How to make sure your references are worth more than the paper they're written on
When the Greeley consultants work with medical staff leaders and medical staff professionals who are experiencing credentialing challenges, many of our clients complain that the information contained in references is so bland and uninformative as to be virtually useless. Must it always be so? The answer is a definite no. But getting value out of references requires careful design, careful reading, and use of the telephone. We will tackle the first two (careful design and reading) in this edition of Medical Staff Leader Connection and the last one (using the telephone) in a future edition.
When designing your reference form, begin by asking what you want to know. We want the reference’s assessment of the practitioner’s competence. The first challenge to confront, then, is to define what your medical staff means by competence. Today, this question has been answered by the Accreditation Council for Graduate Education (ACGME), the American Board of Medical Specialties (ABMS), and The Joint Commission. All of these organizations have adopted the six general competencies (patient care [and procedural skills], medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice) as a contemporary definition of competence. Thus, your reference questionnaire should include questions about each of these dimensions of physician performance. However, if you simply listed each of these categories on your reference form and asked the reference to rate the practitioner on each dimension of performance, you would receive little helpful information. Even if you included the definition of each of the general competencies, unfortunately, you would still receive little helpful information.
The key is to distill these six general competencies into specific competencies you really want to know about. For example, to cover the patient care (and procedural skills) competency, you might ask the referee to rate the practitioner on his or her technical skills with separate ratings for clinical judgment, bedside manner, and compassion. You could assess communication by rating thoroughness of medical record documentation and a separate evaluation of legibility. You can see how each of the other general competencies could be made more specific to assess a practitioner’s competence.
The reference form should also include questions concerning how the reference knows the practitioner and for how long. Be sure to include an area for the reference to write, allowing you to obtain more nuanced information the referee may be willing to provide.
The next step for getting value out of references is careful reading. This means reading between the lines to understand what the reference is hinting at or not saying at all. For example, how would you interpret a reference that ends with a phrase such as, “If you would like additional information about this applicant, please feel free to call me”? The answer is that you should interpret this sentence as a big red flag that screams, “CALL ME!” A reference that is totally benign and tells nothing suggests either a problem with the physician’s performance or a totally perfunctory reference that needs to be fleshed out with a phone call. A reference that rates each of the applicant’s characteristics as excellent but “Gets along well with others” as very good is telling you there is probably a significant problem with this aspect of the practitioner’s performance.
The key in reading references is to recognize that few references will tell you anything blatantly negative. Look for subtleties, and, when you find them, pick up the phone. That is a challenge we will tackle in a future edition of Medical Staff Leader Connection.
Richard A. Sheff, MD, CMSL, is chair and excutive director of The Greeley Company, a division of HCPro, Inc. in Danvers, MA.