Dissecting the final steps of the reappointment process
The department chairs have reviewed the reappointment applications. All questions and concerns have been addressed, and the applications are recommended for approval. The credentials committee makes a recommendation to the medical executive committee (MEC) for approval, and in turn, the MEC recommends approval to the board. The board accepts the recommendations and approves the reappointments.
There may be occasions when the board requests additional information on a reappointment and defers its decision until that information is obtained. In this case, MSPs will need to check the appointment period of the applicant to ensure that medical staff membership and clinical privileges do not expire during this time. If the delayed board decision will create a gap in the practitioner’s appointment, MSPs may want to suggest a limited-time appointment until the information requested is received. Doing so will prevent a gap in the appointment period and provision of services of the practitioner; however, if there are concerns regarding whether the practitioner should be allowed to continue to provide services, then temporary appointment is not an appropriate option. At this point, always refer to the bylaws for direction on how to proceed.
Additionally, it is a Joint Commission and CMS requirement for surgical services to keep a current roster of each practitioner’s surgical privileges. Most hospitals now use a credentialing database, and some such databases and web-based programs also offer privileges modules to track this information. Hospital departments may be given access to that program so they can answer questions about whether a particular physician is privileged to perform a specific procedure. Access to this program is granted to the surgery department and, typically, to nursing administration.
If the hospital is not using a credentialing database or does not have a privileging program available, copies of the privileges must be made available to the surgery department and to any other department deemed appropriate. This can be done by making paper copies and filing them in a notebook in each department, but that is a very time-consuming, paper-wasting process. Instead, consider scanning and maintaining the privileges on a secure site on the hospital’s intranet. Have the practitioner’s photo on their privilege form so that nursing staff can easily see who the practitioner is when reviewing their privileges. Doing so also increases awareness among the staff as to who belongs in the hospital and who may not.
When surveyors visit the surgery department, they will ask to see current privileges. They will also ask the person who schedules procedures how they know that the practitioner’s privileges are current. If the hospital has a credentialing database, the electronic privilege information in it will update automatically when providers are reappointed. If the hospital has a manual process for updating privilege notebooks, make sure to update them at reappointment.
The last step is sending notification to the provider. The Joint Commission standards require that the medical staff bylaws specify the time frame for communicating decisions to the providers; such notification should be sent as soon after the board decision as possible. The bylaws may state that notification will be made within 30 days of approval, but letters should go out within a few days, when possible—doing so conveys a sense of professionalism in the process.