Credentials committee composition: Turn to experienced physicians

Dear medical staff leader:

Truly effective medical staffs must govern themselves, credential and privilege new practitioners, and monitor the quality of care provided by these practitioners. In the past, medical staffs assigned responsibility for credentialing and privileging a new practitioner to the physicians who were most knowledgeable about that applicant's specialty. Another common approach was to charge each department chair with credentialing and privileging responsibilities. However, both these approaches are flawed.

Medical staffs discovered that by allowing each department to decide whether an applicant qualified for membership and privileges, it opened itself up to anti-trust liability. On the other hand, when assigning the responsibility to department chairs, medical staffs struggled with inherent variation in the level of the chair's credentialing and privileging expertise.

As a result, best practice is now to establish a centralized multidisciplinary credentials committee composed of between five and nine medical staff members. The credentials committee should not, as once was believed, be the place "old presidents of the medical staff went to die."  Instead, the members of your credentials committee should be experienced physicians who know the institutional history of your past credentialing dilemmas. As committee members, they will be involved in the organization's current credentialing decisions and, as a result of their continued education and training, they will anticipate the organization's future credentialing dilemmas.

Your organization has expended time, energy, and money training and educating these leaders. It is logical to now rely on these leaders' expertise.

Past presidents or other experienced medical staff leaders knowledgeable about the credentialing make excellent credentials committee members. These leaders may seek "subject matter expertise" from specialty-specific physicians when the need arises. This committee structure and composition will ensure that your organization's most knowledgeable and experienced physicians are heading one it's most important committees.

Joseph Cooper, MD
The Greeley Company