To further illustrate the dangers surrounding negligent credentialing, Dr. Sagin proceeded to discuss real-life examples of physicians with criminal or at least questionable histories.  Some were granted privileges to practice despite repeatedly changing locations, so that they could continue their criminal activity – including manslaughter.

The point? “Credentialing exists to protect patients – that is the number one credentialing principle,” he explained. “Credentialing done poorly puts patients, doctors and hospitals at risk.”

He then listed four basic steps to credentialing:

Step 1 – Establish policies and rules (with MEC and governing board)

Step 2 – Collect and summarize information (gather first-hand information through phone calls; should be a doctor-to-doctor phone call, don’t have an office staff member do it)

Step 3 – Evaluate and recommend (the medical staff should put together the file and make a recommendation to the board)

Step 4 – Review, grant, deny or approve

Dr. Sagin then fielded another question from the audience, about how to handle ‘red flags’ that come up during the credentialing process.

“Once you start investigating, those who have real problems tend to melt away when they know you’re on to them,” answered Dr. Sagin. “That’s why I strongly recommend routine interviews.”

Also, in reference to Step 3 in the credentialing process, Dr. Sagin suggested that a simple clinical question be presented to the applicant, just to be sure he or she has basic knowledge.

One practice to avoid, he added, is bringing the applicant to a department meeting for a vote on whether or not to offer a position. “This could give the appearance of competitors conspiring with one another on keeping someone off staff.”

Another audience member had a question for Dr. Sagin, this time regarding the role of the board in the process. “The board is making sure that the process is solid, fair, rigorous and being adhered to,” answered Dr. Sagin.

He also stressed the importance of policies when establishing an excellent credentialing process. “If an issue arises and there is no policy in place for it, stop and create a policy, then apply it,” suggested Dr. Sagin.

Privileging Challenges

Telemedicine and new technology must also be taken into consideration when establishing credentialing guidelines and procedures, noted Dr. Sagin, which can be a challenge, as technology is constantly evolving. Those in attendance received a handout from Dr. Sagin that included a sample policy and procedure that addressed new technology. In it, a step-by-step process is listed “whenever a privileging question arises for which there is no policy or privileging criteria, the credentials committee will follow these steps to coordinate the development of a policy and applicable criteria.” 

The first step involves asking the practitioner to provide detailed information about the device, technology or protocol in question. The second step states that the credentials committee will review the issue and determine if the technology will be permitted within the institution at all. If the answer is “no” then the process ends here. The third step states that the credentialing committee should then develop a research paper concerning the issue, and the fourth step involves the credentials committee submitting the results of its research to subject matter experts for their opinions. The fifth step states that “the task force or specialty shall have approximately 15 days to advise the credentials committee concerning the specific issue” and step number six then includes the credentials committee reviewing the recommendations of the specialty (ties) and/or task force. Next, step number seven states that the proposed rule should then be sent to the medical executive committee for final review and recommendation to the board. “Once approved, the rule will be incorporated in the credentials policy and procedure manual and will, until changed, guide the institution in the processing of any requests for the privilege in question” (step 8).

Another important point Dr. Sagin addressed during his presentation is the Joint Commission’s role in credentialing, such as their terms, their standards for evaluating competence and their suggestion that proctoring be used for performance monitoring.

During the presentation, he defined two key terms from the Joint Commission – OPPE and FPPE. OPPE is the Ongoing Professional Practice Evaluation, which is “the routine monitoring of current competency for current medical staff members while maintaining their privileges at the healthcare organization,” he said. FPPE is the Focused Professional Practice Evaluation (FPPE), which Dr. Sagin explained is “the establishing of current competency for new medical staff members, new privileges and concerns from OPPE.”

He went on to say that if there are concerns from the OPPE, a focused professional practice evaluation will be implemented. He noted that each organization defines the circumstances requiring FPPE, and it may include proctoring prospectively, concurrently or retrospectively. Dr. Sagin then gave examples of proctoring scenarios and the challenges a proctor may face.

He said that, based on a paper from the American Academy of Family Practice, proctoring is defined as:

An objective evaluation of a physician’s clinical competence. In most instances, a proctor acts only as a monitor to evaluate the technical and cognitive skills of another physician. A proctor does not directly participate in patient care, has no physician-patient relationship with the patient being treated, does not receive a fee from the patient, and represents and is responsible to the medical staff.

Clinical Privileging Myths

“Just because you’re good, doesn’t mean you always get a privilege,” Dr. Sagin warned.  “Today, ‘competency’ must mean current competence. It’s not just about pedigree anymore. The competency equation seeks to answer how recently the applicant has performed the various procedures that he or she will be required to perform in this position.”

Dr. Sagin said the crucial competency equation that should always be posed during the credentialing process is: Competency equals “Have you done it recently” plus “When you did it, did you do it well?”

He said that the definition of “recently” can vary from facility to facility: “Last three years? Last year? Last ten years? It’s up to you.”

Other myths he listed include the notion that clinical privileges are “owned” by physicians; clinical privileges are defined, determined and granted by the clinical departments; a physician is entitled to all clinical privileges requested, unless he or she is not sufficiently trained or qualified; exercising privileges is like riding a bicycle and “textbook” criteria are available for delineating privileges.

At the end of the seminar, Dr. Sagin conducted an hour-long Q & A session with the audience, and stayed afterward to speak one-on-one with those who had additional questions.