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Audit your credentialing program

Credentialing Resource Center Connection, January 20, 2005

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Dear credentialing colleague:

Each year your hospital's board of directors commissions a complete audit of the hospital's financial position and the procedures used to account for all funds.  This audit is conducted in order to assure the board that all is well, avoid litigation, survive federal probes, and to identify needed improvements in the financial management program.

Often, the board will request this audit in spite of the fact that your hospital has excellent internal audit procedures and a very capable staff, dedicated to excellent financial performance.  Such audits are expected by bond holders, state and federal agencies, and many other external entities.

A hospital's credentialing program is no less important than its financial position, and should be subject to periodic audits for many of the same reasons.  Some readers may assume that the Joint Commission on Accreditation of Hospital Organizations (JCAHO) conducts full audits of hospital credentialing programs.  This, however, is not the case. In its surveys, the JCAHO simply assures that its standards have been met, and does not purport to certify the adequacy or effectiveness of the program itself.  To maintain a high quality and effective program, a full audit of the credentialing system should be carried out in much the same manner as the financial audit.  Medical staff should review all policies and procedures of the credentialing program, including an evaluation of all personnel job descriptions and skills, and a random sample evaluation of credential files to ensure that all required materials are present.  Evidentiary reports should also be developed demonstrating that the program is contributing effectively to the achievement of its three primary goals:

* Patient Protection

* Physician practice facilitation

* Institutional Protection

Remember, the financial position of the hospital is no more or less important than these three crucial goals.

That's it for this week.

All the best,

Hugh Greeley

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