Credentialing and privileging monthly: Overcome credentialing challenges posed by hospitalists

Hospitalist medicine is the fastest growing specialty in the country, yet its growth is still not adequate to meet the current demand. Given the demand for hospitalists, it is not surprising that physicians with atypical backgrounds are applying for privileges as hospitalists, creating dilemmas for credentials committees and medical executive committees (MEC).

One hospital recently faced this challenge when a well-trained and highly competent emergency medicine physician on their medical staff applied for hospitalist privileges. Both the physician and the hospitalist group seeking to hire him theorized that if the physician is competent to treat patients at their most acute and unstable moments in the emergency department, shouldn’t they be deemed competent to provide their care for the rest of the hospital admission?

The credentials committee, in a split decision, recommended to deny the request for hospitalist privileges on the grounds that the physician did not meet eligibility criteria. The MEC voted, also in a split decision, to recommend granting the requested hospitalist privileges. Given so much disagreement within the medical staff, the board was uncomfortable acting on the MEC’s recommendation, and chose to appoint an ad hoc task force to research the issue and return with a recommendation.

The task force, composed of credentials experts, began by confronting a challenge that rears its ugly head in credentialing more often than we recognize. This challenge can best be described as the tension between “managing tight” and “managing loose.” Managing tight is about standardizing the credentialing process to the point of excellence and high reliability. Managing loose is about being flexible, creative, and responsive to physician, hospital, and patient needs. Every organization must determine at any given time and regarding any particular challenge where it wants to fall in this spectrum between managing tight and managing loose.

In the case of the emergency physician applying for hospitalist privileges, if the medical staff chose to manage tight, it would begin by carefully evaluating the eligibility criteria for hospitalist privileges. If the eligibility criteria require residency training in internal medicine or family medicine (or pediatrics in the case of a pediatric hospitalist), the emergency physician would be ineligible to apply and the application would not be processed. Hence there would be no need to issue a denial, which in turn means there would be no report to the National Practitioner Databank and no right to a fair hearing.

If the medical staff has not adopted eligibility criteria, the application should not be processed. Once these criteria are put in place, then the credentials committee can process the emergency physician’s application to determine if it meets the criteria.

If the medical staff chose to manage loose, it would begin by recognizing the important patient care need for more hospitalists. In order to meet that need, the task force might consider an alternative pathway that would allow physicians who do not meet the eligibility criteria to demonstrate their competence as a hospitalist. Some might even argue that medical staffs that choose to manage loose can simply skip the step of establishing eligibility criteria all together. This would allow the medical staff to recommend approval of hospitalist privileges for the emergency physician, which in turn would set a precedent that physicians with training in other fields might also be eligible for hospitalist privileges.

There is clearly a need for medical staffs to find a middle ground between managing tight and managing loose. The task force found such a middle ground by providing the emergency physician two options. The first option was to participate in a mini residency, a training period of three to six months during which the physician could ramp up knowledge and skills in inpatient medicine.

The second option was to grant hospitalist privileges to the physician, but with the proviso that the physician could not practice those privileges independently until he demonstrated current competence. All of the patients the physician cared for in the hospital needed to be co-managed by another physician with hospitalist privileges. After a period of focused professional practice evaluation (FPPE) to evaluate his competence to treat inpatient clinical conditions, the credentials committee could authorize the physician to practice hospitalist privileges independently.

Viewing credentialing and privileging challenges within the framework of finding a middle ground between managing tight and managing loose will help medical staff leaders achieve a solid and reliable credentialing process.

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