4 Steps to Becoming an Effective Credentials Chair to Ensure Good Decisions

There is no doubt that being the chair of the credentials committee comes with great responsibility. Ultimately, deciding to appoint a physician to the medical staff falls on your shoulders. 

When a credentialing committee doesn’t run effectively, it can jeopardize the quality of patient care and the hospital’s reputation. Below, we will look at a scenario that some credentialing chairs may relate to, as well as ways to improve the function of your credentials committee. 

Challenges Facing a Credentials Chair

Hugh Greeley, the author of Hugh’s Credentialing Digest, provides the following example.

A new credentials chair struggled to perform the job well despite their best efforts. In this particular incident, four issues seemed to compromise the committee’s functions.

1. Committee members are apathetic and non-participatory. Attendance is poor, and participation is even worse. Members just sit back and listen unless an issue relates to their specialty.
2. The long-term medical staff services professional (MSP) retired after many years, and the replacement is untrained and “not detail-oriented.”
3. The community needs additional physicians, and management is busy recruiting. But, spots are being filled too quickly with underqualified candidates. Locum tenens doctors are being utilized until more physicians are hired.
4. There is a lack of a hospitalist program. This has led to primary care physicians trying to cover their hospitalized patients while unsupervised physician assistants (PA) and advanced practice registered nurses (APRNs) manage the other hospitalized patients.

Four Steps To Resolve Credentialing Committee Chaos

1. Select your own committee members. Work with your Chief of Staff to reappoint current members or select their replacements. New committee members will need confirmation from the Medical Executive Committee (MEC). Keep the committee small and set expectations at the first meeting. Consider a short period of discussion and education on credentialing before the start of each session to help members understand their role in providing quality care to the community.
2. Arrange for the training of new personnel involved in the credentialing process. There is a lot to learn; the better equipped MSPs are, the more efficient this process will be. Online education is available through the National Association of Medical Staff Services (NAMSS). If possible, find a mentor for new MSPs to help them through this training process.
3. Improve recruitment. Adjusting your recruitment program may bring in better qualified candidates. Meeting with serious candidates to discuss clinical, cultural, and overall intentions may prevent hiring candidates that are a poor fit. This can help avoid embarrassing and costly incidents from occurring.
4. Put necessary clinical programs in place. In this case, the hospital didn’t have a hospitalist program. But, other institutions may lack other clinical programs that can significantly improve patient care, such as teleneurology to manage acute strokes. This would involve working closely with hospital leadership to explain the benefits of these services.

The First Step is Followed by Long-term Planning and Solid Leadership 

Many readers will recognize that while these steps may improve the situation somewhat, the long-term issue is a need for more top leadership, including the Board and MEC. In this case, ineffective leadership led to apathy and failure to provide:

• Long-term education of MSP leaders
• A sound succession plan
• Development of a strategic plan for medical staff to meet the needs of the community

As most of us can relate, changing hospital culture and adding clinical programs takes time. But, making necessary changes to improve your credentialing committee processes benefits the community you serve without compromising the quality of care.

How Primary Source Data is a Credential Chair’s Best Friend

Rather than relying on committee members, MSPs, and members of MEC, a credential chair can initially screen all applicants. By screening against primary source data, you can quickly identify candidates with red flags as designated by your organization’s rules, regulations, and bylaws.

That way, it’s not left to a visual scan of an application to determine whether an applicant should move further along the approval process. If an applicant is excluded by the Office of Inspector General (OIG) or listed on an abuse registry, they can be flagged early in the screening process, saving everyone time. 

Verisys Connect® is a self-service data search portal that provides real-time data solutions for checking current and historical records through FACIS, Verisys’ proprietary database. A single search pulls the following from over 5,500 primary sources:

• State license(s) status
• Disciplinary actions
• Exclusions
• Debarments
• Sanctions
• Other critical primary source data, such as criminal or abuse records

FACIS is the largest and most comprehensive sanction database. It is continuously updated with over 75,000 records added monthly and undergoes rigid quality assurance. In addition, our advanced technology uses matching logic to check for nicknames, alternative spellings, and various formats of hyphenated last names. All this gives you the most accurate results with a single click.

Learn more about how Verisys can assist your healthcare organization with pre-screening potential candidates.