credentials

December 5, 2019

Posted on by hortyspringer

QUESTION:        Our hospital recently received a request from a former Medical Staff member for a complete copy of his credentials and peer review files.  The files are thick – he had a fair number of clinical and behavioral concerns while on our staff.  Are we required to provide the copies as requested?

 

ANSWER:           State law needs to be reviewed.  However, in most states, hospitals are not required to provide former Medical Staff members (or even current members) copies of their credentials and peer review files.  (In contrast, state law often does require that employees be granted access to personnel files maintained by Human Resources.)

Assuming state law is silent, the next question is whether the hospital has a policy addressing such requests.  Naturally, if a policy exists, it should be followed.

If there is no such policy, the hospital should consider how such requests from former Medical Staff members for copies have been handled in the past.  While a hospital is not bound by the past and is always free to adopt new procedures, it should be careful to avoid allegations that individuals are being treated differently for a discriminatory reason.

The best practice, of course, is to adopt a policy that governs Medical Staff members’ access to their credentialing and peer review files.  For existing Medical Staff members, the policy might describe the rules for accessing “routine” and “sensitive” documents, with sensitive documents receiving special protection (for example, names of those who raised a concern will be redacted).  For former Medical Staff members, the policy could state simply that copies will not be provided, but that the hospital will provide information upon request to other hospitals as directed by the former Medical Staff member for credentialing and peer review purposes.

September 13, 2018

Posted on by hortyspringer

QUESTION:        We are reviewing an application from a new applicant who has excellent credentials with respect to his education, training, experience and current clinical competence.  However, the applicant has had trouble working with others and was even subject to a behavioral performance improvement plan at his last hospital.  The Credentials Committee is split over how important behavior really is when a candidate otherwise has excellent credentials.  How should we proceed?

ANSWER:            This is a question we hear often.  You finally find a physician who has excellent credentials, but acts out a little.  While everyone has a “bad hair day” once in a while, it is a mistake to bring someone into your organization whose behavior will undermine your culture of safety.

This is the terminology used by The Joint Commission when it issued its 2008 Sentinel Event Alert.  According to the Sentinel Event Alert:

“Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions….All intimidating and disruptive behaviors are unprofessional and should not be tolerated.”

The Sentinel Event Alert was followed by the adoption of a leadership standard that required hospitals to adopt a code of conduct or professionalism policy.

Recognizing the importance of working professionally and respectfully with others, most credentials policies require applicants to demonstrate an “ability to work harmoniously with others, including interpersonal and communication skills sufficient to enable them to maintain professional relationships with patients, families, and other members of health care teams.” The bottom line is that behavior matters in the quality of care you provide in your hospital.

So in credentialing the applicant, get as much information from previous hospitals and past employers about his or her ability to work with others.  Ask for a copy of the behavioral performance improvement plan.  Ask for a copy of the underlying concerns that led to the adoption of the performance improvement plan.  Request a copy of any correspondence that relates to behavioral concerns.  And don’t forget to make follow-up phone calls to references and to others who may have worked with the applicant in the past to get a candid evaluation of any problems.

A physician who experienced a problem period because of personal issues, but then improved should not be problematic.  A physician with a longstanding pattern of inappropriate and unprofessional behavior is not likely to change when he or she lands at your hospital.  Don’t forget the middle option of conditional appointment which can also be useful in laying out expectations and consequences should the inappropriate behavior reoccur.

Please join us in our national program – Credentialing for Excellence – where we discuss this and other credentialing challenges.

October 5, 2017

Posted on by hortyspringer

QUESTION:        Can credentials and peer review information about a practitioner be shared with a sister hospital if the sister hospital has the same Board, but each has its own separate Medical Staff?  Should they?

ANSWER:            Hospitals that are affiliated under the same Board, in a system, can exchange information, although we recommend several steps to maximize legal protection. We generally recommend including a provision in each hospital’s Medical Staff bylaws or credentials policy, as well as a statement on the application form, that the applicant understands that information will be shared among entities in the system and that the sharing of this information is not intended to be a waiver of the state peer review protection statute.  It is also a good idea to have a formal information?sharing agreement among the hospitals which clearly defines what information will be shared, when it will be shared, and to whom it will be forwarded.

As for whether the hospitals should share information, the answer is yes. Two hospitals under one Board would be considered one corporate entity.  Each individual hospital (or clinic, health plan, ambulatory surgery center and any other related facility) is part of that one entity.  Important to the Medical Staff leaders responsible for helping to maintain high standards of care through careful and thorough credentialing of physicians is the fact that because it is one entity, credentialers may be “deemed” to be making recommendations as to whether a specific practitioner is qualified and competent based on the collective knowledge of the entity as a whole, rather than the knowledge contained within an individual hospital.  The standard in the law — when it comes to doling out liability — is that the credentialers “knew or should have known” the relevant information that came from the sister facility.

May 5, 2016

Posted on by hortyspringer

QUESTION:        Can credentials and peer review information about a practitioner be shared with a sister hospital if the sister hospital has the same Board, but each has its own separate medical staff?  Should they?

ANSWER:            Hospitals that are affiliated under the same Board, in a system, can exchange information, although we recommend several steps to maximize legal protection, standardize the process, and quell any paranoia that may exist with regard to such sharing. We generally recommend including a provision in each hospital’s medical staff bylaws or credentials policy, as well as a statement on the application form, that the applicant understands that information will be shared among entities in the system and that the sharing of this information is not intended to be a waiver of the state peer review protection statute.  It is also a good idea to have a formal information-sharing agreement among the hospitals which clearly defines what information will be shared, when it will be shared, and to whom it will be forwarded – all of which is drafted in compliance with and with appropriate references to the state peer review statute.

As for whether the hospitals should share information, the answer is yes. Two hospitals under one Board would be considered one corporate entity.  Each individual hospital (or clinic, health plan, ambulatory surgery center and any other related facility) is part of that one entity.  Important to the medical staff leaders responsible for helping to maintain high standards of care through careful and thorough credentialing of physicians is the fact that because it is one entity, credentialers may be “deemed” to be making recommendations as to whether a specific practitioner is qualified and competent based on the collective knowledge of the entity as a whole, rather than the knowledge contained in an individual hospital.  The standard is the law – when it comes to doling out liability – that the credentialers “knew or should have known” the relevant information that came from the sister facility.