Dear director: I want to hire a former resident colleague of mine. But since we’ve been out of residency, he’s settled two lawsuits and had another quality investigation. My Medical Staff Office tells me I won’t be able to get him credentialed. He’s a great guy and was a fantastic doctor as a resident. Shouldn’t I be able to hire who I want?
I used to think of credentialing as a rubber stamping process – more of a warm welcome than a skills assessment. I avoided this committee like the plague out of fear of publicly falling asleep at a meeting. The rationale back then was that each doc had been vetted numerous times throughout their life and if the chairman wanted to hire them – particularly if they were full time nights – they should be able to do so without interference. If they’re bad, we have malpractice insurance that will protect the group and then we can fire the doc down the line.
At some point over the last 5-10 years, my opinion on the importance of credentialing shifted dramatically. In fact, this committee is one of the most powerful in the hospital. It sees everyone’s dirty laundry and makes decisions that impact the overall quality of care within the hospital. My attitude change was in part due to my sitting in on credentialing meetings involving physicians who had some serious skeletons in their closets. I also got some additional education on credentialing and became aware of the situations where a poor credentialing process led to problems for the hospital and medical staff. Credentialing is about patient care, as well as protecting the physician, and avoiding problems within the medical staff down the line. What I learned is that while it might not be too hard to get privileges at a hospital, it’s exceptionally challenging to remove physicians from a medical staff. Credentialing needs to be tough enough up front to save a ton of time and problems down the line.
Why all the fuss?
If you owned a private, non-medical business, you could hire your own employees and weigh the risks and benefits of each decision. While you may occasionally make a bad decision, and it could cost you some business or upset customers, you could fire the employee and move on relatively unscathed. If you were a private practice physician without a hospital affiliation, or potentially ran a stand alone ED or Urgent Care Center, you could even hire the doc of your choice and just put your malpractice insurance to the test if the new doc isn’t a quality physician. Hospital medicine is unfortunately not that simple. Over the last decade, I’ve seen and heard about multiple cases in which physicians had complications after doing procedures they weren’t qualified or privileged to perform. This opens the door to bad patient outcomes and is a legal nightmare. Besides reviewing quality issues, another part of the credentialing process is to look out for serious character flaws in physicians—things that might lead to bad outcomes. Red flags to look out for are when physicians fail to disclose significant issues on their hospital application (these turn up through another avenue), physicians who jump jobs frequently and quickly, peer references that are anything less than very good, and those who have significant gaps in their work history.
Malpractice suits may not even be the main reason that credentialing committees will have concerns. But suits will generate discussion and are certainly a part of the practice of medicine. If you practice medicine long enough, you’re going to get sued and likely carry some baggage from job to job. This doesn’t mean that you’re a bad person or a bad doctor or that you can’t get credentialed, but it may make it a bit more challenging. I remember offering a job to someone that had been sued a dozen times. Although the doc had settled 2 of them (over 20 years), he was dropped from the others and as we dug into the details of the cases, which required a lot of my time and a significant amount of time lobbying decision makers about why we needed this doctor, it ultimately became clear that he was a good provider and worthy of receiving privileges to practice in our ED.
Why the Hospital Cares
The hospitals are extremely concerned about who we hire. While we can hire the doctors, unfortunately, we don’t credential them. In reality, the ultimate authority to grant hospital privileges rests with the hospital’s board of directors. Like it or not, this is a mandatory condition for Medicare participation outlined by CMS and the courts have upheld this principle that hospitals have oversight and responsibility for credentialing and that proper credentialing needs to be in place to protect the welfare of the patient. While the board may have some physicians on it, usually it’s made up of non-medical professionals who may bring their own opinions as to how much is too much to be on the staff. Fortunately, they usually make decisions based on the recommendations of the medical executive committee, credentials committee, and the department chairman.
We also balance protecting the patient with protecting the physician’s ability to practice medicine. Complicating matters is that hospitals have an obligation to report certain credentialing issues to the National Practitioner Data Bank. This includes when a decision is made to deny privileges to a doc as well as when a physician is removed from the medical staff. Obviously, data bank reporting is a significant event for a physician and is a part of the public record so a hospital’s board does not take this lightly. They also know that any action that could result in a data bank report could be subject to an appeal and then a lawsuit by the individual physician. Physicians involved on these committees are inherently and appropriately protective of our colleagues. When committees review cases, we can usually see ourselves making a similar mistake on any given day so the MEC typically does everything imaginable to avoid making a recommendation to the board that would involve a databank reporting action. However, there is a fine line as hospitals (or more officially their board of directors) have an obligation to protect patients but everyone involved in the credentialing process wants and needs to be fair to the physician.
Hospitals have been sued by patients, and made huge payments when they lost, over bad outcomes caused by physicians where the hospital was held accountable for not being aware of prior issues. Let’s say I hire Dr. Smith but don’t do my due diligence on her. It turns out that Dr. Smith is an alcoholic and had I looked at her application and references more closely, I would have realized that she had several gaps in her employment and changed hospitals fairly frequently. She had a couple of bad outcomes which during our interview, she attributed to bad luck, and although I found her to be very personable, there were some comments in her paper references that alluded to “interaction issues.” I never called her references. Dr. Smith then grossly mismanages a patient’s care because she’s too intoxicated at work and the patient dies. Because there is a direct connection between Dr. Smith’s issue and the patient’s outcome, the hospital could be sued for a failure to be aware of Dr. Smith’s alcohol abuse. Not only should we have picked it up through her credentialing process, we likely would be held accountable for a failure to recognize and take appropriate action that Dr. Smith was working while intoxicated. We all know the importance of following the dollar to see how decisions are made, so after hearing more of these examples, I find it easy to see how rubber-stamping applications transitioned to thorough personnel file review even though almost all physicians are good, honest, high quality and high-performing providers who generate no significant discussion during the review process.
