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HOW THE CREDENTIALS COMMITTEE PROTECTS A HOSPITAL’S REPUTATION

June 15, 2020

A GOOD REPUTATION IS BUILT OVER TIME AND LOST IN A DAY

The Credentials Committee plays a key role in the reputation of a health care system or a single hospital. There is much more in play than medical competence. Yet, that set of criteria carries the most weight when hiring a provider at a hospital, clinic, or health system.

Hugh Greeley’s message to the credentials committee and the medical staff services professionals provides valuable organizational processes to assure that moral and professional character is considered alongside education and clinical competence during the credentialing process.

A health care institution’s reputation is at the forefront when it comes to physician recruitment, the health care consumer’s choices, and the quality of board appointments. In light of the recent awareness of human rights and equality, paying close attention to the moral character of providers and leadership will build a stronger, more ethical institution.

By Hugh Greeley, author of Hugh’s Credentialing Digest

THE ROLE OF MORAL AND PROFESSIONAL CHARACTER IN CREDENTIALING

Early credentialing tradition specified that an applicant to the staff be legally and clinically qualified, and of good moral and professional character. These principles hold true today, yet the latter (good moral and professional character) receives far less attention than the former, especially at the medical staff level.

In the past and in many organizations today, an applicant’s moral and professional character is modestly evaluated through professional references and a criminal background check. The results of both are not automatically actionable, but they require some consideration before a decision can be made.

REPUTATION MATTERS!

Consider for example the conundrum the credentials committee would find itself in if a reference reported that an applicant had defaulted on his or her medical education loan or had lost a civil case involving the discharge of an employee due to that employee’s sexual orientation, stance on abortion, or religion. Or perhaps that reference might include a newspaper’s report that the applicant had publicly and violently expressed disdain for Muslims, Christians, or atheists. That would be an interesting meeting indeed.

Some committee members might say these issues have nothing to do with clinical competence, while others might claim that they go to the very heart of medical staff professionalism.

HOW THE ORGANIZATIONAL PROCESS PROTECTS A HOSPITAL’S REPUTATION

Likely, the credentials committee would punt the matter to the medical executive committee (MEC) with a recommendation worded as follows: “We have found that this applicant is legally qualified for appointment, that he has demonstrated clinical competence in his treatment of patients, and is held in high clinical regard by his peers. We have also identified information that transcends both legal and clinical issues and suggests that the MEC carefully review this information prior to making a recommendation to the board.”

The MEC meeting during which the credentials committee’s recommendation is considered also would be an interesting and carefully documented one. If a positive recommendation were to reach the board, the issue might be addressed more directly.

For example: “Our reputation is dependent upon that of our physicians. Appointing this physician to our staff when he has clearly failed to repay a government-guaranteed medical education loan would not create a positive image for the organization and will likely lead to this providers’ exclusion from government programs. Do we want to walk that line?” Or, “I will not be a party to the appointment of a bigot to our staff unless he has signed a binding document promising to relinquish his appointment without contest in the event he engages in any such action in the future.” This might be followed by a senior board member and attorney stating, “We must adhere to high standards in our appointment decisions. Issues affecting our reputation must be seriously addressed. Would we hire such an applicant?”

FULL TRANSPARENCY OF APPLICANTS HELPS MAKE THE RIGHT HIRING DECISIONS

The conversation might well be cut short by the CEO, proclaiming, “Well, I’m shocked that we are considering offering this applicant employment. That decision is now on hold. The board might well appoint him as a private physician, but it is doubtful that we will hire a person who has defaulted on his medical educational loans.” (A side discussion with the medical director of the employed physician group certainly could disrupt the board meeting.)

“Order, I call for order!” the chair might snap. “I would entertain a motion that this issue be tabled pending further investigation and consideration.”

“So moved, seconded, and carried unanimously.”

It is becoming clear that credentials committees should be provided with accurate, verified information about an applicant’s professional and moral conduct, as well as information pertaining to education, training, experience, and evidence of current clinical competence. If the inquisitive public can easily obtain such information, so too should the credentials committee or board. No longer should we tolerate the hackneyed comment by a committee member that, “it has nothing to do with clinical competence and therefore is not our business.”

WHERE AND HOW TO FIND REAL-TIME PRIMARY SOURCE DATA

Verisys Connect is Verisys’ self-service data search portal that provides real-time data solutions to check into criminal background, a history of disciplinary action, and other critical primary data sources.

Data Insights for Health Care Best Practice outlines data sources and how including a larger net of data insights can help protect a health care organization from reputational damage.

Also, the e-book, “Closing the Five Critical Gaps in Health Care Screening, Verification and Monitoring for Credentialing” reveals the data solutions that close the data gaps so often missed and that contribute to organizational risk.

Hugh GreeleyWritten by Hugh Greeley
Credentialing and Healthcare Industry Expert
HG Healthcare Consultant
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