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Review your policy on document retention and destruction

Credentialing Resource Center Connection, November 4, 2004

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What happens to your old credentials files, ancient committee meeting minutes, incomplete applications, and letters, long ago inserted into a physician's file, congratulating him on his appointment to the library committee?  How does your hospital store confidential peer review materials that were used in a disciplinary hearing or investigation conducted by the credentials committee? How do you ensure adequate protection of external peer reviews when used to assist in complex clinical situations? Where is your shredder and how is it used? In other words, who determines the "who, what, when, where, and why" of document retention, storage, and destruction, and what is the credentials committee's role in the process?

If your answer to some of these questions is, "I have no idea," it may be time for the credentials committee and the medical services personnel (MSP) to sit down with qualified legal council and review your current practices and policies. These issues are especially important in light of the propensity of plaintiff attorneys, the Justice Department, Office of Inspector General, and other regulatory bodies to inquire about our systems and processes.

Credentials committee members should be comfortable dealing with these issues and be able to ask any question pertaining to the handling of confidential materials. The need for advice from a skilled attorney is nearly self evident when dealing with this subject. It may also prove beneficial to involve your hospital's chief information officer in the discussions due to the impact that HIPAA may have on your decisions and the actual drafting of your policy and procedure.

A very brief and non-scientific survey of 20 MSPs disclosed that only one in five medical staff offices actually have a written policy addressing the complicated issues involved in handling confidential documents.  Only two of those surveyed have a procedure to audit the implementation of their policy and none, in the past 12 months, had provided their credentials committee with an overview of their procedures to secure or destroy old, confidential materials.

That's it for today

Hugh Greeley

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