Choosing credentials committee members

Who can be a credentials committee member? CMS and accrediting bodies only refer to the general function of a credentials committee. They do not specify the committee structure or provide requirements for membership on the committee. Your organization’s medical staff bylaws and/or credentialing policies and procedures set the actual criteria for credentials committee membership. Although it’s good to enumerate some basic requirements for membership, it’s also worthwhile to note that more effective credentials committee members are often those who exceed the minimum qualifications.

Typically, medical staff bylaws require that a member of the credentials committee be an active member of the medical staff in good standing for three to five years. The bylaws might include additional requirements for the committee chair, such as having served on the credentials committee or another significant committee previously. The chair may be required to have a certain amount of time on the credentials committee prior to becoming chair.

Sometimes, credentials committee leadership is tied to another office, such as president-elect of the medical staff. In some cases, the president-elect automatically holds the job of chair of the credentials committee. The rationale for connecting leadership offices is that having these multiple duties provides better on-the-job training and better preparation for the prospective president of the medical staff.

Regardless of the organization’s size, credentials committee members should be chosen from the pool of clinically respected practitioners. Although not normally a written requirement, it is a good practice to confine membership to such practitioners. Their clinical acumen will help them make good credentialing decisions and will help their peers accept their choices more easily.

Some organizations require prospective committee members to have prior training on the credentialing process. Providing such training might be the responsibility of the medical staff services department, the credentials committee chair, or both. Even without an introduction to the committee, most medical staffs employ a combination of on-the-job training and educating their credential committee members after they are in the position. The committee chair might enlist the medical staff services department for this training as well.

Look for the following qualifications when seeking credentials committee members:

  • A member of the medical staff with at least three to five years’ experience
  • A practitioner who is somewhat familiar with the credentialing process (he or she can expect to learn a lot while on the committee)
  • A clinically respected practitioner
  • A committed medical staff member who can devote the necessary time and energy to committee work

When a new member joins an organization’s credentials committee, there are things the medical staff office can do to orient the newcomers to their tasks. At a minimum, the MSP should develop an orientation program for new credentials committee members and chairs that provides:

  • The background for the committee’s responsibilities
  • Documents that outline the responsibilities, the relevant accrediting body, and CMS standards
  • Ongoing mini-sessions that can be presented at the meetings or provided online to support the knowledge of the committee members
  • Case study-based educational sessions (when there is time for discussion)

Source: The Credentials Committee Manual