Create a professional reference questionnaire policy

Although nearly all hospitals use professional reference questionnaires during the credentialing process, few have a policy that addresses appropriate use of the questionnaire. Such a policy should answer the following questions:

• How many references should be required?
• When do references need to be obtained (e.g., at initial appointment, at reappointment when there is insufficient clinical activity, when a practitioner requests new privileges)?
• Who is considered an appropriate reference source?
• When is follow-up required (e.g., outstanding queries, incomplete information, red flags)?
• Who will follow up with reference sources when they provide insufficient information?
• How long does a credentialing professional or credentials committee member have to follow up with reference sources, and when should the applicant be notified if the reference source has not responded?
• Under what circumstances should an application be deemed incomplete (e.g., if requested information is not received in a timely manner or at all)?
• How should MSPs obtain references for low- and no-volume providers?

Your medical staff should have a policy that places the burden on the applicant to prove his or her clinical competence and provide all the information the medical staff leaders, credentials committee, MEC, and governing body need to make evidence-based decisions regarding membership and privileges.