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Documentation of continuing medical education

Credentialing Resource Center Connection, May 17, 2007

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Sally J. Pelletier, CPMSM, CPCS, is a consultant with The Greeley Company, a division of HCPro, Inc., specializing in the areas of credentialing and privileging.

Dear credentialing colleague:

Quite frequently medical service professionals and medical staff leadership question what documentation is appropriate to maintain in the credentials file related to evidence of a practitioner's attendance in continuing medical education (CME) programs.

The Joint Commission standard MS.5.10 requires that all licensed independent practitioners and other practitioners who are privileged through the medical staff process participate in continuing education. An individual's participation in continuing education must be documented and considered in decisions related to renewal or revision of individual clinical privileges. There is a need to evaluate CME at the time of initial appointment and reappointment, or when processing a request for new privileges for relevance related to the education, training, current competence and clinical skills of an applicant related to the clinical privileges he/she has requested.

Hospitals may document proof of attendance in a variety of ways, including the following:

• An attestation statement by the practitioner wherein he or she attests to participation in a CME program with proof of attendance available upon request
• Obtaining a copy of all the program certificates that the practitioner has attended within a specified timeframe
• Obtaining a copy of the log/information submitted with a license renewal when CMEs are required by the practitioner's state licensing body

In addition, your hospital may have established criteria related to certain special or non core privileges that require ongoing specific CME to maintain the privilege. This information should also be tracked and documented if it is a requirement.

If a practitioner has recently completed a residency or fellowship training program, the requirement for CME may be waived per your hospital's policies.

Remember, credentialing has no other master than the patient.

That's all for this week.

All the best,

Sally J. Pelletier, CPMSM, CPCS

http://www.greeley.com/consulting.cfm

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