Assemble a capable team for credentialing

Individuals who immerse themselves in credentialing are best prepared to tackle the field’s constantly evolving challenges. For this reason, the credentials committee should be made up, to the extent reasonable and practicable, of members with experience in credentialing. This experience may come from time spent in any of the following roles:

• Membership on other related committees (e.g., the medical executive committee)
• Department chair
• Medical staff officer
• Previous membership on a credentials committee
• Physician executive (e.g., vice president for medical affairs or chief medical officer)

It is generally advisable to waive term limits for the credentials committee chair and members. These individuals should serve as long as they are willing and are doing a good job. Seasoned credentials committee members understand their roles and obligations better than novices and usually are more adept at detecting red flags in an applicant’s credentials file.

Many medical staffs choose to rotate an officer (e.g., president-elect or secretary/treasurer) on the credentials committee as a defined part of his or her duties. This is a reasonable practice, as it makes it likely that a future medical staff president or chief of staff will be familiar with this important medical staff function. It also means that a member of the medical executive committee is always serving on the credentials committee and can act as a conduit of information and communication between the two bodies. Despite the benefits of such crossover, it is generally unwise for a president or chief of staff to serve as the credentials committee chair since this will result in frequent turnover of the important position. Experience and skill should be the primary criteria for appointing the chair.

Some credentials committees invite a member of the hospital board to attend their meetings. This can demonstrate to the board the rigor the medical staff brings to its credentials responsibilities. It also facilitates communication between the medical staff and board regarding difficult applications.

Editor’s note: This is an excerpt from Negligent Credentialing: Strategies for Reducing Hospital Risk by Todd Sagin, MD, JD. Looking for more medicolegal insights from Sagin? See him live at the 2017 Credentialing Resource Center Symposium.