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Developing a policy for professional reference questionnaires

Credentialing Resource Center Connection, June 14, 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:

Nearly all hospitals use professional reference questionnaires as part of their credentialing process. The questionnaires help capture information from an applicant's or re-applicant's peers related to his or her competence to perform the privileges requested, professionalism, ethical behavior, medical knowledge, clinical skills and judgment, communication, interpersonal skills, and so on. However, few organizations have a policy that correlates to the questionnaire and addresses "the five W's" (and one H):

-          What:

o       Type of information does the organization require from the reference (as delineated in the professional reference questionnaire)?

o       Is the number of references the organization requires the applicant to collect?

-          Who:

o       Does the organization consider an appropriate reference (1)?

o       Will follow up on insufficient and/or incomplete information?

o       Will conduct a telephone reference (e.g., the department chair, a credentials committee member)?

-          Why :

o       Is it important to collect peer references (i.e., a purpose statement)?

-          When:

o       Will the organization obtain references from the applicant (e.g. at initial appointment, at reappointment [as needed], or when a practitioner makes a request for new privileges)?

o       Does the organization require follow up by either an MSP or a medical staff leader (based on incomplete information and/or a "red flag")?

o       Should the organization make a follow-up request to the reference (time interval) and notify the applicant that the reference has not responded?

o       Would the organization deem the application incomplete if it does not receive the requested information?

-          Where:

o       Does the organization file the completed references (e.g., is it done electronically, or are hard copies maintained in credentials file)?

o       Does the organization place the burden for the return of the reference's data (e.g., if the reference is not returned, is the burden placed on the applicant)?

-          How

o       Will the organization communicate the reference request,,(e.g., fax, email, or other method)?

o       Will the organization obtain references for low- or no-volume providers?

o       Will the organization handle non-responses?

(1) Note: Peer references are required and a peer is defined as an individual within the same professional discipline (e.g., MD/ DO to MD/DO, certified nurse midwife to certified nurse midwife). The hospital's policy may further define what it requires with regard to references. For example, for a radiologist the hospital may decide that, in addition to obtaining references from another radiologist, they want to collect a reference from an orthopedist or an emergency medicine physician; for an orthopedist, in addition to another orthopedist, the institution may want references from the applicant's OR clinical director or the anesthesiologist.

It is important to ensure that a peer is specifically providing information about medical knowledge, technical and clinical skills, and clinical judgment. An individual such as the OR clinical director could comment on the "soft" skill components (e.g., such as professionalism, ethical behavior, communication, and/or interpersonal skills.

At The Greeley Company, we are always promoting "the Five P's" - Our policy is to follow our policy. In the absence of a policy, our policy is to create a policy. If you do not have a policy at your facility related to professional references, now is the time to consider creating one.

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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