If you don’t know the answers to these 5 questions, your credentialing accreditation could FAIL!

Are your files complete?

Is your staffing adequate?

Is your reappointment process up to standards?

How do you credential allied health professionals correctly?

Is your peer review process working?

See answers below.

5 MAJOR FACTORS Contributing to ACCREDITATON CREDENTIALING FAILURES:

Incomplete, missing and disorganized documentation in credentials files.

Presentation is everything. As your appearance makes a first impression, likewise, the state of your credentials files will impress a surveyor, either positively or negatively. Your files should be organized in a manner so the surveyor can find what he/she is looking for with little assistance. With the new tracer methodology used by TJC, you may not be present to look for documents when the surveyor examines your files. Do they pass the test? Does the file contain a history, a paper trail of evidence to assure the surveyor of the practitioner’s current competence and that you credentialed him appropriately? Surveyors have commented that they can tell whether a survey will be successful by the state of the files. CSS will conduct file audits and assess your survey-readiness.

Inexperienced, inadequately trained credentialing staff unable to correctly interpret and implement accreditation standards and regulations.

It is surprising that many medical staff offices are functioning with inadequately trained personnel. Indeed, inexperienced staff can unwittingly sabotage your efforts to maintain an efficient credentialing process by overlooking important information when reviewing an application. They may not be familiar with the “red flags” that could indicate an incompetent physician.

Is your staff able to review and evaluate documents for compliance? Can they correctly interpret complex bylaws, regulations and accreditation standards. Is their workload so overwhelming that they take seemingly innocent little “shortcuts” just to get the job done and miss vital information or skip important steps in the credentialing process just to get the job done? Those in the profession know there is always more work required than available staff.

On the other hand, you may have approval to hire more staff, but can’t find anyone with skills and experience in credentialing. Or you need additional help but haven’t been able to get approval to hire more staff in spite of a growing workload.

There are solutions to these problems that CSS can provide that include interim staffing, education, training and staffing needs analyses. Have you considered that the Medical Staff Services Department is the equivalent of a Human Resources Department for the medical staff? And at your facility, is the ratio of staffing in HR comparable to the ratio of staffing in the Medical Staff Office, i.e., number of employees to HR staff vs. number of physicians to MSO staff? Take a close look at what’s around you for a compelling argument for additional help and look to CSS to assist you in developing your proposal.

Breakdown in the reappointment process that tolerates illegal appointment extensions and temporary privileges.

A thorn in your side may be the JC standard that requires appointment terms not to exceed two years – not by a single day! How frustrated are you with this seemingly unreasonable requirement, knowing that despite a national movement by NAMSS to abolish this rule in favor of documenting continuing competence, we are “stuck” with the hard reality that we must not only undergo a re-credentialing process, but that it must be completed within a limited time-frame. And more often than not, we are confronted with those practitioners who are consistently delinquent in completing and returning their forms, causing added stress to you and your staff. What is a medical staff services professional to do short of hand-delivering the forms and filling them out for the physician?

And unfortunately, it can happen that a frustrated medical staff will approve extended appointment periods and/or temporary privileges until the re-application process is complete. Some even include this option in their bylaws! This solution should be avoided at all costs as it is indeed in violation of regulatory requirements. In this scenario it is better to terminate the practitioner’s privileges on the expiration date and immediately implement a fast-tracking application process that will bring the practitioner back on staff with minimum interruption to his practice at your facility. Usually, by the time you are at the point of terminating the physician’s privileges, he is willing to do anything to cooperate and likewise, the medical staff that wants him on staff will provide the opportunity. On the other hand, if the practitioner has little or no activity at your facility, why do you want him back? CSS offers assessment and assistance for your reappointment process!

Confusion over how to credential allied health professionals and document current competency.

We have come to the point where accrediting bodies are now requiring the same extensive evaluation of allied health professionals as physicians while our hospitals aren’t “programmed” to provide data on AHPs. What can be done until this technology problem is resolved sometime in the distant future? Are you collecting any data for assessment of your applicants? If so, who is providing the information? And now many AHPs employed by the facility are required to be credentialed as well. How do you determine which categories of AHPs must be credentialed?

An interdisciplinary AHP committee should be functioning in your facility to help you address these issues. This committee can be comprised of medical staff, administrative staff, nursing directors, quality management and allied health professionals representing all categories of AHPs pacticing at your facility. And remember, the burden or proof is always on the applicant. You can institute a requirement that the AHP periodically provide you with their patient rosters and then have your committee review random chart audits to assess competency – one way to get the job done!

Peer review malfunctions. Why is it that physicians are reluctant to participate in peer review activities? Is it apathy, or fear of finger-pointing?

Physicians today are often too busy to participate in department and peer review committee meetings, even with an attendance requirement for continued medical staff membership. And, if facilities drop, diminish or ignore meeting attendance criteria for reappointment, there is no incentive to come to these important meetings. If this is your situation, find a physician “champion” on your medical staff to recruit physician participation. It doesn’t have to be the Chief of Staff or Vice President of Medical Affairs. Look to your “quality physicians” for someone known and respected by the medical staff and is interested in encouraging physician involvement in peer review as vital and essential for good patient care.

Are you still conducting peer review strictly within your clinical departments instead of an interdisciplinary group? Although successful peer review is dependent on peers with expertise in the specialty undergoing review, a pitfall to restricting peer review to a single discipline is the potential implication of prejudice, bias and even anti-tort. Diversify your peer review program to protect your physicians and your facility. Include all disciplines represented on your medical staff and when required, invite additional expertise from physicians in the specialty under review.