1. Template Presentation: Your Department Name Overview
Reporting Structure and Staffing
Interactions with Your Organizations Name At large
Scope of Services
Credential / Privileging Primer

2. Your Department’s Structure and Staffing
Credentials/Privileging
2.3 FTEs
*2 CPCS staff
Enrollment
2.4 FTEs
Information Specialist
2.0 FTEs
1 CPCS staff
Medical Education
.5 FTE
VP / CMO
Director, Medical Staff Services
CPCS /CPMSM
Medical Staff President
CMO/SVP Medical Affairs
*Always remember to note who is certified!

3. Your Department’s Organizational Interactions
Pharmacy
HIM (Outpatient Record Systems)
Clinical Care Areas
Nursing
Radiology
O.R.
Lab Services
Human Resources
Employed Credentialing
Payroll system
Education Systems
Marketing
Organization Website
Physician Finder
Physician Events
Provider Systems
Hospital System
Performance
Improvement
Occ Health
HIS
HIM systems
Billing Systems
Finances
Employed Practices
Practice Database
Legal / Risk Management
Medical Staff Services
*Comment on certification knowledge needed in these areas 3 3

4. Your Department’s Functional Services
Medical Staff Services
Credentialing Privileging
Enrollment
Medical Education
Information Services
Other

5. Department Scope of Services: Credentialing / Privileging
Credential / Privilege medical and allied health staff
# medical staff members, # allied health members
Avg. # new applicants/year; # reappointments/year
Credential for Enrollment medical and allied health staff
# new applicants/year; # reappointments/year
Credential for PHO / PO membership
# members
# new applicants/year; # reappointments/year
Self-Insured Entities Professional Liability Enrollment

6. Department Scope of Services: Medical Education
Describe the accreditations program and education programs offered, including volume
Comment on certification exam and related medical education questions
Discuss the relationship between ongoing competency, medical education and maintenance of board certification.

7. Department Scope of Services: Information Services
Manage Focused Professional Practice Evaluation Process
Create and Maintain the Ongoing Professional Practice Reports
Department and Specialty Specific OPPE reports
Medical Staff E-Learning Coordination
Mandatory learning activities
MSO System Maintenance
Report creation and distribution
Expirable Process Maintenance
Web crawlers, internet grabber creation and maintenance
Application and Forms creation
Intranet Page

8. Department Scope of Services: Other
Medical / Allied Health Staff Orientation Program Management
Medical Staff Meeting Management
MEC, Medical Staff, Credentials Committee, Professional Conduct Committee, Medical Education Committee, Department / Specialty Meetings
Medical Staff Bylaws and Policies Management
Medical Staff Leadership Support
Nominating Committee activities, Medical Staff Treasury support
Medical Staff Event Management
Relate knowledge needed in these areas to your certification

9. Key Activity: Ensure Regulatory & Accreditation Compliance
The Joint Commission (TJC) / Centers Medicare & Medicaid Services (CMS)
Medical Staff Standards Chapter
Leadership Chapter
National Committee for Quality Assurance (NCQA)
Health Plan Accreditation Standards
ACCME – Medical Education Accreditation
Board of Registration in Medicine
Credentialing regulations, Reporting regulations,
License Physicians and Acupuncturists
Department of Public Health (DPH) / State Licensing Authority
Division of Professional Licensure
License APN, PA, Podiatrists, Dentists, RPA, Psychologists

10. Governing Body Responsibility
The Joint Commission: Standard MS EP 8
“The governing body or delegated governing body committee has final authority for granting, renewing, or denying privileges.”
CMS: Requirement
“There must be an effective governing body that is legally responsible for the conduct of the hospital.”
(a)(2) - “The governing body must appoint members of the medical staff after considering the recommendations of the existing members of the medical staff.”
Your States Rules and Regulations for Advance Practice Nurses / Physician Assistants
Showcase your accreditation knowledge to Leadership

11. Credentialing Checklist
Verify Practitioner - Notarized government issued identification, candidates interviewed, Criminal background status, OIG status
Review Application / Privilege Request
Verify Education, Residency, Fellowship, “primary source” schooling, training programs
Confirm Board Certification Status
Verify MA license, CSR, DEA
Verify Professional Liability Coverage - Claims history
NPDB query
Confirm Work History
Obtain and Verify References (including Program Director, Dept. Chair)

12. Red Flags Obvious Loss of licensure or narcotics registration
Multiple liability judgments or settlements, NPDB alerts
“yes” answer on application for membership or licensure
Negative response from references
Disciplinary Actions reported
Subtle
> 4 years in medical school with single degree
Unexplained gap in work history or training
Numerous moves (>3 in 5 years)
Paperwork delays, numerous requests for references
Information on application/CV differs from responses
Urgency on the part of employer

