Tip: Take these two steps to promote compliant retention of credentialing records

To avoid compromising the integrity of credentials files, the files should be properly secured and retained for an appropriate length of time.

1. Identify a secure method and location

Paper credentials–related materials can be maintained in locked file cabinets and offices, and digitized versions can be saved in password-protected computer files. It is useful for hospitals to have a systemized method for keeping track of anyone who accesses a file other than the authorized credentialing staff who, by virtue of their position, manage and review credentials materials on a regular basis. Hospitals should strongly discourage department chairs from keeping their own files on practitioners.

The court may regard information kept outside of the formal medical staff quality, peer review, or credentials file as discoverable. It is harder to claim the peer review privilege for documents that are kept in disparate locations and according to the whim of the person in possession of that document. Medical staff leaders should be instructed to forward all peer review findings, documentation, and correspondence to the medical staff services department (MSSD) for placement in an individual’s peer review file or for attachment to the minutes of an appropriate peer review committee. This type of instruction can take the following forms:

  • Occur as part of an orientation program when medical staff leaders assume their positions
  • Be articulated in a medical staff policy
  • Be reinforced periodically by MSSD personnel and physician executives (e.g., VPMA or CMO)

2. Determine an appropriate length of time

Another concern that sometimes arises regarding peer review/credentials files is how long they should be kept. Obviously, a file must be kept as long as the practitioner holds privileges at the institution. Once he or she leaves, files should be kept at least past the statute of limitations for malpractice suits to which he or she may become subject. These limits vary from state to state, and in most locations, patients who are children can bring suit at least until they reach the age of maturity. It is useful for the hospital to have a policy on record retention that is crafted in consultation with local counsel. As more and more credentialing files become digital, it will become common practice to retain them indefinitely.

Source: Negligent Credentialing: Strategies for Reducing Hospital Risk