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Credentialing medical staff is almost like conducting forensic research! It is complex, has many moving parts and requires absolute attention to details. At stake from not conducting appropriate credentialing are heavy penalties, patient harm and loss of community trust. This essential part of any healthcare organization is all about protecting patients and providing them with the confidence that the medical provider of their choosing is qualified to help them with their medical needs.

Hospitals are obligated to do primary source verification on the credentials of their respective medical staff. Provider files are processed through a committee process that ultimately ends with Board approval. This process happens before a provider is allowed on the medical staff. It is incumbent on hospitals to avoid negligent credentialing at all cost.

Negligent Credentialing Defined

Negligent credentialing is a tort or a legal wrong, based on negligence. Negligence is conduct that does not correspond to what a reasonable person would do to protect another individual from a risk of foreseeable harm. Under the law, a person/entity is generally liable for any damages caused by his or her negligent conduct.

Patients go to a hospitals and clinics expecting that physicians are going to properly diagnose and treat their medical condition. The law imposes a legal duty on the hospitals and clinics to hire only doctors and staff who are qualified and competent. In other words, hospitals must verify that their medical providers are licensed and in good standing with the appropriate professional boards.

If a hospital fails to carry out its duty to hire only duly licensed and qualified providers, its conduct is negligent. If a patient is harmed by unqualified medical staff, the hospital can be legally responsible for damages along with the responsible medical provider.

What is Negligent Credentialing – Really, What is it Exactly?

Negligence can occur in two different areas: application and privilege requests. When a provider applies for membership and privileges, they submit an application. They respond to attestation questions, provide explanation for the gaps, and disclose details as required along with any unique situations that may affect their request for membership.

The data elements and supporting documents help in assessing the credentials and determine if they qualify to meet all criterion as detailed in the by-laws, rules and regulations and credentialing policy of the entity.

If a medical staff professional fails to validate, verify, and confirm these data elements at the primary source, it may result in negligent credentialing. Some examples of what must be verified at the primary source include:

• Education
• Boards
• Work history
• All state licenses
• DEA
• NPDB
• Claims verification
• Hospital affiliations
• Peer reference
• Comprehensives background checks
• Verify hospital affiliations and privilege forms from the past two reappointments
• Assess if privileges were dropped at prior two appointment and are the same privileges being requested at your entity

Clinical privileges are one of the most important elements that require a different level of scrutiny. The requested privileges should align with the education and training. Board certification lends additional weight; however, the most important factor in granting clinical privileges is based on the last two years of clinical competency, i.e. case logs and OPPE / FPPE reports. During reappointments, review any quality reports, complaints and peer review cases. Meeting the number of cases for each privilege as indicated in the forms is vitally important to assess competency.

Negligent credentialing comes into play when patient harm is caused, the harm may be due to provider incompetence. Did the entity follow medical staff bylaws, rules and regulations, policies, core/non-core privileging criteria, review prior case logs, clinical quality reports, peer review cases and any complaints from any other medical support staff?

The importance of establishing and uniformly applying credentialing criteria as well as documenting grounds for exceptions to minimize negligent credentialing claims is very important. Key takeaway is to – document, document and document!

Who is Impacted?

The effects of credentialing, whether negligent or compliant, are felt throughout an organization and the entire community it serves. Unfortunately, negligent credentialing is the event that will be remembered most. The impact of negligent credentialing is twofold:

• External – When one member of the medical staff is found negligent, it impacts the credibility of the entire organization –public trust is lost.

• Internal – The leadership involved in approving membership to their medical staff have to be accountable to other members of the medical staff, to any resulting financial hardship, and often have to implement corrective measures within a short timeline.

Education to Help Identify Negligence

Recruitment

Educate the recruiters and hiring teams on the impact of negligent credentialing; identify examples of exploratory questions, articles in the media, discuss high profile cases and explain why it is important to ensure hiring the right person is crucial to the well-being of the entity and the community it serves.

Committees that Decide on Approval for Membership and Privileges

Credentialing Committee Members, Medical Executive Committee Members and Board Members.

• When a new member joins in any of these three committees, make it a point to share the by-laws, credentialing policies, plus any pertinent rules and regulations. Walk them through the entire process and highlight criteria that may lead to a “red flag”.
• The importance of establishing and uniformly applying credentialing criteria as well as documenting grounds for exceptions to minimize negligent credentialing claims are vital to your medical staff operations.
• Encourage participation from the risk, compliance, and legal teams. They all bring their expertise to help navigate through undue influences. Medical Staff Professionals (MSP) – you are not alone, seek support from these individuals.
• Appropriate documentation is an art that MSPs have to learn. Inappropriate chatter versus specific discussions regarding the provider, capture exceptions and the reasons behind decisions, capture details on guardrails that the committee members are recommending as a condition for appointment.
• Ensure those guardrails and conditions are forwarded to the department chair and supervising provider.

How to Identify Hidden Triggers in Individual Credentialing Efforts

Being able to identify hidden triggers will help your team reduce the risk of negligent credentialing.

• Incomplete applications or unusual delays in responding to the questions/requests from Medical Staff Professionals (MSP).
• Gap explanations, selecting ‘Yes’ to the disclosure/attestation questions without appropriate explanation and lack of supporting documents.
• Short-term work history (exclude Locums and Military personnel).
• Lack of current peer references i.e. within the past two (2) years, only listing partners, missing authoritative reference, inability to provide current and valid contact information for the reference.
• Excessive malpractice claims that were settled and how current these cases are. Some specialties by nature have excessive number of cases filed i.e. OB/GYN – MSPs are aware of these susceptible specialties. If self-insured, high premiums to insure providers, NPDB reports.
• Call references and reach out to the relevant MSO for details on any data submitted on the applications – remember the provider has signed an authorization to release information.
• Wait! Did you conduct a background check? If the provider was convicted of a DUI, then was a substance abuse program recommended? Run as FSMB? Exclusion check?

How to Prevent Negligent Credentialing

Hire dedicated/trained Medical Staff Professionals (MSP)

• MSPs are great in digging up stuff!
• MSPs are your first line of defense in preventing negligent credentialing.
• MSPs are the first step to uphold patient safety.
• Allow your MSPs to do their job, they have a unique blend of dedication and doggedness to sniff out unwanted attributes.
• Keep political influences out of their way, you will never regret that decision!