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

In the May 20 Medical Staff Leader Connection, we wrestled with the challenge that arises when credentialing decisions are not pure black and white, but are suffused with shades of gray. Specifically, we identified that a dynamic tension occurs when MSPs and medical staff leaders must weigh the goal of high quality patient care against the need for physicians and the hospital to be successful. We recognized that although high quality patient care should always be our ethical “true north,” if we focus on high quality care to the neglect of physician success and hospitals success, we will put physicians and the hospital at risk of failing, which in turn would adversely affect the quality of patient care. In this edition of Medical Staff Leader Connection, we will continue our exploration of credentialing gray areas by discussing another way that credentialing dilemmas sometimes present: the choice between “manage loose” and “manage tight.”

All organizations struggle with determining where they want to be on the spectrum between the two poles of manage loose and manage tight at any given time on any given issue. There is a value to each pole. Manage loose is creative, flexible, customizable, empowering, and, in the credentialing world, seen as being “physician friendly.” Manage tight is the way we achieve high reliability, patient safety, cost effectiveness, and high levels of patient satisfaction. As an industry, healthcare has been too much on the manage loose end of this spectrum. Many of the macro level changes we are seeing in healthcare today—pay for performance, evidence based medicine, transparency, RAC audits, and core measures—are symptoms of the needed transition healthcare is making from too much manage loose to more manage tight. But there is such a thing as too much manage tight. So the goal for healthcare leaders is to navigate this transition to more manage tight without managing too tightly.

Let us apply this kind of thinking to credentialing and privileging. To begin, we now recognize that the “5 Ps” discussed in the May 20 issue (“Our Policy is to follow our Policy. In the absence of a Policy our Policy is to create a Policy.”) is a tool to help you get credentialing in your organization on a more manage tight footing. In addition, The Joint Commission’s introduction of ongoing professional practice evaluation, focused professional practice evaluation, and the general competencies raised the bar for credentialing and peer review, pushing our entire field to become somewhat more manage tight. By introducing language that privileging should be an “objective, evidence-based process” (MS.06.01.05), The Joint Commission clearly intended to challenge the credentialing field to raise the bar and adopt a more manage tight approach to privileging.

A tension arises in many medical staffs because, as a group, MSPs tend to function fairly far on the manage tight end of this spectrum. They are comfortable with following accreditation standards, drilling down into subtle concerns they pick up in individual applications, and not allowing an incomplete file to move forward in the credentialing process. In contrast, many physicians function more on the manage loose end of this spectrum. They tend to want to give fellow physicians the benefit of the doubt and don’t want to do anything to make it harder for them to earn a living than it already is. Physicians also tend to make assumptions about the competence of other physicians that are not always grounded in data or experience. Finally, many physicians do not understand or respect many of the accreditation standards that govern credentialing today.

These differences, though of course only generalizations that may not be true for every circumstance, do create natural tensions around credentialing and privileging decisions. Physicians may be frustrated that a fellow physician cannot be granted temporary privileges or that another is made to “jump through hoops” to be granted privileges for some new technology. In these situations, the MSP often feels like the “enforcer” of standards that do not add value in the eyes of many physicians, which can create uncomfortable tension as the two parties try to work through the difficult credentialing or privileging decisions.

Medical staff leaders and MSPs may find it helpful to reframe such challenges as opportunities to discuss where the organization wants to be in the spectrum between manage loose and manage tight on that specific credentialing or privileging decision. This allows all of the involved parties to recognize both the value of their own approach and the value of whatever approach the other party recommends. The goal in such moments, especially when the decision is not black or white, is to openly discuss the key issues with an eye to determining the wisest course. Framing the discussion this way can be helpful in getting unstuck when conflicts arise. Balancing the goals of achieving physician success, hospital success, and good quality patient care within the manage loose/manage tight framework can be the best guide to charting a wise course through the credentialing and privileging challenges you face.

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