Credentialing is key — 7 ways to avoid mistakes & keep your patients safe

There are countless of examples of non-credentialed individuals performing cases at healthcare facilities — from the teenager who posed as a physician at West Palm Beach, Fla.-based St. Mary's Medical Center for a month to the non-credentialed physician who was present in the operating room during the ill-fated procedure Joan Rivers underwent at Yorkville Endoscopy in New York. While the first instance did not lead to any severe breaches in patient safety, the second made national headlines surrounding the death of the famed comedienne. 

These incidents are, unfortunately, not uncommon, and leave patients open to the possibility of irreparable harm. In many cases, it leads to malpractice kimbroughlawsuits, loss of accreditation and even the facility being shut down.  

Healthcare facilities, such as ambulatory surgery centers, need to double down on physician credentialing to keep their patients safe and their business thriving. You need to know as much as possible about the staff at your facility before letting them take care of patients, says Sharon Kimbrough, CPCS, CPMSM, manager of medical staff services and credentialing at Surgical Care Affiliates.

Here are seven ways for ASCs to avoid physician credentialing errors:

sasso1. Do not allow physicians to book a case before credentialing is completed. According to Marcy Sasso, CASC, of Sasso Consulting, typically surgeons call a center and want to do cases there right away, but you have to wait until they have the right privileges approved. "Letting a physician slide because they want to bring a case tomorrow is not a good enough reason to permit the rules to be bent," she says. ASCs need to show that their governing body has approved the new surgeons or procedures. Physicians sometimes call the medical director to ask for an exception and too often an exception is made.

2. Complete every step of the credentialing process. The steps typically include gathering all required documents, sending those for committee review and then bringing it to the ASC's governing body for approval, says Ms. Sasso. The process time frame may be different for different centers.

Having a checklist in place for whoever does the initial credentialing is the key to ensuring that nothing is missed. ASCs must also hound physicians for the necessary documents, as they often want to gain privileges with promise to give in documents later. "Follow the guidelines that the governing body has put into place and outlined in the bylaws or policy and procedure manual," says Ms. Sasso.

3. Close all gaps in an application. Sometimes physician credentialing applications may have gaps, such as missing or unverified pieces of information. "These could be as small as the applicant forgetting to confirm something or it could be bigger. We need to investigate fully," says Ms. Kimbrough. Leave enough time in the credentialing process to double-check and cross-reference everything.

4. Complete credentialing for new procedures. Physician credentialing is not just a one-time process. Physicians also need to be credentialed for new procedures. For example, says Ms. Sasso, if you have an orthopedic surgeon who is privileged to do knees and shoulders and then one day, he wants to book a carpal tunnel procedure, you must make sure that his privileges have been updated to reflect the fact that he can perform carpel tunnels.

"He may be licensed in his scope [of practice] to do this procedure, but if he wasn't granted privileges by the ASC's committee he cannot perform it until the committee has approved an addendum to his privileges and shows the review in their minutes," says Ms. Sasso.

5. Stay on top of re-credentialing. Physicians have to be re-credentialed every few years. CMS and The Joint Commission recommend re-credentialing every two years, while the Accreditation Association of Ambulatory Health Care allows for a three-year cycle. "It expires just like physicians' state licenses," says Ms. Kimbrough. "We try to make sure they are re-credentialed at the end of the current cycle so that the transition from one cycle to next is seamless. People think there may be wiggle room, but it is a hard stop."

6. Let the entire team know when a new physician is credentialed. It is important that all staff members in an ASC know who the newly credentialed physicians are. Once in the OR, it is unlikely that staff members think anything is wrong. "Communication is key," says Ms. Kimbrough. "The credentialing team should let everyone know who is credentialed and starting to perform cases. So when someone shows up the staff has an inkling as to whether they should be there or not."

7. Ensure that ASC leadership is engaged in the credentialing process. According to Ms. Kimbrough, ASC leaders and the credentialing team need to be aligned and proactive. There must be constant communication regarding credentialing. Both ASC leaders and the team need to stay on top of changes in the credentialing and regulatory world.

"Credentialing is critical," says Ms. Kimbrough. "When the process is being completed consistently and appropriately, everything works well. It protects your patients and your facility."

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