Medical Staff

Board oversight of credentialing and quality

Medical Staff Leader Insider, August 11, 2011

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How does a hospital’s board oversee the medical staff’s credentialing and quality processes?  It’s difficult, especially because many board members are community leaders, such as bankers, lawyers, businessmen, religious leaders, and do not have medical backgrounds. Yes, they rely on the medical staff to bring them pertinent information that assists them in making good decisions, but the board also provides oversight by ensuring that the medical staff operates within its policies and procedures.

Although federal and state laws and regulatory agencies state the board is ultimately responsible within the hospital, the board delegates hospital affairs to administration and the monitoring of practitioner quality to the medical staff.  The medical staff performs this function by conducting appropriate credentialing and privileging and peer review. This all occurs within the purview of the bylaws and rules and regulations approved by the medical staff and the board, which the board expects to be comprehensive and compliant with all regulatory requirements.

To ensure that the bylaws, policies, and procedures are compliant, some boards regularly review significant process. The board may conduct an annual internal audit of credentialing and peer review to ensure that the medical staff is following the approved processes for these functions. Audits give the board reassurance that the credentialing, privileging, and peer review decisions being made are sound.
On a less frequent basis (every 3-5 years), the board may consider requesting that an external expert in the field assesses significant medical staff processes. These audits should answer the following three questions:

  • Are the processes within regulatory compliance?
  • Is the medical staff following approved processes?
  • Are there any best practices in the field that the medical staff should consider adopting?

This allows the medical staff and board to keep abreast of useful information and tools that they can consider incorporating into their existing processes.

Mary J. Hoppa, MD, MBA, CMSL, is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Danvers, MA.

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