Credentialing & Privileging

Credentialing for Graduate Medical Education

Credentialing Resource Center Connection, October 11, 2007

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Anne Roberts, CPMSM, CPCS, is the director of medical affairs at Children's Medical Center in Dallas, where she oversees the medical administration, graduate medical education, and medical staff services department.

Dear credentialing colleague:

As I undertook the development of a graduate medical education (GME) department over the last few years, I found that there were very few hospitals that had hospital-based GME departments, as most of the work related to GME was done through medical schools. The Accreditation Council for Graduate Medical Education (ACGME) standards establish strict guidelines for those medical schools, generally listed as sponsoring institutions. A sponsoring institution is responsible for ensuring that the programs meet regulatory requirements but the ACGME standards are not prescriptive regarding how institutions perform credentialing.
       As a credentialing and privileging specialist, my first instinct was to ask, "How do these sponsoring institutions credential their residents? (For the purposes of this article, "residents" refers to all medical students, interns, residents, and fellows.)  How do they get their ticket to be here? How does the hospital ensure that the medical school has done its due diligence to ensure that the trainees who are in our institution have the appropriate credentials?" The answers were not what I had expected, so we decided to create our own hospital-based GME department.
        Our first step was to identify who was coming through our doors. We had rotators from our main affiliated medical school, we had house staff residents who trained primarily at our facility, and we had external rotators that were coming in from other institutions. Once we were able to get our arms around who was training in our facility, we wanted to ensure that we had up-to-date affiliation agreements with each resident's institution. The affiliation agreement covers all of the legal issues associated with resident credentialing, and if the resident came from other institutions we also required his or her institution to provide documentation upon request that he or she had completed drug screening and background screening prior to his or her arrival at our facility.
        Because this practice was not common for most training programs, we had to revise many of our affiliation agreements, and we did get some pushback. But we refused to budge-we are a pediatric medical center, and our first priority is quality and patient safety. In the end, no institution could argue with our new requirements.
        Next we incorporated the residents into our credentialing process using the same database that our medical staff office uses. We are now able to:

  • Conduct primary source verification of medical students' training permits or licenses
  • Verify graduation from medical school
  • Query the Office of Inspector General (OIG)
  • Obtain documentation of immunizations
  • Develop a comprehensive orientation program that students complete online prior to their arrival
  • Hold an in-house orientation for all house staff residents or fellows, in addition to an annual online refresher course
           
            We also asked each program director to develop supervision grids for each program (house staff and rotators). These supervision grids included a list of procedures that all residents or fellows, by program year, could perform while participating in training, and under what level of supervision. We require each resident to review his or her supervision grid at the beginning of each academic year, and sign an attestation indicating that he or she understands what procedures he or she can perform and the supervision requirements for each. For outside rotators, the resident and the program director from the outside rotation must sign an attestation indicating that their resident can indeed perform the listed procedures under the established level of supervision before they can begin a rotation. Below is an example of supervision levels:
  • Level 1: The individual can perform the procedure only under direct supervision
  • Level 2: The individual can perform the procedure under indirect supervision (i.e., under the specific written descriptions of lines of responsibility for the care of patients on each type of teaching service)
  • Level 3: The individual can perform the procedure under indirect supervision and can supervise others performing the procedure

     We then identified the need for policies and procedures that were a hospital-specific supplement to the medical school's policies. These were developed, approved by the GME committee, medical executive committee, and the governing board. Our next project for GME is to develop a support team that will assist the program directors with any accreditation needs (preparing for ACGME internal reviews or site visits, or complying with the standards such as duty hour tracking).
     As The Joint Commission has increased its standard requirements related to GME programs, we have found that implementing credentialing and privileging into our GME department has been essential. We successfully completed an unannounced survey last week and The Joint Commission surveyor specifically asked to look at several resident's credentials files, and wanted to see how we informed our staff of what procedures the residents were allowed to do and under what level of supervision. As all staff in the hospital have the ability to view privileges for all residents, fellows, allied health professionals, and members of the medical staff online, this was easy for us to explain to our surveyor. 
      Credentialing and privileging of residents and fellows is on the list of things that Joint Commission surveyors are asking to see. The hospital is responsible for everyone who is in their facility, so it is no longer an option to expect that the medical school has everything covered.

Remember, clear, effective communication is the key to success!

That's all for this week.

All the best,

Anne Roberts, CPMSM, CPCS



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