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Some notes from NAMSS

OLYMPUS DIGITAL CAMERAThere’s more to come, but here are some notes from the National Association Medical Staff Services (NAMSS) Educational Conference:

Credentialing issues aren’t in the top tier of problems that the major accreditation organizations encounter, but that doesn’t mean credentialing challenges have gone away. This was the word at today’s panel discussion that brought together executives from DNV, HFAP, The Joint Commission, NCQA, and URAC. Some of the top credentialing issues included:

• Primary source verification and use of agents
• Provisional credentialing
• Delegation of credentialing responsibilities to other entities
• Credentialing/recredentialing of AHPs
• Changes in bylaws in response to CMS changes
• Lack of performance indicators or measures to be evaluated

Nevertheless, “we have very few issues with credentialing. I think it’s because whenever a credentialing person is hired, there’s some sort of screening that includes ‘obsessive-compulsive.’ Every time I go [into a facility], I know there’s been a huge amount of work done and it’s just as clear and precise as possible,” said Frank Stelling, MEd, MPH, of NCQA.

Another high point was the announcement/celebration of the Carol Cairns Aspire Higher Scholarship Award, offered by the Greeley Company in honor of Carol Cairns, CPMSM, CPSC. Starting in 2014, a scholarship will be awarded annually at the NAMSS conference. More details will be available in November at the Greeley Company website. Cairns is a frequent contributor to the Credentialing Resource Center and to HCPro’s medical staff services professional and credentialing offerings, including the recently released Medical Staff’s Guide to Overcoming Competence Assessment Challenges book. This scholarship couldn’t have a more fitting honoree.

Some of the best advice at NAMSS came from a non-MSP. David Glickman, today’s keynote speaker, told his audience to “find the funny” as a way to get through stressful situations. He then offered some hilarious book titles for the medical staff services professional. Among his suggestions were “Harry Potter and Healthcare Reform,” “50 Shades of FPPE: Loving the Pain,” and “Oh, The Places You’ll Go [To Avoid A Medical Executive Committee Meeting].” If you can find the funny, it can make grueling tasks and conflicts a little less punishing, he said.

Opportunity knocks

Does your organization use or provide telemedicine services? If so, is the medical staff involved in telemedicine contract deliberations?

These audience poll questions were included in the first installment of the Overcoming Competency Assessment Challenges webcast series recently, and the answers were worth noting. All audience members who responded to the poll questions said their organization uses or provides telemedicine services. However, only 40% said the medical staff is involved in telemedicine contract deliberations. As webcast presenters Carol S. Cairns, CPMSM, CPCS, and Anne Roberts, CPCS, CPSMSM, observed, there’s clearly an opportunity for more medical staff, credentialing, and quality improvement offices to get involved in the telemedicine contracting process.

Cairns and Roberts offered practical advice for the MSPs who are (or will soon be) navigating this opportunity, as well as tips for privileging temporary practitioners and practitioners seeking new technology privileges. If you missed it, this webcast is available on demand from HCMarketplace, and more information is available here. Tune in to the second installment of this series, which will cover assessment challenges associated with advanced practice professionals; and the finale, on assessing practitioners in ambulatory settings, selective practice, and single practitioners in a specialty.

As always, thanks for reading, and if you have a question or comment, please email me at

Best regards,

Mary Stevens, Managing Editor, Credentialing Resource Center Blog

Survey says: Stay tuned

If you completed the recent Credentialing Resource Center salary survey, thank you! The results are in and we’re analyzing the information you provided. The survey garnered more than 500 participants and the early findings are interesting indeed. We look forward to providing the complete set of results in a future issue of Credentialing Resource Center Journal.

In the meantime, don’t forget to register for our three-part Overcoming Competency Assessment Challenges webcast series. The series kicks off on June 18 with a presentation that will focus on the challenges associated with assessing the competency of practitioners with temporary, telemedicine, and new technology privileges. Session 2 (July 23) will address advanced practice professionals and Session 3 (August 27) will tackle the challenges associated with practitioners in the ambulatory setting, practitioners with a narrow and/or specialized focus, and single practitioners in a specialty. You can get more information about these webcasts here.

