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July 20, 2020

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

This post uses examples provided by an anonymous credentials chair to illustrate issues that jeopardize function and undermine efficacy within the committee, such as the need for reallocation of problem management and apathy among credentials committee members.

Blog author Hugh Greeley provides a detailed and specific plan to address these issues, effectively providing actionable models that can be tailored to any credentials chair.

The following is provided by Hugh Greeley, author of Hugh’s Credentialing Digest

Recently I received a very interesting question from a credentials chair who wishes to remain anonymous. Apparently, he was assigned as credentials chair in January and has tried to perform his job well. He mentioned four issues that seem to compromise the provider credentials function:


  1. His committee members are apathetic and non-participatory. Attendance is poor and participation is worse. Unless an issue relates to their specialties, they sit back and listen.
  2. His long-term Medical Staff Services Professional (MSP) retired after many good years, and her replacement is untrained, and “not detail-oriented”.
  3. The community is in need of additional physicians, and management is busy recruiting “any warm body” and using locum tenens doctors to fill in until more physicians can be recruited.
  4. There is no hospitalist program, and primary care physicians are trying to cover their patients with Physician Assistants (PA) and Advanced Practice Registered Nurses (APRN).

He wondered what he should do to begin to address these issues.

We spent about forty minutes on the phone and developed the following plan of action.

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  1. He will meet with the Chief of Staff and request permission to select his own committee members. The bylaws specify that committee members are selected by the Chief of Staff to be confirmed by the Medical Executive Committee (MEC). We agreed that the committee should be kept small and that he would start the first meeting by stating that each meeting will begin with a short period of discussion and education about credentialing. (He will, of course, include the MSP in each meeting and will ask her to present part of the educational content).
  2. He will meet with the new CEO and arrange for the new MSP to begin training for the position including association with, and education through the National Association of Medical Staff Services, NAMSS. He also will encourage the CEO to find a telementor for her. However, he does not hold out much hope for her because of personality issues and past performance.
  3. He will also speak with the CEO about the recruitment program and will offer to meet with each serious candidate for a three-part interview that includes discussions of clinical, culture, and overall intention. He is certain that the CEO will accept his offer because of two recent recruitment debacles that were both embarrassing and costly.
  4. He will place the Hospitalist/PA/APRN issue into the lap of the Chief of Staff and the CEO in a formal meeting, during which he will point out that the facility needs a program and that it should join the rest of the nation in this regard. He believes that his committee will be able to deal with the competency issues with PAs and APRNs but is not in favor of permitting patients to be cared for in the hospital without physician supervision.


Many readers will recognize that, while these steps may improve the situation somewhat, the long-term issue is a lack of leadership on the part of the MEC, CEO, and Board.

This has led to apathy and failure to provide for long-term education of Medical Staff Professional (MSP) leaders, lack of sound succession planning, and lack of medical staff strategic planning for the needs of the community.

Hopefully, this medium-size, semi-rural organization will be able to make the changes necessary to serve the community without compromising the quality of care provided.


The bottom line falls on the credential chair’s shoulders to follow the process when appointing physicians to the staff. The ability for a chair to run an effective committee has everything to do with the culture of the entire organization as well as the competence of those appointed to the committee.

Rather than relying on committee members, medical staff professionals, and members of the medical executive committee, a credential chair can screen all applicants initially against primary source data publishers for red flags designated by the 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 that applicant is excluded by the OIG or listed on an abuse registry, they can be flagged early in the screening process.

Verisys Connect® is Verisys’ self-service data search portal that provides real-time data solutions to check current and historical national license status, a history of disciplinary actions, exclusions, debarments, sanctions, and other critical primary source data such criminal or abuse records.

CheckMedic® is the enterprise-wide, turn-key solution to screening, credentials verification, and continuous monitoring against more than 3,500 primary sources including FACIS®. CheckMedic® issues a MedPass® to each provider and employee as a comprehensive digital credentialing profile for all data, credentials, peer reviews, board certifications, license status and history, and other relevant data. The MedPass® is a secure, portable digital credentials profile and has custom alerts for expirations, CEU requirements, and actionable adverse actions.

Data Insights for Health Care Best Practice is a downloadable whitepaper outlining 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.

Juliette Willard Written by Juliette Willard
Healthcare Communications Specialist
Being creative is my passion! Writer. Painter. Problem Solver. Optimist.
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