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Q&A: Should physicians' quality data be kept in the credentials file?

Credentialing & Verification Update, September 12, 2007

A: It has been the practice to separate credentials files and quality documents, for two primary reasons.

One is the rationale that this will provide another layer of protection from discovery if a plaintiff should request a copy of the credentials file. In my experience doing expert witness reviews, separating the documents does not help in this regard. Plaintiffs' attorneys know what to ask for and, in many cases, the courts allow them to have it. I have seen three cases this year from three different states where the plaintiff asked for and received the entire credentials file and associated peer review materials.

Another factor to consider is whether the data is peer review information or performance improvement data. They are not the same thing. Peer review is the evaluation or review of the performance, actions, and medical care rendered by a practitioner by professionals with similar types and degrees of clinical expertise to determine whether accepted standards of care have been met. Data such as numbers of admissions/consults/surgeries, medical record completion stats, and meeting attendance typically are not considered peer review.

The bottom line is that it's not where you store the papers, but what the laws and the courts in that state say about the confidentiality and discovery of peer review materials, especially as they relate to negligent credentialing issues. Some states have a description of peer review that covers credentialing, but others do not.

The other primary rationale for separating the peer review materials is that some people who have access to the credentials file don't necessarily need access to peer review materials. For instance, in some organizations, the MSO performs only credentialing and privileging, and another department (e.g., QI) conducts the peer review. During an accreditation survey, the organization may not want to give the surveyor access to peer review materials when he or she is surveying for compliance with credentialing standards. At one hospital where I previously worked, the medical staff chose to allow the provider access to his or her own credentials file, so the peer review materials were kept in a separate file.

Both of these issues need to be taken into account when determining a policy for access to files.

Editor's note: Kathy Matzka, CPMSM, CPCS--a Lebanon, IL-based speaker, consultant, and writer with over 20 years of experience in medical and professional staff services--fielded this reader question.

Questions and topic suggestions can be e-mailed to CVU at mcoler@hcpro.com. We'll find an expert or resource to tackle the credentialing or verification issues that are challenging you.

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