Credentialing monthly: What is the role of the credentials committee in addressing unprofessional conduct?

If you believe everything you read, it may appear that we are in the midst of a disruptive physician behavior epidemic. As I travel to hospitals across the country, I am not convinced that the frequency or severity of unprofessional conduct (the term I prefer to use instead of “disruptive behavior”) has increased. Rather, I believe that we are changing our expectations of physician behavior.

In other words, medical staffs are no longer tolerating behavior that they tolerated in the past. The Joint Commission has weighed in on this issue with Sentinel Event Alert #40, which highlights the adverse affect unprofessional conduct has on patient safety. The Joint Commission also issued leadership standard LD.03.01.01, which requires hospitals to address unprofessional conduct throughout all levels of the hospital, including management, staff, and board members—not just physicians.

As members of the self-governed medical staff, department chairs are accountable for the behavior of physicians within their department. Thus, they are responsible for intervening when a physician displays inappropriate or disruptive behavior.

In addition to department chairs, the credentials committee plays an important role in keeping problem behavior in check. I’d like to share with you a clear set of actions a credentials committee can take to fulfill its role in eliminating unprofessional conduct:

1. Take a close look at the criteria for medical staff membership, which are located in your bylaws or credentials manual, and make sure they address professional conduct. If you don’t have criteria in place that address professional conduct, consider this sample language: “Physician must produce a history of consistently acting in an appropriate and professional manner in previous clinical settings.” This would not preclude a physician who has had a rare outburst from joining your medical staff if he or she acts in an appropriate and professional manner the majority of the time. This would however, prevent chronic offenders from joining your medical staff. 
2. Once the credentials committee has established criteria for membership that address professional conduct, it now has the grounds for gathering information on an applicant’s conduct in previous clinical settings. This is where references come in handy, especially those your medical staff services department sends to MSPs at those settings (not the handpicked references of the applicant’s choosing). The credentials committee owns the content of those reference queries and needs to ensure it has answered any questions about an applicant’s conduct.
3. One of the credentials committee’s most important roles is to prevent what I like to call an “information error.” An information error occurs when information existed that your hospital could have or should have discovered but didn’t, and that information would have caused the committee to make a different credentialing decision. In this case, the credentials committee needs to gather all the information it needs regarding the applicant’s behavior in previous clinical settings to make a well informed decision. If the committee has any concerns about the applicant’s conduct, the committee should drill down into those concerns to resolve them to the satisfaction of your medical staff’s professional conduct policy. The credentials committee is responsible for making sure this policy is well written and consistently implemented. The credentials committee should not make any decisions regarding an applicant when concerns regarding his or her conduct remain unresolved.
4. The credentials committee needs to guard against the second kind of credentialing mistake: a “decision error.” A decision error occurs when the medical staff and hospital are aware of potential issues regarding an applicant but lack the wisdom, clarity, or courage to make a wise decision. When the credentials committee receives a recommendation from the department chair regarding each applicant and re-applicant, it is responsible for ensuring that the department chair appropriately understood the physician’s past behavior and made a wise decision. Typical concerns that occur at this stage include:
   • The physician admits a lot of patients to the hospital and may have been given too much latitude with his or her behavior in the past.
   • The physician is well-liked, resulting in their friends on the credentials committee approving the reapplication based on camaraderie, not objective evidence.
   • Members of the credentials committee or others are afraid to lose referrals from the applicant or reapplication and continue to approve his or her membership on the medical staff in spite of significant, chronic behavior problems.
   • The physician threatens to sue the hospital if it tries to affect his or her membership or privileges based on behavior concerns, and the hospital backs down.
   • Credentials committee members and other medical staff leaders lack a consensus concerning whether to take poor physician conduct seriously and what types of behavior are tolerable.
5. The credentials committee needs to remember that the goal of the medical staff professional conduct policy is not to “kick physicians off the staff” for bad behavior, but to help every physician act in an appropriate and professional manner as much as possible. Therefore, the credentials committee should recognize when to recommend to a department chair that further interventions are warranted to address a physician’s behavior. This may warrant initial or reappointment for a period of less than two years while the interventions regarding their behavior are carried out.

By fulfilling its role, your credentials committee can help make unprofessional conduct a thing of the past, and in so doing enhance patient safety and collegiality throughout your hospital.

Richard A. Sheff, MD, CMSL, is the chair and executive director of The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.