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Perfecting your background check policy

Credentialing Resource Center Connection, August 2, 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:

It shouldn't be a secret to credentialing specialists, medical staff leaders, and hospital administrators that one of the fastest growing industry standards for credentialing over the past few years is to obtain a background check for initial applicants for membership and privileges. 

In 2001, The Greeley Company published The New Credentialing Standard  - Protecting Patients and HealthCare Organizations as a proposal by Hugh Greeley to raise the bar for credentialing. Increasingly a hospital's desire to protect patients, and public accountability has driven organizations to check on past behavior for those applying for medical staff membership and privileges, as well as for their employed staff.

If your organization has jumped on this band wagon, your policy should define how a "hit" on a background check will be handled. The organized medical staff and administration's decisions during the development of the policy should focus on how an offense could impact patient care, patient safety, and staff safety. Additionally, if you are going to conduct background checks, it is a good practice to do an extensive search to pick up all the information.

At a minimum, the following should be considered:

- Will your organization define a zero tolerance policy within your bylaws that clearly states that if an applicant has a felony conviction, he or she is not eligible for appointment or privileges and your organization will not process his or her application? 

- Have you defined whether or not there are certain barrier crimes that your organization will not tolerate, such as crimes against children or crimes of a sexual nature?

- How will you handle practitioners who do not disclose information or respond in a conflicting manner to a routine question on the application? Do you have a clause in your bylaws or on your release form that says that any misstatement or misrepresentation will be cause for your organization to cease processing the application? If you have that particular clause, what is the culture of your medical staff leadership to adhere to that policy? Will leadership "allow" the practitioner a one time "grace" to correct what must have been an oversight on their part?  (But you might ask yourself, "How many people forget that they had a felony conviction?")

- How comprehensive will the search be? What timeframes will you include in the background check (e.g., since the completion of training, lifetime, or just since adulthood)?

- What venues and/or locations will you require in your background checks?  For example, if a general surgeon from New Hampshire applies to a healthcare organization in Michigan, does it make sense to query Michigan, the state that the physician is moving to, as opposed to New Hampshire, where he or she could be fleeing from a checkered past?

- At what times will you require a background check (e.g., initial appointment, reappointment, upon return from a leave of absence)?

- How will you ensure that the individual's privacy is not violated during the background check?

- Who will receive the information your organization collects during a background check, and under what circumstances? Will it be the entire credentials committee or a subgroup? 

- Will the physician well-being committee need to get involved, e.g. if the background check uncovers a drug-related offense?

Conducting background checks is a best practice to incorporate into your credentialing process. Having a policy that is well thought-out ahead of time will allow the organization and medical staff to more effectively manage potentially troublesome situations in the future. 

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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