Credentialing & Privileging

When the board asks, give it to them

Credentialing Resource Center Connection, June 3, 2005

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Dear credentialing colleague:

When the board of directors at the Enron Corporation asked Andrew Fastow, its chief financial officer, how much money he had made personally from a series of "third party" transactions, he procrastinated. Clearly, the board should have insisted, but it did not until too late.

When deciding what credentials information should go to the board regarding applicants and re-applicants, it is important to note the collapse of Enron and the other examples of ineffective governance that we have seen recently. Yes, these examples are often used to justify greater oversight by the board, however, when it comes to credentialing, it is important that the board have access to all information relative to a recommendation for appointment and/or clinical privileges (with the exception of patient specific information that may be protected by the HIPPA act). After all, it is the board that makes the decision to accept or deny an applicant, and the board that bears the final responsibility for that decision.

The board depends heavily on the recommendations of its credentials and medical executive committees. However, when any recommendation is not unanimous, or when any member of the credentials committee, executive committee, or management suggests the need for specific board examination, the entire credentials file should be made available to the board or its appropriate subcommittee. There never was significant compelling justification for the lack of transparency in the credentialing process, however, in the past, boards often did make determinations without having access to the credentials file. In most circumstances this did not constitute a problem, but problems can arise when information in the file could cause reasonable people to differ concerning the final outcome of an application. It is vital that the board fully understand the rationale employed by the credentials and/or executive committee when justifying past performance that is at variance with the norm.

Implementation suggestion: establish a set of circumstances which will automatically bring a file to the attention of the board. These might include lack of unanimity between the various clinicians at the medical staff leadership level, concerns raised by the CEO or VPMA, or evidence in the file of past disciplinary action, significant malpractice history, or disruptive behavior.

Whenever the board or its appropriate subcommittee meets to discuss a recommended appointment or reappointment, the credentials files or a comprehensive summary of the files should be available either electronically or in hard copy.

That's it for this week.

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



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