13. Privileging Checklist
Privilege form complete & accurate
Appropriate professional liability coverage for request
Privileges appropriate for the specialty
Confirm documentation to support eligibility
Training documentation
Certificates
References

14. Review Recent Privileging Cases
Malpractice Claims At Alamogordo Hospital Settled (2008)
About 80 malpractice claims that forced an Alamogordo hospital to seek bankruptcy court protection last summer have been settled for more than $33 million
Dr. Christian Schlicht, an anesthesiologist and pain management specialist, is accused of using fraudulent credentials to operate on patients even though he wasn’t a surgeon and injected the cement into patients’ spines in a procedure that turned out to be neither safe nor effective.
Schlicht had told him in late 2008 that some of Schlicht’s neurosurgery training was falsified
William Hamman, a Pilot, passed himself off as a NY Cardiologist (2010)
Hamman is a licensed pilot who worked for United Airlines until the airline grounded him when his lies came to light. In addition to the real credentials he possessed, he also had ones he made up, including M.D. and Ph.D. degrees, as well as 15 years of clinical experience as a cardiologist. In reality, he did attend medical school for a few years, but never graduated.
"We need to be vigilant that the credentials of physicians are real, current and that the doctor is board certified and participating in their board's lifelong learning program," said Dr. Richard J. Shemin, chief of the Division of Cardiothoracic Surgery at the Ronald Reagan UCLA Medical Center in Los Angeles.

15. What is Negligent Credentialing
What is Negligent Credentialing? (Topics you need to be aware of for certification)
A widely adopted civil tort theory of liability.
A type of corporate negligence.
The failure to perform “diligent inquiry” into a practitioner’s credentials to ensure that only qualified and competent professionals are selected and retained to treat patients.
Inquiry performed at the time of Medical Staff appointment, reappointment, and privileging.
Includes the on-going requirement to supervise, monitor, and continuously reassess the practitioner’s performance. 15

16. What is the Basis of Liability?
The entities and persons who credential and privilege practitioners owe a duty of care to patients to exercise reasonable care in the selection, retention, supervision, monitoring and assessment of the practitioners who treat them.
When that duty is breached and the patient is injured by an incompetent or unqualified practitioner, the patient has the right to sue those entities and persons who were responsible for the proper credentialing and privileging of that practitioner.

17. What “Diligent Inquiry” Is Expected?
Obvious sources
Extent of practitioner’s training and experience in performing procedures
Malpractice case payments from the National Practitioner Databank (NPDB)
Results of disciplinary investigations and actions by Boards of Registration
Prior practice and employment references
Less obvious sources
History of 3 + malpractice cases (regardless of results)
Number and results of peer review cases
Ongoing Professional Practice Evaluations (OPPE)
Focused Professional Practice Evaluations (FPPE)
Patient safety event reports
Complaints by nurses of substandard care
Patient complaints
Professional conduct events

18. Negligent Credentialing Case Law: Examples
Darling v. Charleston Community Memorial Hospital (Illinois, 1965): First case. Hospital liable ($110K) to teenage athlete who suffered permanent injury because the Hospital granted surgical privileges to a general family practitioner who negligently set the patient’s broken leg.
Johnson v. Misericordia (Wisconsin, 1980): Hospital liable for damages to patient who suffered permanent paralysis when his femoral nerves/artery were damaged during a procedure by an orthopedic surgeon who failed to disclose pending malpractice cases and was untruthful about prior hospital privileging.
Frigo v. Silver Cross Hospital (Illinois, 2007): Hospital liable (~$8 million) to patient who suffered an amputated foot where the podiatrist, who did not have the advanced training required for surgical privileges, negligently performed a bunionectomy.
Kadlec Medical Center v. Lakeview Medical Center, Anesthesia Assoc. (Louisiana, 2008): Hospital found partially liable (~$8 million) to patient who suffered extensive brain damage during tubal ligation where Hospital credentialed locum anesthesiologist fired by his prior Hospital/practice group (excellent references provided) for diverting and ingesting demerol while working.
The Court found that the Hospital was accredited by the JC, and incorporated the JC’s credentialing standards into its corporate and medical staff by-laws. This created an obligation by the Hospital and the Medical
Staff to ensure that physicians are qualified to exercise the privileges granted the. When the physician was found to be negligent in his care of this patient, the Court ruled that the Hospital’s and Medical Staff’s decision to grant privileges to the family practitioner to treat patients with complicated injuries, he was unqualified to do so, and the decision to grant him the privileges was a direct cause of the patient’s permanent injuries. Thus, the Hospital was liable for the damages. 18