New Medical Staff Models & Credentialing Challenges

Accreditation Monthly, July 22, 2008

Dear Greeley Medical Staff Institute Member:


You are processing an application for a candidate new to your medical staff. As part of the application, the candidate lists being a member of the ABC Medical Center medical staff. You write to the ABC medical staff office (MSO) for a reference and get a "good standing" letter. What the candidate didn't tell you is he was let go from the group holding the exclusive contract at ABC for hospitalist services because of suspected impairment and patterns of disruptive behavior. Since the contract was handled outside the ABC MSO, it had no knowledge of what occurred and why he was terminated because the problem did not go through the process outlined in the medical staff bylaws for investigation or due process. What to do?

In the May column, Rick Sheff addressed the question "Is the old medical staff model dead?" In August, our coauthored new book, The Greeley Guide to New Medical Staff Models: Contemporary Solutions for Today's Physician-Hospital Relationship Challenges, will be released. Through our consulting and research, at least 17 medical staff models were identified. Traditionally, independent physicians made up the majority of medical staff members in most community-based hospitals. More and more, however, hospitals are utilizing employment agreements and exclusive contracts with physicians. In fact, such models are increasing exponentially in some organizations.

These employment and exclusive contract agreements often have "termination with cause" clauses, but just as many have provisions for termination without cause requiring only notification within a specified number of days. Normally, what you see in these agreements with the individual physicians is that if the group or the individual is terminated, they automatically waive their right to a fair hearing and due process under the medical staff bylaws. Hospital privileges are often tied to the agreement and are forfeited if the agreement is terminated. What happens if an employed or exclusive contract physician shows evidence or is suspected of having a problem? One scenario is that should a physician prove to be incompetent, disruptive, or impaired, the agreement is terminated and thus the administrative burden of dealing with this issue through a lengthy and costly medical staff can be obviated. Such problems will never be the subject of the medical staff process for investigation, fair hearing, or appeal as required in the medical staff bylaws. Further, impaired physicians may never receive the evaluation and referral for help to a physician health program as required by The Joint Commission's standard MS.4.80.

Given these changes, the challenge for medical staff professionals and medical staff credentials committees is getting the information needed to make the best possible decision about a candidate new to the staff. Consider the following ten practices as strategies to meet this challenge:
  1. Always remember that credentialing has no master other than the patient.
  2. The burden is on the applicant to provide all the information you deem necessary. Do not process an application until you have all the information you need. No exceptions.
  3. Do not make:
    1. Information errors: Undiscovered information existed that could have been known and would have affected a credentialing decision (practices four through ten address this concern)
    2. Decision errors: The necessary information was known, but leaders made the wrong decision
  4. Use all sources to obtain the information you need. Pick up the phone, do a Google search, and expand your field of inquiry as outlined in practice five below. Remember, verbally releasing or obtaining information still requires that you receive written information in a timely manner as backup documentation for the credentialing file.
  5. An emerging best practice is to identify not only where the physician held privileges but who employed them — hospital, exclusive contract group, or another group practice. In many hospitals, physician employment and contract issues do not reside in the MSO; indeed, the MSO might be the last to know that the physician was terminated, particularly if the medical staff due process for investigation, fair hearing, and appeal was never activated. The burden on the applicant is to provide the information as to who in the organization can specifically address any issues that occurred under the employment or contracted agreement. Don't act on the application without it.
  6. Have the applicant sign an "absolute" release waiver that helps diminish the chance of a defamation lawsuit.
  7. Ask and answer specific questions. The principle here is there should be a specific question in writing and then an answer to that specific question.
  8. Allow responding hospitals or individuals serving as references to answer all questions on the reference form with "yes," "no," or "prefer not to comment." If the latter is checked, go back to practice seven and ask the specific questions that require an answer.
  9. Consider neutral letters as red flags. Suppose you are credentialing a new applicant to your medical staff who indicated previous affiliation with Community Hospital. In response to a request for information, you get a letter that the physician was on staff from such and such date to such and such date, the so-called "name-rank-serial number" letter. In the May Kadlec reversal, the federal court upheld a Louisiana hospital's action of providing a neutral letter that was factually correct but incomplete. Although this ruling is still on appeal and only applies to Louisiana, the question becomes: Is this just a hospital's standard operating procedure to send a form letter or does this now become a potential red flag that damaging information is being withheld? Once again, the burden on the applicant is to provide independent verification of information indicating the presence or absence of a problem.
  10. Expand your list of potential red flags and have a low threshold for red flags to be investigated. Consider the following:
    • Resignation as partner from a group
    • Ending an employment arrangement with a healthcare facility
    • Any gaps in CV, particularly with employment or medical staff membership
    • Moved significant distances or has moved a lot during his or her professional career
    • Change of specialties
    • Requesting fewer privileges than normally granted under a core privileging system
    • Gaps in insurance coverage, change in carriers, or reduction in coverage
    • Professional liability history
    • Reference letters are neutral
    • Category ratings are "poor," "fair," or "average"
    • Responses from hospitals and/or employers simply give dates of service or very limited information (as in Kadlec, it was factually correct but still misleading and incomplete)
Now more than ever, strong medical and healthcare leadership is required to do the right thing, ensure patient safety, and help physicians be the best they can be. The Greeley Company Medical Staff Institute is your partner in helping to ensure physician success, hospital success, and quality care for your community.

If you have any questions about the Greeley Medical Staff Institute or your membership benefits, please contact Debbie Barreira, Client Relations Manager, at or 888/749-3054 Ext. 3126.

Until next time, be the best you can be.
William K. Cors, MD, MMM, FACPE, CMSL
Vice President of Medical Staff Services
Senior Consultant
The Greeley Company


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