QUESTION:    The MEC and Board serve as approval-type bodies for credentialing decisions.  So, our custom is to have the chair of each department present applicants within their departments to the MEC for approval.  Usually, this just involves the department chair offering up a list of applicants who have been “recommended” for appointment, reappointment, and clinical privileges.

At the Board level, the MEC’s recommendations for appointment, reappointment, and clinical privileges are presented.  This generally involves the Board being given a list of applicants and the Chief of Staff verbally reporting that the MEC has recommended the listed individuals.

Is something more required or recommended?

ANSWER:    When hospitals credential applicants for appointment, reappointment, or clinical privileges, much of the hard work is done by the Medical Staff Office and Credentials Committee, which look closely at any history that the applicant may have, follow up on any concerns, and obtain more information from the applicant and outside resources, and, in the case of the Credentials Committee, carefully deliberates and decides how to proceed.  While these functions are invaluable to the credentialing process, they do not replace the important role that the MEC and Board play in carefully considering and acting upon applications for appointment, reappointment and clinical privileges.

When no concerns have been raised about an applicant (which is the case most of the time), the MEC and Board can likely fulfill their duties by approving a list of applicants, with the understanding that the Medical Staff Office, department chairs, and Credentials Committee have done their jobs diligently, in accordance with the Medical Staff Bylaws and related policies.

The situation differs when material concerns have been raised about an applicant.  In that case, the MEC and Board should be provided more information about the concerns and the reasons for the recommendations of the department chair and/or Credentials Committee – even if the department chair and Credentials Committee have decided to recommend appointment or reappointment and the grant of clinical privileges, with no additional conditions or restrictions being put into place.

It can be helpful in emphasizing the Board’s responsibility for approving applicants for the Board Chair to require that the Chair of the Credentials Committee or the Chief of Staff personally present the approved list of applicants for Board approval.  The Board Chair would – each time – ask the presenter whether he or she personally approved the actions.  This all is pro forma but it emphasizes that the Board expects that those who send the list forward for Board approval understand the Board’s responsibility and accept responsibility for the recommendations they are making.

After being alerted to the general nature of the concerns involving the applicant, the MEC or Board (as applicable) can decide whether it would like to review the applicant’s credentials file, obtain additional information, or refer the matter back to the Credentials Committee for further consideration and recommendation.  Those bodies can only make such decisions, however, if they are made aware that there is something unusual about the applicant who is before them for approval.

So, the answer to your question is that, yes, when making credentialing decisions, it is sometimes necessary for the MEC and Board to be given more than a name on a list.

Please join us at The Credentialing Clinic this fall for more practical advice and tips for leaders performing credentialing functions.