Introduction

HortySpringer Pathways Webinar Session 4: Speed Training: Credentialing and Privileging Potpourri

Have you heard of speed dating?  Well, welcome to “speed training.”  During this final installment of the 2025 Pathways leadership training program, we will cover four distinct areas, each lasting approximately 30 minutes.  These short, targeted sessions are great for offering bite-sized, “need to know” training to specific audiences (though all registrants are welcome to stick around for the full two-hour session).

Topics to be Covered:

• Speed Training for Board Members: In recent years, many hospital governing boards have drifted away from their close oversight of the Medical Staff, largely deferring to the MEC to handle credentialing.  Often, that goes seamlessly.  But how can governing board members satisfy their duty of care to the hospital (and its patients) if all they see is a list of names presented at quarterly meetings?  In this fast-paced segment, we will discuss the hospital board’s overall authority for Medical Staff credentialing and provide recommendations for exercising that authority without getting bogged down in the details.  We will walk through a couple of options, including a sample report that offers the board the information it needs to fulfill its duties.

• Speed Training for Physician Recruiters: Buckle up for a speedy run-down of the credentialing continuum, with emphasis on eligibility criteria and time frames for the process.  We will discuss tips for talking with potential candidates for employment about the Medical Staff credentialing process (e.g., the importance of getting an application in timely, the importance of being upfront about “issues” in the practitioner’s background that could hamper or delay credentialing, avoiding misleading language in letters of intent).  We will also walk through a checklist of contract terms that recruiters/employers/contractors should consider utilizing to avoid being “stuck” with a candidate who is not eligible for appointment and privileges at the hospital. 

• Speed Training for Practitioners Not Involved in Leadership: Looking at the credentialing continuum, we will cover the credentialing process from the perspective of an applicant for appointment or reappointment.  After requesting an application, what should you expect in terms of process and timeline?  Will  you automatically be considered for temporary privileges – or do you need to request those?  Why does application processing take so long?  What’s the big deal if information is missing from your application?  What happens if you ignore a letter asking for more details about the application?  Can you just call up the department chair or Credentials Committee chair to talk it out?  Once the application is submitted, what obligation do you have to inform someone if your credentials change (for example, you are notified that the state board is investigating your practice)?  If you withdraw the application before final action, will that be reported to the state board or NPDB?  If you’ve been recruited or have signed an employment contract with a hospital or its affiliate, is the credentialing process just a formality? 

• Speed Training for Credentials Committees: Looking at the credentialing continuum, we will discuss the activities within the continuum that fall within the scope of the Credentials Committee’s duties (e.g., recommending waivers, reviewing complete applications, requesting more information when any questions/concerns are raised, articulating how questions/concerns were resolved prior to recommending appointment and privileges, tailoring FPPE where applicable, reviewing and modifying FPPE upon completion, reviewing and recommending privilege delineations developed by departments or specialties, reviewing and making recommendations on requests for new privileges and privileges that cross specialty lines).  We will also discuss the activities that fall outside the Committee’s scope of authority (e.g., making recommendations regarding the employment of a practitioner, making eligibility determinations, granting waivers, and other administrative matters).