In our last issue of Risk Review, we examined the process and rationale for verification of professional liability insurance and licenses – two critical components of credentialing.
Understanding and awareness of credentialing issues are vital not only to a facility and its Medical Staff Office (MSO), but to every physician anticipating an application for or renewal of privileges. Each physician applicant will appreciate the goals of the MSO to be objective and fair by consistently applying Medical Staff and Governing Body endorsed credentialing procedures for that facility.
In this issue, we review the steps necessary to securing and maintaining Professional References and performing consistent, meticulous Privileging. While the JCAHO Medical Staff standards provide guidelines with regard to competency and privileges, it seeks to further refine requirements related to these activities in the near future. The focus of these changes - slated to be effective in 2007 – intensify the spotlight on objectivity and evidence-based decision-making:
The credentialing and privileging process involves a series of activities designed to collect, verify, and evaluate data relevant to a practitioner’s professional performance. These activities serve as the foundation for objective, evidence-based decisions regarding appointment to membership on the medical staff, and recommendations to grant or deny initial and renewed privileges. In the course of the credentialing and privileging process, an overview of each applicant’s licensure, education, training, current competence, and physical ability to discharge patient care responsibilities is established.
References:
The “Credentialing, Privileging and Appointment,” section of the Medical Staff standards proposes new language providing uniformity and specificity regarding the kinds of information that should be included in the reference:
A 6. Peer recommendation includes written information regarding the practitioner’s current:
• Medical/Clinical knowledge
• Technical and clinical skills
• Clinical judgment
• Interpersonal skills
• Communication skills
• Professionalism
If your facility does not already do so, develop and use a standardized form for all references to complete. Don’t leave it up to the person providing the reference to decide what s/he will say about the applicant to your Medical Staff. You are looking for a timely response from the reference, so make it as easy for him/her as possible to be both objective and specific. Include a stamped, return envelope both as a courtesy and to expedite the return of the referral.
Joint Commission on Accreditation of Healthcare Organizations Hospital – 2007 Medical Staff Standards (Pre-Publication Copy)
Credentialing, page 2 