Who Does What?

I’d like to discuss the topic of what we expect medical staff leaders to know and do vs. those individuals who support the medical staff credentialing and privileging process — specifically the medical staff professionals (MSPs).

When I’m working with an organization on credentialing and privileging, I often find that MSPs struggle to effectively manage the credentialing/privileging process. Sometimes, it is lack of knowledge, and in other cases, it is a lack of time. Many times, individuals who work in credentialing/privileges are overwhelmed by all the paper and have a difficult time assembling a coherent file for review by medical staff leaders (when you have a lot of paper, it is important to clearly identify the important paperwork, since medical staff leaders usually don’t have the time to carefully examine each and every piece of paper collected for initial appointment or reappointment).

If individuals in a medical staff office are hampered by lack of knowledge or are overworked and overwhelmed, is there a chance that files that are prepared for review by department chairs and the credentials committee won’t be as thoroughly scrutinized as they should be?

Most medical staff leaders heavily rely on MSPs to point out the issues in a credentials file — red flags such as gaps, lukewarm (or worse) references, applicant asking for privileges that he/she does not meet criteria for, etc. I’ve been in this business for thirty years, and I still see (and hear) department chairs ask “where do I sign” and I still see credentials committee meetings held at noon where the members are expected to arrive, pick up and eat their lunch — and, oh, by the way, thoroughly review some files during the meeting. I personally have seen some major items missed as a result of this type of process.

I’ve also been to the noon credentials committee meeting to see a checklist on each file, where the reviewer is expected to go through the file to make sure that the applicant is licensed, has a DEA, that the NPDB was queried, etc. In other words, the credentials committee member is asked to perform a file audit — in my opinion, definitely the work of the MSP.

In addition to review of individual credentials files, what should a department chair, credentials committee members and medical executive committee (MEC) members be able to rely on the MSP to know?

In my opinion, these medical staff leaders should be able to turn to the MSP for:

  1. Expert knowledge of regulatory/accreditation issues that impact credentialing and privileging. That means Medicare Conditions of Participation requirements, Joint Commission, DNV or HFAP accreditation requirements, regulations related to the National Practitioner Data Bank, and state-specific licensing requirements. If the MSP doesn’t have the immediate answers, she/he should know how to get the answers.
  2. Knowledge of what should be documented, and how the work of the various individuals and committees involved in credentialing/privileging should be documented, etc.

Obviously, the MSP is also responsible for oversight of credentialing processes (initial appointment, reappointment) and creation and maintenance of credentials files (whether in paper or electronic format) — among other tasks associated with the credentialing process.

Let’s be fair — What should the MSP expect of medical staff leaders, such as department chairs, credentials committee and medical executive committee chairs? At a minimum, the MSP should expect the chairs to:

  1. Reserve adequate time to review credentials files that are his/her responsibility. Ask questions when necessary. Pay special attention to requested privileges to assure that affirmative recommendations are made only for those privileges that the chair believes the applicant can safely and competently exercise.
  2. Spend the time to adequately prepare for meetings. The credentials and MEC chair have to take the time to collaborate with the MSP on what should be on the agenda, and assure that he/she reviews all agenda items prior to meetings, understands the important issues and is able to communicate those issues to committee members.
  3. Lead a well-run meeting. Make sure that there is thoughtful consideration of the issues before the committee, whether they are new appointments, reappointments, requests for new privileges, policies, procedures, privileging criteria, etc.

Finally, chairs should keep up with important information about the issues that impact the work of his/her committee by making a commitment to read available journals, newsletters and other materials — that will help to keep him/her updated on new developments, solutions and knowledge about what other medical staff organizations do to meet similar challenges.

I believe that attending meetings is a great way for medical staff leaders to obtain new information, as well as an invaluable opportunity to network with other medical staff leaders. If you can’t attend a meeting in person, you should consider “attending” a webinar. You will still have some opportunity to network with your colleagues if the webinar allows for some interaction between the attendees and the speaker(s).

Finally — if your medical staff organization doesn’t have the support you need to do your job as a medical staff leader — speak to your CEO. There are hundreds of qualified MSPs across the country — perhaps your organization needs to make the commitment to finding one (or more) for your organization. If you need a job description for this type of position, contact me — I’ll send you a sample.

3 thoughts on “Who Does What?

  1. Misty

    Do you think it is necessary to have a credentialing & privileging process within physician offices that is independent of the healthplan credentialing process? Or is it okay to rely on the healthplan credentialing process?

  2. Vicki

    I think that the healthcare organization that employs/contracts with the physician offices needs to have a process through which they can affirm to patients that they know that the practitioners to whom they are directing patients are credentialed and competent. I certainly wouldn’t advocate duplicating credentialing processes. It sounds as if the healthplan is responsible for the credentialing process. The physician office may just want to have a copy of the health plan requirements for credentialing so they can identify the specific standards that their practitioners met when credentialed by the health plan.

  3. Christian

    This is great information and should be shared with the credentials committee members (and MEC) before they agree to take on the role on a committee. They too have responsibility to understand what the Medical Staff Office prepares for them. I will definately be sharing this information.
    Thank you!


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