QUESTION:        A department chair instructed our Medical Staff office to provide an application to someone who was formerly on our staff but who has not practiced in a hospital setting for several years.  The application contained no recent peer references. This applicant was persistent, and has now asked for temporary privileges.  What should we do?

ANSWER:            This application is incomplete!  So, temporary privileges cannot be provided!  (Many applicants do not recognize this.) Hospitals are required to verify from primary sources information regarding every applicant’s education, training, practice history and current competence for all privileges requested.  These requirements are found in accreditation standards, the Medicare Conditions of Participation and, in many states, hospital licensing requirements.

The courts in most states have adopted the doctrine of negligent credentialing/hospital corporate negligence.  Hospitals must, in order to meet the standard of care in credentialing, obtain relevant information related to an applicant’s satisfaction of all qualifications. You must confirm practice history following the applicant’s tenure on your staff, as well as current competence.

Every applicant has the burden of demonstrating satisfaction of all qualifications and of resolving any doubts.  Incomplete applications cannot be processed.  (If you don’t have language to this effect in your Bylaws or Credentialing Policy, add it soon!)  So you should write a letter stating that the application is incomplete and that it cannot be processed unless and until complete information is provided and verified, demonstrating current competence for all privileges requested.  If your bylaws have a time frame for the provision of this information or else the application is deemed to be withdrawn, add that as well. (No NPDB report is required for withdrawal of an incomplete application.)  Assume that this letter is aimed at multiple audiences, so it makes sense to provide some education about accreditation, regulatory and legal standards.

And — finally — it would make sense to have a process whereby applications are provided only by the Medical Staff Office in response to a written request, and then on authorization of the Medical Staff professional and the CMO/VPMA.  That way, if an applicant pressures a department chair, the chair can state that the standard process requires a written request to the Medical Staff Office. (The once-common practice of using a pre-application eligibility questionnaire has declined for many reasons, but every application should be scrutinized for eligibility before it is processed.)