Establish best practices for the credentials committee

The two most important medical staff committees in the credentialing process are the medical executive committee (MEC) and the credentials committee. The latter is not a required committee, and some smaller hospitals have the MEC carry out all credentialing tasks. Where a credentials committee exists, its function is usually to conduct the most intensive evaluation of initial and reappointment applications for hospital membership and/or privileges.

In general, the credentials committee and MEC should only review completed applications in which all required information has been provided and verified in accordance with medical staff policies and accreditation requirements. The credentials committee should also strive to have the application evaluated by a relevant subject matter expert who can render an informed opinion on the appropriateness of granting the requested privileges. This subject matter expert may be a department chair (or designee) or another qualified clinician.

It is also wise to have a credentials committee member review a file before the meeting at which it will be discussed. This member can then present the committee with any concerns (e.g., red flags) and bring the committee’s attention to any irregularities in the file. He or she should serve as the go-to person to answer any questions about the applicant that other committee members raise. When someone hasn’t been explicitly assigned this duty, it is too easy for committee members to overlook an important issue during their brief meeting.

A credentials committee should almost never advance a file to the MEC if it believes that additional information must be obtained to resolve a concern. The committee should place the burden on the applicant to provide any such information and table further evaluation of the file until it receives the requested materials. Moving a file forward in the absence of such valuable information may come back to haunt the committee if the hospital and medical staff are sued for negligent credentialing. The plaintiff may argue that if such information had been acquired, a better-informed medical staff and board would not have granted privileges or membership to the applicant. In that case, the practitioner would not have been in a position to harm the plaintiff. Failure to acquire sufficient information on an applicant is a frequent allegation in corporate negligence lawsuits.

Individuals who immerse themselves in credentialing are best prepared to tackle the field’s constantly evolving challenges. For this reason, the credentials committee should be made up, to the extent reasonable and practicable, of members with experience in credentialing. This experience may come from time spent in any of the following roles:

  • Membership on other related committees (e.g., the MEC)
  • Department chair
  • Medical staff officer
  • Previous membership on a credentials committee
  • Physician executive (e.g., VPMA or CMO)

Source: Negligent Credentialing: Strategies for Reducing Hospital Risk by Todd Sagin, MD, JD