Don't let physicians slip through the credentialing cracks

Medical staff leaders and board members need to understand that sidestepping the hospital bylaws or the written credentialing procedure will be looked at unfavorably during a malpractice or negligent credentialing lawsuit.

CMS and other accrediting bodies require that accredited hospitals include the foundation of the privileging process in the medical staff bylaws so there is no question as to what requirements need to be met in order to grant privileges. While medical staff bylaws are the governing document of the medical staff, the document must be approved by both the medical staff and the governing board of the hospital. Typically, development and approval of the bylaws is complex and lengthy, ­reflecting that bylaws language is often targeted during ­malpractice suits.

"The bylaws are a valuable source for risk mitigation, particularly for patient safety and healthcare quality," says Teresa P. Sappington, FACHE, CJCP, CPHQ, CPMSM, a consultant specializing in medical staff affairs and healthcare regulatory compliance, "The medical staff establishes what they believe to be the best risk mitigation processes and procedures to ensure quality of patient care and patient safety. Approval by the board indicates agreement with the medical staff."

From Credentialing and Peer Review Legal Insider, October 2012