Risk Management: Credentialing
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What about faxing references? Understandably, there are instances when faxing a reference may be helpful in moving the credentialing process along. However, it is imperative to receive the original and replace the fax before considering the file “complete” – as we discussed in the last issue, it is far too easy (and sometimes tempting) to alter an original document before faxing. Even though the fax machines used – both to send and receive – provide high-quality resolution, it is often difficult to detect alterations. Original signatures should be a mandate for quality and equity in credentialing.
The next consideration: Who decides how references are determined? Hugh Greeley on the hcPro Credentialing Connection Web site writes:
The applicant/reapplicant should not be the source of his or her references… the healthcare facility should determine which types of individuals should provide the references.
Later in this same edition, Dr. Greeley advises:
Determine in advance how many references you require and from what types of individuals (e.g., for all recently trained physicians, references from their residency director is required; for surgeons, chief of surgery, chief of anesthesia, operating room supervisor, and director of emergency medicine; for obstetricians, chief of obstetrics, obstetrics supervisor, pediatricians, etc.).
Solicited references should match those identified in the application; if a disparity appears, an explanation for the disparity should be included in the file. For example, Dr. X provides both Drs. Smith and Jones as references on the application form. However, Dr. Jones is on sabbatical half way around the world. To expedite the referral process, the Medical Staff office apprises Dr. X of this situation, asking Dr. X to provide a substitute reference. Dr. X does so providing Dr. Williams as the alternate reference source. There should be documentation in the file that explains the existence of letters of reference from Dr. Williams, when Dr. Jones was listed by the physician on the application for privileges.
Most facilities now recognize and promote the need for obtaining professional references from practitioners other than partners… those in partnership have vested financial interests. These interests arguably color objectivity. Who doesn’t want to see his or her partners thrive so that the practice thrives? Taking partnership interests out of the mix affords greater objectivity to the physicians providing references. Certainly, you will want to see references from those who taught, mentored, proctored, had oversight of or worked along side the applicant in other medical settings.
Privileging:
The Joint Commission opines:
Membership on the medical staff is not synonymous with privileges… Practitioners practice only within the scope of their privileges as determined through mechanisms defined by the organized medical staff.
Which leads us to the question: How are privileges determined and by whom?
hcPro’s “Our Credentialing Approach” suggests:
Privilege criteria should be clinically specific (as opposed to departmentally specific) …criteria must be recommended by the chair of the applicable departments or the chiefs of divisions within those departments and approved by the credentials committee, the medical executive committee, and the board… [and] the criteria must be met before a request for clinical privileges can be considered complete.
This system [privilege delineation] must not only be flexible enough to add the new procedures physicians wish to perform or conditions they wish to treat, but also be firm, fair, and consistent.