Role of the credentials committee in the reappointment process

A question arose recently about the role of the credentials committee in the reappointment process. Unlike initial application processing, the practitioner going through the reappointment process is a known entity (or should be if he/she has membership and/or privileges).

Accreditation standards, facility-specific medical staff bylaws, and/or credentialing policies and procedures may contain detailed instruction as to what is collected, reviewed and approved. MSPs know that The Joint Commission Standards relate to the medical staff making recommendations to the governing body and the governing body takes final action.

How does the recommendation for reappointment reach the “medical staff”? What is the role of the credentials committee? Do committee members have to review entire files that have already been reviewed by the department chair?

The reappointment process goes like this:

1. Application and collected required documentation is collated by the MSPs
2. The department chair is provided a copy of the reappointment file including a request for privileges (as appropriate).
3. The department chair recommendation is presented to the credentials committee on a “consent agenda”.
4. Following the credentials committee review, the recommendation is sent to the medical executive committee and finally to the governing board.

In this case, the credentials committee members did not review every document collected in the reappointment process. However, committee members and the department chair would be notified of any “unusual” finding.

The role of the credentials committee? Make sure that every step in the reappointment process is followed consistently and that all questions regarding clinical competency, ethical conduct, and ability to perform requested privileges are answered.

How would this process work in your organization?

Carole La Pine, MSA, CPMSM, CPCS