What to do when credentialing decisions aren't black and white: Part I

Many of you are familiar with The Greeley Company’s principle for effective credentialing known as “The 5 Ps” which states:  Our Policy is to follow our Policy. In the absence of a Policy our Policy is to create a Policy. This principle teaches us to establish consistent processes and rules that guide our actions during each step of the credentialing process. We create policies for what constitutes a completed application, who reviews it, what our criteria will be for membership and privileges, etc. Following the 5 Ps will help your medical staff achieve a well designed credentialing system that provides clear guidance for how to address challenges as they arise.

But some challenges will inevitably arise for which no policy can provide the solution. These are the judgment calls credentialing specialists have to make when the choice isn’t black or white, but a shade of gray. How many malpractice cases are too many? Should you allow your general surgeons to perform carotid endarterectomies when their volume is low in order to keep that procedure available to your community? Will you accept a physician in a much needed and hard-to-recruit specialty even though he or she is not as good as most other physicians on your medical staff? No policy can answer these questions.

The most important credentialing principle has always been that credentialing exists to protect patients. Thus, the ethical “true north” for credentialing specialists is to act in the best interests of quality patient care. The problem is that sometimes doing so can hurt physicians, your hospital, or both. For example, one hospital I worked with had an OB-Gyn group practice that desperately needed another member because the physicians in the group were burning out due to their grueling work load. The hospital finally succeeded in recruiting a partner who happened to have a significantly higher number of malpractice cases than other group members. Should the medical staff recommend that the board appoint this applicant? Assuming there is no “smoking gun” hidden within the malpractice cases that demonstrates blatant incompetence, this is a judgment call. The medical staff could recommend denial, which might be the action that best protects patients.

But while protecting patient care is important, so is helping the physicians. If this group falls apart, the hospital will lose its entire maternity service and millions of dollars in gynecological surgical revenue, putting the very financial viability of the hospital in jeopardy. Given this line of thinking, should the medical staff instead recommend approval for a limited initial appointment combined with a well designed focused professional practice evaluation (FPPE)? As the physician shortage intensifies, difficult choices like these will become increasingly common.

Faced with such a difficult choice, what guidance can help medical staff leaders and the board make a wise decision? The best way to frame difficult decisions like this is to recognize that for healthcare to work for any of us, we must find a way to achieve physician success, hospital success, and good quality care at the same time. Although ensuring quality patient care is critical, focusing too much on that one goal and failing to help physicians and the hospital succeed will ultimately undermine the quality of patient care. Focusing too much on any one of these—physician success, hospital success, or quality patient care—to the neglect of the other two will undermine healthcare.

When faced with difficult choices, medical staff leaders and governing boards should ask, “How can we best achieve a balance of physician success, hospital success, and good quality patient care at the same time?” When confronted with credentialing choices that are not black and white, using this frame will help your hospital to make wise decisions.

I can hear the chorus of voices rising at this moment saying, “Is this as good as it gets? Isn’t there a policy we can put in place to provide clear guidance when such problems must be faced?” Unfortunately the answer is no. This does not excuse lax decision making that puts patients at risk or taking the expedient, easy way out when important information is missing from a credentials file. But once all the information is gathered and understood, choices that involve shades of gray will still have to be made. Having a fair and open discussion focused on how to best balance physician success, hospital success, and good patient care, and making the difficult choices such challenges will inevitably require, is as good as it gets.

Rick Sheff, MD, CMSL, is chairman and executive director of The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.