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Checking applications during reappointment

Credentialing & Verification Update, April 25, 2007

Requiring applicants to complete applications for reappointment is a crucial step in satisfying the hospital's legal burden to ensure practitioner competence. Though the reappointment process is similar to the process for initial appointment in that each requires gathering and verifying credentials information, the reappointment process generally looks at the practitioner's capability based on his or her clinical performance, insurance history, and ability to work with hospital colleagues.

The checklist that follows contains some-but not all-matters that hospitals are typically expected to inquire about during reappointment.

• Patterns of care and membership status at all hospitals where the practitioner holds medical staff privileges
• Proper completion of medical records
• On-call duty response rate
• Continuing medical education
• Complete medical staff rounds
• Compliance with medical staff bylaws and hospital policies, rules, regulations, and procedures
• Number of procedures performed, circumstances surrounding those procedures, and their outcomes
• The practitioner's interpersonal relationships with other staff members, especially with nurses and support staff
• Malpractice insurance and claims history
• Drug utilization reports from the hospital pharmacy and the medical records department
• Patient/staff complaints and risk management reports
• NPDB information
• Information from the Office of Inspector General's list of excluded individuals and entities
• Licensure status
• Health status

In the next issue of CVU: three key steps to verification during reappointment.

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