Strengthening the reappointment process

Hospitals can reduce liability exposure by strengthening the precision and documentation of their reappointment procedures. The reappointment process requires focused attention to complete the required list of detailed requirements. From an overview perspective, the process itself can be better served, given some of the following strategies:

• Implementing automated credentialing management systems to track verifications.
• Conducting regular internal audits of credentialing files.
• Integrating automated OPPE and FPPE data into reappointment reviews.
• Ensuring thorough peer review documentation.
• Maintaining clear oversight of the reappointment process by following the chain of command within the medical staff/allied health leadership, up to and including the medical executive committee and ultimately the hospital governing board, as stated in the medical staff bylaws.
• Scheduling reappointments so that approximately 2.775% of the total number of reappointments are conducted each month. This would complete some 33.3% of the reappointments per year, thereby establishing a more deliberate and thorough review that results in 100% completed reappointments in three years.

To transition to a monthly reappointment schedule, the medical staff bylaws should include wording that allows for reappointments to be performed before the actual reappointment date. This enables a better distribution of providers as well as grouping specific departments so that workloads for both the clinical departments and the medical staff office are more balanced, thereby avoiding a highly pressurized environment when an exceedingly large volume of providers must be reappointed at the same time.

These measures can help ensure that reappointment decisions are supported by comprehensive documentation and objective performance data.

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