Common sense credentialing

An extraordinary amount of time, effort, and resources goes into credentialing and privileging physicians. Applicants fill out lengthy (and, all too often, multiple) application forms. Medical staff services departments spend untold hours tracking down primary source verifications, National Practitioner Data Bank reports, and especially references from places the applicant has practiced. Why do we do all of this? If your answer to this question is, “The Joint Commission says we have to,” I suggest you look for a different answer.

Nothing turns off and de-energizes physicians faster than those words. Far too often, those words are linked to an over-interpretation of the specific wording of the standards and scoring guidelines. Regardless of their accreditation provider, when organizations say “because we have to,” it usually results in overly complex processes that waste resources and almost guarantee noncompliance because of the sheer burden of following such complex processes.

All of this should cause credentialing specialists and medical staff leaders to question everything we do in credentialing, why we do it, and how we could do it more simply and effectively. In other words, we should adopt a common sense approach to credentialing. The place to start is to ask the question, “What are the goals for all of our credentialing and privileging activities?” Making this question an agenda item for your credentials committee meeting might be a fruitful exercise. Is it to meet regulatory and accreditation requirements? That should be an outcome but not a primary goal. Is it risk management with the goal of reducing liability for the hospital and its physicians? In part, but again credentialing done well should produce good risk management as a byproduct, not as a primary goal.

I’d like to propose a common sense goal for which all credentialing and privileging activities should be directed. The real goal of everything we do in credentialing and privileging should be to make a reasonably accurate prediction of a practitioner’s performance in our organization over the next window of time (typically two years) to the best of our ability, given available information and resources. Framing the goal in this common sense way has several advantages. First, it recognizes that no credentialing process can ever guarantee any practitioner’s level of performance. Though the best predictor of future behavior is past behavior, it is never a guarantee. Second, currently recognized credentialing best practices—such as using eligibility criteria, determining the data elements required for a completed application, and the critical analysis of each application—should all be aimed at making reasonable, well-informed decisions about the likelihood of a practitioner’s performance over a finite period of time. The operative word here is “reasonable.” Not gathering enough relevant information to make a good prediction is not reasonable. Keeping a poor quality physician on your medical staff because he or she brings lots of revenue to the hospital is also not reasonable. 

This common sense goal for credentialing should be center stage as your medical staff wrestles with whether to require board certification or maintenance of certification. Your credentials committee should review the latest research seeking to link board status to provider performance and outcomes. Then hold a discussion to determine to what extent board certification contributes to achieving your common sense goal for credentialing.

Staying with our intention to be reasonable, is it reasonable to require a surgeon to submit a log of his or her cases during the past two years as part of the application process? Today, the answer is yes. But what about requiring the surgeon to submit data on the outcomes of his or her cases? Is this reasonable? Not if we look to the second half of our common sense goal, namely to make this prediction based on available information and resources. Sure, it would be great to have access to the results of peer review at every institution at which a physician is or has practiced, but this would be an unreasonable goal. What about peer review results in your own organization? This is where we have to acknowledge we are on a “crawl, walk, run” journey.

In other words, if we think of the process of wrestling your medical staff’s peer review activities into something that achieves meaningful, effective peer review as a journey, we must admit that most of us are still in the “crawl” stage of this journey. Today, you likely get data on a provider’s volume, medical records completion, probably core measures, and most likely incident reports. This data provide, at best, only a modicum of relevant information to help achieve your common sense goal for credentialing. For today in many medical staffs, this is as good as it gets. We should use whatever data our peer review program generates today to make as accurate a prediction of a provider’s performance in our organization for the next few years. This is reasonable. It is also reasonable to expect your medical staff to drive changes over time to get to the “walk” and eventually “run” stages of this peer review journey.

At the end of the day, keeping a common sense goal in focus for all your credentialing efforts will help keep your credentialing program on a reasonable track. Today, this is as good as it gets.
 

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