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Mutual accountability of credentialing

Credentialing Resource Center Connection, December 20, 2006

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I recently conducted a credentialing audit at a large healthcare system.  This organization has had many credentialing problems over the years and recently decided to have regular credentialing audits in an effort to always be prepared for unannounced surveys. They just spent months taking the necessary steps to prepare for a Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey, since they know they won't have that luxury next time. And I applaud this organization for taking a step that will help them focus on what they need to do to improve.

I believe that the medical staff leaders thought that a credentialing audit would show that their credentialing problems were the result of either lack of personnel in the medical staff office, or that the personnel involved in credentialing does not always perform verifications correctly. And, honestly, that was sometimes an issue.  However, to the medical staff leadership's surprise, the audit pointed out that the bulk of credentialing problems resulted from medical staff leaders (mostly department chairs and the credentials committee) not doing their jobs well.

Many years ago, I was the accreditation coordinator/medical staff professional (MSP)/quality assurance coordinator at a hospital.  We were working hard to prepare for a JCAHO survey.  My boss, the CEO, said to me one day, "Vicki, I know that we are going to do well on our survey, because you have worked so hard." 

I immediately knew that my boss was wrong and that no single person can bear the weight of preparing for a survey.  I had taken too much ownership and had somehow conveyed to my organization that through my Herculean efforts, our hospital was going to pass the survey. We did, but not because of what I did or didn't do-oh, okay, I'll take a little credit!

This story reminds me of the credentialing process itself. There are many individuals involved in designing, implementing, and sustaining an excellent credentialing program.  All individuals must know their role or roles and perform these consistently. That means that the MSPs, department chairs/section chiefs, credentials committee, CEO, medical executive committee and board must also know what they are supposed to do, when they are supposed to do it, and then do so consistently, thoughtfully and, carefully.  If everyone doesn't do their job well, the process will fail.

The recent credentialing audit I discussed earlier uncovered some problems in the way the medical staff office was managing applications and performing verifications.  They missed a few verifications, and missed a few reapplication dates (yes, a few reappointments went over two years).  However, the biggest problem identified by the survey was that department chairs didn't review pertinent information in the credentials files.  I saw privileging criteria that had not been met (and no one noticed it), some peer references which acted as "red flags" were seemingly ignored, among other issues.  It looked like department chairs were doing what department chairs should never do: Simply asking "where do I sign" and assuming that everything in the file was okay.

Excellent credentialing depends on everyone who is involved.  We all must do our best work every single time, on every initial appointment and every reappointment.  We have to imagine that the practitioner we are credentialing today might be in the emergency room tomorrow or on call to perform surgery the next time someone we care about needs help.

Remember - credentialing has no other master than the patient.

Thanks for reading.  Sally will be back next week.

Guest columnist

Vicki L. Searcy, practice director, credentialing & privileging

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