Roles and responsibilities of the credentials committee

The roles and responsibilities of both the chair and the members of the credentials committee are laid out in the policies and procedures or the medical staff bylaws. Policies and procedures are easier to change than bylaws, so most medical staffs find it advantageous to place most of the detail regarding the credentialing process into a policy/procedure format. With the rapid changes occurring in most medical staffs today, these details will probably need to be revisited on a more frequent basis.

The basic work of the credentials committee will depend on the credentialing process model the organization uses. The most common process is to have the initial application information compiled and verified by the credentials verification organization (CVO) or the medical staff services department and then delivered to the appropriate department or section chair.

At the departmental level, if a section chair weighs in with recommendations, the recommendations are usually passed to the department chair for final approval. Once department-level recommendations are complete, the application goes to the credentials committee members for their recommendations. It is then referred to the medical executive committee (MEC) for further action. The MEC reviews the application and the department chair’s findings, makes its own recommendations, and then sends it to the board for final approval or disapproval.

The chair has the overall responsibility for running the credentials committee, including convening the meetings, setting the agenda, and reporting results to the MEC either in person or by filing a written report. The applicant files from the departments/sections are divided among the members for review prior to the committee meeting.

File reviews must be accomplished in a timely fashion so as not to slow the credentialing process. Completing file reviews is a major time commitment for credentials committee members outside of the regularly scheduled committee meetings. If files are clean, then the reviewing member can present them fairly quickly. Files with major and/or ongoing issues can take much more time. The reviewer must be able to summarize the issues accurately as well as make an initial recommendation about whether to go forward. If there are red flags in an application, the assigned reviewer may be responsible for making and documenting person-to-person phone calls to clarify the situation.

Finally, because many credentials committees are responsible for determining credentialing and privileging criteria, members may serve on ad hoc groups that are assigned these tasks by the larger committee.

CRC members can click here to see a sample chart of credentials committee members' roles and responsibilities.

Editor’s note: This article was excerpted from our Medical Staff Briefing newsletter.