the number converted to formal applications, the number of applications that were not fully processed for some reason (withdrawn, rendered incomplete due to failure of the applicant to provide requested data, etc.)

C. Data that shows the time between application submission and completion of data gathering and primary source verification. Also, the time needed for review by the department chair, CC, MEC, and final approval by the board. (Don't forget to indicate the total time from indication of interest and receipt of an application and initial appointment.)

D. Information regarding the number of applications denied or rejected (this number should be close to zero), number of fair hearings, and number of physician-generated suits alleging anticompetitive behavior.

E. Identifiable turf battles and their disposition, along with the time needed to discuss and adjudicate them.

F. Credentialing standards violations identified by state, federal, or private survey agencies (such as the JCAHO or HFAP).

G. Similar data demonstrating the effectiveness of the reappointment process.
 
You could easily develop a terrific report that contains valuable data for planning, legal, regulatory, or strategic use. Such a report will also serve as a baseline for future CCs at your institution.
 
That's it for this week.

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

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