And unlike the business owner who can fire an employee, it’s extremely challenging to remove a physician from a medical staff. Removing a physician from a medical staff is also likely to land everyone involved in a court case for years as the physician being removed typically has the right to an appeal hearing and then still has the right to go to court. Even if the hospital covers your legal expenses as the chairman, it’s going to involve a lot of time and stress. From a selfish point of view, shouldn’t we want only quality physicians on the medical staff since they’ll be taking care of the patients we admit from the ED? If they make mistakes and get sued, we’re more likely to be named in a lawsuit.
Pre-Screening New Recruits
When I’m recruiting, my goal is to align the recruitment and credentialing processes. Although most employment contracts build in the caveat that employment is dependent on credentialing, if the physician can’t get credentialed, this could be a disaster for all parties. The chairman is 6 months behind in finding a new candidate and gets a “black eye” for bringing a physician to the hospital that does not meet its standards. The new hire may have already relocated for the job and is counting on a paycheck that’s not going to come. Complicating matters is that the potential employee may still sue the group for failure to provide the job. Therefore, the chairman has the responsibility to understand the background situation a provider has, check references (typically by phone) to better understand any questionable circumstances, all prior to making a job offer. By reviewing malpractice cases, references, and gaps in employment, I can usually make sure the clinician will not have issues with credentialing. In a small percentage of docs, the credentialing committee may need additional information. Often this is to see if there is an actual fire when everyone sees a lot of smoke. This may be as simple as asking follow up questions for any reference that has something potentially negative in the response, or reviewing letters from attorneys regarding malpractice suits but could also involve sending cases out for an independent third party expert opinion all at the applicant’s (or your group’s) expense. Because every new provider undergoes a Focused Professional Practice Evaluation (FPPE), privileging may be granted with a more thorough FPPE or oversight plan.
What’s the Chairman’s Role
Several years ago, I had a doc I liked and was sorry to hear that he was moving to another state. That meant a new state license and a new hospital application. Although he was a good doc, he had been a part of a state investigation after a complaint was filed against him. It wasn’t reported to the data bank and there was no significant negative outcome but it was clearly an issue that he and I would have to deal with during his transition. We both agreed that he needed to own the issue, declare it, and be prepared to thoroughly discuss it because I would be including it in his reference. He received his credentials without issue.
Chairmen play a huge role in the credentialing process. For starters, we should always be asked to complete an evaluation on a doc who is applying for privileges at another site. We have a responsibility to give a thorough and meaningful reference that is accurate, fair and factual. As tempting as it is, and I’ve been there—I’ve actually been relieved when bad docs told me they were leaving and the new hospital never called for a reference—we can’t just pass our problems on to the next hospital. Take Dr. Smith from the example above. Let’s say her new hospital had great references on her because you lied. It turns out that she had several bad cases because of alcohol abuse and you forced her to resign and promised to give a good reference for leaving quietly. Lying or withholding critical information that impacts credentialing could lead to you being held responsible in court, with a resultant big payout on your part as part of a bad outcome. This is another time where we may need the applicant to sign a specific release of information form.
Hospital credentialing has gone from a rubber-stamping process to a serious multi-step process involving a range of stake-holders. Physician applicants bear the burden to provide all of the necessary information during the proceedings. Hospitals have a duty to protect patients. Hospitals have the ultimate credentialing responsibility (albeit relying on physician recommendations), can get sued over improper or poor credentialing and can end up in court when a provider has their privileges removed. And chairmen bear the responsibility to investigate the skeletons. If you’re sending off one of your docs who has question marks on his/her record, spend some time with them to get to know the details so that you can be honest with their new employer. If you have questions about a new recruit, make sure you get more details over the phone and then call further references. If there is something that would make you regret hiring this doc, now’s the time to figure it out. And if you do your due diligence and still believe that the physician provides high quality care and was a victim of unusual circumstance, then spend time discussing the issues with the chair of the credentials committee to see what other information may be necessary to make credentialing a success.
Tips on fair credentialing
Credentialing needs to be structured and fair in order to balance patient safety and the career of the physician.
- Have objective criteria for appointment: They can be an unrestricted license, board certification (or eligibility), no previous terminations from a medical staff, and not excluded from Medicare. So even if you’re the CEO’s son-in-law, if you can’t meet these criteria, you shouldn’t be credentialed.
- Credentialing committees shouldn’t process incomplete applications: A committee should not process an application until all the information is there. Its worse to grant privileges to someone only to find out afterwards that the person has significant issues and now the challenge of the medical staff will be to remove the provider. It is also important to have an out for the physician applicant. An application can be automatically withdrawn if it stays incomplete for a certain length of time. This allows a committee to ask for additional material (references, written answers to questions about performance, etc…) and the applicant can choose not to continue down the credentialing pathway when it’s not looking good and safely get off the bus.
- The phone is your best friend: Don’t be afraid to call and dig into the applicants past every time you see a red flag on the application. Every chairman has reviewed references on providers where a problem was hinted but wasn’t spelled out. (Seeing 3’s on a 1-5 scale on these types of evaluations is generally a big hint). The details may come up in a phone call because many chairmen are afraid of putting something negative in writing and then getting sued for it.