Supporting Safer Healthcare

The Happy Hospitalist is not so happy at the moment. What has stirred up Dr. Happy’s inner curmudgeon? 

Physician Credentialing.

As my experience is on the other side of that particular desk, I’ve excerpted a few portions of his recent post on the topic, and added some commentary below.

“For physicians to do a hospital admission or daily visits or procedures inside a hospital they must first obtain hospital credentials.”

Absolutely true. 

“Every hospital has their own set of rules.”

Mostly true.  There are some universal standards which guide physician credentialing in the U.S., many of which are set by CMS Hospital Conditions of Participation, but there are also a myriad of specific rules that organizations establish to assure safe patient care within their walls.  For example, Hospital A may have the staff, equipment and ability to perform cardiac catheterization, but Hospital B may not.  Therefore, a perfectly qualified physician may not be permitted to even request cardiac cath privileges in Hospital B.

 ”I recently applied for hospital privileges to another hospital…  In this case, they sent me a packet of information almost 40 pages long.  They mark everything I need to sign with tiny little sticky pads. About 10-15 tiny little sign and date here sticky pads dotted the hospital credentialing paperwork.  Forty pages of legal mumbo jumbo.”   

I suspect this is absolutely true.  (Be glad someone took the time to add those helpful little sticky notes!)  First there is the actual application, which has questions ranging from name, address, phone, etc, to experience and education questions that start with the day you gleefully threw your cap into the air during medical school graduation. 

Then there is the “Release of Information and Authorization” form, which is written by lawyers and usually contained in one page of squint-inducing fine print.  This form authorizes anyone who ever knew you to spill everything they know without fear of being sued in retaliation.   

Next comes the “Delineation of Clinical Privileges Request” form.  This one can range from one page to ten or more, and it outlines both the privileges a physician in a given specialty may request at the hospital, and often the criteria he/she must meet in order to request the privilege.

Remember that cardiac cath procedure at Hospital A?  It may be that an applicant there has to produce evidence of having performed X number of them within the past two years before the little “I request this” box may be checked on Hospital A’s form.  Could be however, that should one be filling out Hospital C’s forms at the same time, the criteria for requesting the privilege at Hospital C is different, as those requirements are set by the hospital’s medical staff leadership.  There are some legitimate reasons for that, but admittedly, it can get pretty confusing for physicians on multiple hospital staffs.

Next comes any additional information the hospital may decide to collect or share with you,  which could include a copy of the Bylaws, Rules and Regulations of the organized medical staff.  We’re talking some fun reading there.  Although the age of electronic communication has, thankfully, given us opportunity to just send you a link where you can go online and read to your heart’s content, rather than requiring us to add a 20-100 page document containing the rules and requirements of medical staff membership, which yes, you are expected to follow. 

There could also be additional requests for information about your last TB test, Hepatitis B inoculation. etc., if those matters are handled by the Medical Staff Office.

“Have you ever been charged with a crime?  Have you ever been convicted of a drug or alcohol related offense?  Have you ever been sued?  Not lost a lawsuit, just sued.  Have you ever been treated for depression?”

All of these seem pretty legitimate except that last one.  If indeed, the question was worded as “have you ever been treated for depression?” or for that matter, have you ever been treated for cancer or diabetes, there needs to be a little re-wording done.  It’s really none of our business if you’ve “ever been treated” for something.  What is our business is whether you are currently dealing with a health issue that could impede your ability to effectively manage the privileges you’ve requested.  For example, a surgeon who is unable to stand for long periods of time due to a health condition needs to say so.  Reasonable accomodation could likely be made, i.e., an adjustable stool could be placed in the OR.  If, on the other hand, a normally happy hospitalist is presently dealing with debilitating depression, he or she may not be able to make effective decisions on critical patient care issues.  The goal of medical staff services administration is both to protect patients, and to assist valuable members of the medical staff when a need arises.  

Could (hospitals) be held liable for allowing a bad apple to practice medicine in their walls.  A physician who has been licensed by the government and certified by their specialty society as an expert capable of providing excellent care?  

The answer to this is so Yes.  Consider the case of Putnam General Hospital and John Anderson King.  Beyond the issue of protecting the hospital however, is the issue of protecting patients.  The vast majority of physicians take that very seriously; as do the vast majority of credentialers.  It may not always seem like it, but we’re really on the same page on this one.

If you have a hospitalist seeing you at your hospital, you can rest assured their past has been raked through the coals and their history and credentials have been picked apart by government agencies, specialty societies and even the hospital you find yourself in.

And that’s really the point, isn’t it?  Because of all these rules, some of which are pretty onerous, hospital patients can feel reasonably assured that their physician has been thoroughly investigated. 

Then Happy Hospitalist adds, absurdly so, a sentiment with which I can at least in part, agree.  As a medical staff services consultant, I know that there is considerable room for improvement in this process in many hospitals.  As HH implies, physician credentialing can be driven over the top by fear, but knowledge and an understanding of the intended purpose are far better drivers.