Hugh’s Credentialing Digest – Credentials Committee Organization and Management

Recently, while watching a credentials committee in action, I was struck by the lack of organization and committee management evident in the room.

Below are a few of my observations:

• The chair arrived late and immediately began a conversation with another member about a patient.

• Of the eight appointed members, only four were present.

• The 67 files in need of review [nine appointments, four locums, eleven advanced practice registered nurses (APRNs) or physician assistants (PAs) and 43 reappointments] had not been pre-reviewed by the chair, who proceeded simply to hand them out to the members, expecting review.

• Members searched for items to review and, astoundingly, asked the most basic questions, such as, “Where is the license or certification?” and “Have we conducted an NPDB check yet?” The most interesting comment came from a member who arrived late: “We should just lose this application—I know this guy!”

• When reviewing the application of an APRN, one member mused about how a particular staff member could actually supervise so many APRNs or PAs.

• The chair, upon noticing the time, called for recommendations and, within a matter of seconds, all files were approved for forwarding to the medical executive committee (MEC).

• Exactly 47 minutes after the meeting began, the chair simply said, “Meeting over. Thanks everyone,” and left.

• The medical staff professional (MSP) was left to collect all the files, rearrange them and otherwise restore them to some semblance of organization.

• One member hung around for a few minutes and asked the MSP if the hospital really needed this many locums physicians.

• Most lunches were hardly touched.

What should have happened?

1. 1. The chair should have reviewed the agenda in advance, should have worked with the MSP to categorize all files into one of three groups: no brainers; needs careful review and discussion; and needs more work prior to committee review. This would have resulted in the need for review of only one file, that of a physician up for reappointment who had not had any clinical activity for the past three years. (He was recommended for reappointment along with the other 43 reappointments, without discussion.)

2. The chair should have arrived in advance and greeted and thanked members, thus demonstrating the importance of the committee’s work.

3. Any file in need of review should have had such review in advance, with the reviewer leading the discussion regarding action.

4. Questions about the “need for more practitioners” should have been resolved in advance, through a planning process. Credential review is not the time to debate whether a physician or specialty is needed.

5. All members should have been educated about the process so they fully understood that files not containing basic material would not be presented. (This does beg the question, “What is a credentials committee’s function?” See my corresponding article addressing its evolving role.)

6. Lunch should not have been served.

The above does not represent a typical credentials committee, but it does suggest that, at least in some cases, the process continues to demand greater attention and also that committee members must be well-oriented and managed by a well-trained and experienced chair and medical staff credentials assistant/manager.

See another post by Hugh Greeley on Embracing Change.

Written by Hugh Greeley Credentialing and Healthcare Industry Expert HG Healthcare Consultant Connect with Hugh