QUESTION:  While conducting routine verification of an application for appointment, we learned that the physician applicant may have been involved in a couple of behavioral incidents at another hospital. We asked the physician to obtain that hospital’s peer review file so that we can consider it as part of our credentialing process. Stating that its file is confidential and privileged, the hospital has refused to release a copy and will not provide any information other than a statement that the physician is “in good standing, with no pending adverse actions.” Since this matter is outside of the physician’s control, should we just accept the physician’s version of the behavioral incidents and move forward with the credentialing process? What choice do we have?

ANSWER:     The situation that you describe is, unfortunately, not too uncommon. Many hospitals are so averse to litigation that they are unwilling to be forthcoming with references and/or information from practitioners’ peer review files. This is unfortunate, since that information is necessary for credentialing by other organizations.

First and foremost, what you need to know is that applicants have the burden of demonstrating that they are qualified in all regards for Medical Staff appointment and the clinical privileges they are requesting – and you do not need to continue processing the application until you receive whatever information is necessary to resolve any concerns that have been raised about the applicant. (Of course, we recommend that you have good bylaws language that outlines all of these principles and that clearly delineates when an application is “complete” and ready to be processed.)

Understanding that the burden is on the applicant, many credentialers make the mistake of believing that their hands are tied in a situation such as this and that they cannot process the application without obtaining the full credentials and peer review files. This is not the case. Leaders have the discretion to determine, based on the facts at hand, the information that is necessary to resolve a concern. In some cases, that may mean obtaining the full peer review file. In other cases, it may suffice to resolve the concern through other means.

For example, consider asking the physician applicant about the incidents. He or she may be able to offer an explanation that would satisfy your concerns (for example, the applicant might admit that the incidents occurred and provide a believable explanation of the steps the physician has taken to prevent a recurrence). If the applicant provides an explanation of the behavior incidents that is either unbelievable or contrary to other information you have received, then, of course, his or her explanation would not suffice and you would want to look for other information to resolve the concern.

You may also choose to speak with others who might have information about the incident.

Or, if the incidents raise specific concerns about the physician’s behavior (for example, the ability to get along with nurses), you might speak with others who have general knowledge of the physician’s behavior (in this case, nurses or nurse supervisors).

In some cases, you may not be able to use alternate sources of information to resolve concerns about an applicant. It may be that the alleged incidents are simply too grievous to be resolved through anything less than the full peer review file of those incidents.

Further, you may need to see the actual peer review file for verification of the facts if the applicant’s veracity is called into question (for example, he or she has been “caught” making omissions or misrepresentations during the application process).

As you can see, credentialing is not black and white. Join us at The Credentialing Clinic this fall to learn more about exercising your leadership discretion in a responsible way as you wade through the sometimes gray credentialing process.