Protecting credentials files from discovery

The degree to which credentials files can be protected from discovery in legal proceedings is generally a matter of state law. Most credentialing work is considered a peer review activity performed by the medical staff and governing board. As a result, state laws generally grant some amount of peer review protection to those parts of a particular credentials file that are acted upon by medical staff committees or the board. It is important to clearly establish in medical staff bylaws and related documents that key stakeholders, including the following, are performing credentialing functions in a peer review capacity:

• Credentials committees
• Those providing information to and working on behalf of the credentials committee or addressing credentialing-related matters at the request of the medical executive committee (MEC) or governing board
• The MEC and governing board when acting on credentials applications