The department chair’s critical function of evaluating a credentials file

Think of your hand on a smooth surface. When you’re a department chair evaluating a credentials file, that’s what it should be like, because most applications are smooth and have no red flags. When you review this file, you are usually following after the medical staff professional or credentialer who put the file together—meaning you’re the first physician to look at it and assess for red flags. A good credentialer or medical staff professional will draw your attention to potential issues, including:

  • Gaps in training or practice
  • Previous corrective action
  • Professional competence or conduct issues
  • Incomplete or inaccurate information provided on the application
  • Unusual requests based on background or training
  • Unusual background or training
  • Multiple changes in practice sites
  • That “funny feeling” inside

Don’t just take the credentialer’s word for it, though. Take the time to go through the file, look at whatever has been highlighted for you, and then look at the other information. Look for any of the red flags listed above. If you find one—and remember, at this point it’s just a “bump,” not an actual problem—your job is to drill down into that bump and determine whether something is a concern. Remember, the whole exercise of credentialing and privileging is to predict, as accurately as possible, a practitioner’s performance over the next few years within your organization. It’s not an exact science, but you want to get it as right as you can—patients are counting on you.

If you find a red flag in a practitioner’s file, it doesn’t mean the person is a bad doctor. Rather, it means you need to dig deeper. Why did that gap happen? Why does the person have so many malpractice cases? Maybe you need to pull the practitioner’s medical records. If the person had a professional action at another hospital, what happened? You are entitled to ask for that additional information—that’s known as placing the burden on the applicant. If you as a department chair feel you don’t have enough data to make an informed decision regarding approval or denial, ask for more information. Let the credentials committee or the medical staff office know what you require, then let them go out and gather it. Don’t make a recommendation until you have all the information you need.

Source: Department Chair Essentials Handbook