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Avoiding Credentialing Hazards


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Avoiding Credentialing Hazards

By Tom A. Augello, CRICO

Related to: Emergency Medicine, Primary Care, Obstetrics, Other Specialties, Surgery

Malpractice insurers and specialty boards try to help hospitals protect patients and providers from bad actors.


  • Christine Cassel, MD, MACP; American Board of Internal Medicine; Philadelphia, PA
  • Jeannette Clough; Mt. Auburn Hospital; Cambridge, MA
  • Jack Mc Carthy; CRICO/RMF; Cambridge, MA


Whenever the newspaper has a tantalizing story about a physician practicing without a license… or in a field he or she wasn’t trained for… or adding one more bad event to a long personal history, hospitals and medical groups are reminded of the hazards associated with credentialing.

The response from the public—and sometimes the courts—is usually to ask, “How could you have let them practice there?” Hospitals and networks are actively looking for ways to maximize protection for providers and patients alike. The credentialing process verifies a provider’s qualifications and good standing, and privileging is a process to match a clinician’s request to perform specific procedures at the facility to evidence of appropriate training and experience.

Now, some third parties as diverse as malpractice carriers and specialty boards are joining the effort. Jack Mc Carthy is president of CRICO/RMF, the malpractice self-insurance program in the Harvard medical system.

“I think that our concern as we review cases is that institutions do a good job of determining who is really qualified to do a procedure, particularly if you are dealing with a new type of procedure. What level of training and experience is really appropriate before you turn someone loose to do it on their own vs. a supervised setting?”

Mc Carthy says that the CRICO board, which includes leaders from each of the Harvard teaching hospitals, is looking for additional reassurance. The malpractice carrier has offered incentives for certain skill development connected to patient safety. And it will explore whether it can expand service to help hospitals understand the risks outside their walls.

“I think the second part of the issue really relates to the setting for the procedure. So in some cases we have seen physicians who are either about to or are doing procedures in their office involving anesthesia of various sorts where they don’t really have the backup necessary if they get into trouble with that patient. If you look at it from the standpoint of a malpractice insurer, there may be situations that we’re insuring where the credentialing and privileging arm of the sponsoring healthcare institution doesn’t extend.”

In addition to help from outside organizations, hospitals themselves are doing a great amount of work to tighten the credentialing and privileging process. Mt. Auburn Hospital in Cambridge, Massachusetts has emerged from a front page controversy that involved a surgeon leaving a patient on the operating table to go to the bank. The hospital is now a leader in making sure the physicians who have privileges are very carefully credentialed. Jeannette Clough is President and CEO at Mt. Auburn.

“Having lived through one or two very significant events at our hospital, we have taken a very different approach to credentialing than we had at the time.  Our approach is that the onus and the accountability for providing the information, its verification and for the application be fully completed, including a full explanation of not only malpractice but any sort of disciplinary actions that have been taken, is really the responsibility of the physician.”

Physicians cannot get privileges at Mt. Auburn now without a criminal background check and a look at disciplinary actions by licensing boards in all 50 states. Other rules have changed. Temporary credentials, for example, have been virtually eliminated. The credentialing committee must have a quorum to meet and consider an individual application.

According to Clough, the past orientation of department chiefs tended to be toward solving the problem of getting a physician on staff for coverage. Now the chiefs are getting assistance with ensuring that credentialing is robust.

Clough says the benefit to physician leaders is most apparent in the process for Reappointment every two years for already-credentialed physicians, a new area of emphasis for the hospital.

“Again, many, many changes, but another one that we took very seriously was this issue around physician behavior. Our physician and hospital leadership formed a committee to look at setting standards of behavior so that now our chairmen and chiefs have a guideline to go by that is required reading and requires a signature of all physicians before they join our medical staff.  It’s standards of professional conduct that is about a page and a half long and really speaks to our expectations.  Again, it makes it much easier for physicians to identify aberrant behavior as they look at both reappointment as well as any issues that might come up before reappointment.”

The hospital is providing additional education to chiefs, and pledged to make the process timely, making sure that verification materials and recommendations are in place within 90-120 days. The credentialing committee has been expanded to include board members and representatives of the lay public. Files are kept on every physician in preparation for reappointment. Complaints are now incorporated.

Clough says this also helps bolster a chief considering a colleague’s reappointment.

“The chiefs and the chairs need to feel as though they have a lot of support and a lot of resources to confront or to question an applicant, particularly on reappointment because I think they have established some sort of a relationship with the person at that point.  If they don’t feel like they are being supported, that would be a problem and you’re likely to have issues go unaddressed, which could come back to influence patient care at a later date.”

Clough says that hospitals face increasing challenges as technology advances rapidly in health care. Determining what a physician is capable of doing is a growing concern in the granting of requests for privileges.

Dr. Christine Cassel is president of the American Board of Internal Medicine. She recently co-authored an editorial in JAMA. It accompanied a study showing that less than half of health plans in America require pediatricians to be board certified. Dr. Cassel believes board certification can be an additional tool for hospitals and networks evaluating competence.

“All of the recognized medical specialty boards now have gone to a requirement for continuous maintenance of certification, which means it is not enough for someone to be board certified once at the beginning of their career and then always and forever more they are board certified.  You now have to do certain kinds of things and pass exams on a periodic basis, usually every 7-10 years, and if you don’t, then you are no longer certified.  Many hospitals who use certification for their credentialing don’t go back and check whether the person has maintained or kept up their certification.”

This year, for the first time, the voluntary performance assessment part of board certification maintenance became mandatory for recertification. Cassel says maintenance certification is offering clinicians and institutions a way to demonstrate some basic ongoing reassurances.

“It is a core value of professionalism that we as physicians stay up to date with the medical literature, make sure that our skills are current and in the modern world understand the measures of quality and outcomes for our patients that are available to us so that we can improve our practice.  It happens that all of those components are part of maintenance certification.  Physicians can certainly do those things outside of the certifying process, but the profession has created for these specialties a certifying process and so setting those expectations is part of why the boards were created.”

At Mt. Auburn Hospital, every provider has been brought under the credentialing umbrella, including moonlighters, and residents. But Clough says, even though she can sleep at night knowing her institution is going above and beyond the basics, there are still some areas in health care that are blind spots for credentialing. She says there is a lot that hospitals don’t know, including outside professional behaviors that have not risen to the level of criminal or civil conviction—or even review by a licensing board.

“Bad behaviors that may be evident in a disrespect to patients, a disrespect to nurses, a disrespect to other colleagues, things along those lines.  It is very hard to find that out.  Lastly, I would say that lacking a general database.  We really don’t know what other physicians are doing in other practice settings as it pertains to infections, in terms of blood utilization, in terms of other daily parameters, length of stay, etc. that may play a part in both the quality of care and the efficiency of care at another hospital. That does not come to us. We have on reappointment what the physician has done within our walls but not what the physician may be doing outside of our walls.”


May 1, 2006
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