Thanks for reading, and if you have a question or comment, please email me at

Most sincerely,

Mary Stevens

Editor, Credentialing Resource Center Blog

Joint Commission identifies most challenging requirements

The Joint Commission has released a list of the most challenging requirements for 2012, which identifies the top five Joint Commission requirements that were identified as “not compliant” for each type of accredited organization and certified program.

For hospitals, the top requirement identified as not compliant in 2012 was RC.01.01.01, “The hospital maintains complete and accurate medical records for each individual patient.” The non-compliance rate for this requirement was 60%. Other areas of difficulty include maintaining integrity of the means of egress, reducing the risk of infections, and fire safety.

Ambulatory care entities had difficulty complying with the requirement that the organization grants initial, renewed, or revised clinical privileges to individuals to practice independently as permitted by law and by the organization, with 52% of ambulatory care facilities not compliant. Safely storing medications, reducing the risk of infections, and managing risks related to hazardous materials and waste all posed problems in the ambulatory care realm.

View the entire list from the Joint Commission here.

How does your organization stack up? How will this information help you moving forward? Leave a comment and let us know!


Readmission reduction – one more time

Two recent articles in The Journal of the American Medical Association (Jan. 23/30 issue) address the issue of readmissions to hospitals within 30 days of discharge.  This is a huge issue as “pay for value” initiatives will be dinging hospitals financially, not to mention the public flogging hospitals will receive with these publicly reportable measures.  To be fair, CMS is aware that 20% of patients discharged are readmitted within 30 days, and that is an incredible amount of money that the healthcare system is paying.  One of the flaws, as pointed out in the articles, is that readmissions aren’t necessarily the “fault” of the hospital.  Hey, but it is easy to punish the hospital; the regulators have been doing that for quite some time.

One of the articles demonstrates that the vast majority of readmissions are for reasons unrelated to the prior hospital stays.  Duh!  Isn’t this what physicians have been saying for years?  Healthcare providers have long known there is a long list of factors contributing to readmissions, including but not limited to:  lack of follow up care, patient non-compliance, access to care, cost of medications, cultural and social factors, information transmission, patient understanding of instructions, transitions of care, and, by the way – people who are hospitalized tend to have bodies that are not working at an optimal level.

So what should we do?  Isn’t this what healthcare reform and patient-centered medical homes are trying to fix?  It sure is!  But are there things we can do now?  The article does list nine strategies for physicians to try to decrease readmissions by improving the level of care.  For that, I commend them.  This is their list, but I bet you could add more.

  • Keep organized information on patients’ medical issues, health goals, functional and psychological status, and behavioral and social issues.
  • Consider patients’ acute, intermediate and long-term care goals.
  • Be explicit with patients about social, economic, cultural and other factors that may impede their care.
  • Use reader-friendly tools such as checklists and “red flag” lists to help patients and caregivers with self-management tasks.
  • Use motivational interviewing and teach-to-goal methods to support self-care.
  • Use pharmacy, patient and hospital discharge lists to ensure a fully reconciled and accurate medication list after discharge.
  • Reinforce medication changes made in the hospital with patients, as appropriate.
  • Use “pill cards” to help patients track drug changes.
  • Allocate time to address care coordination tasks, using templates and checklists for specific tasks.

Healthcare workers and flu vaccination

At last count, 47 states were having “flu emergencies,” with a marked increase of reported influenza cases compared to recent years.  So it’s time for me to share one of my pet peeves again: influenza immunizations for healthcare workers.

This came back into the public arena again earlier this month when ABC News ran a story about eight employees who were fired from an Indiana hospital because they refused this year’s flu shot.  A former president of the National Foundation for Infectious Diseases was reportedly quoted as saying “I cannot think of a reason for any health care professional to decline influenza immunization that’s valid.”  A bit of a strong statement, but one I wholeheartedly agree with!

I feel that  it is unconscionable for healthcare workers to put the at-risk population we care for in jeopardy of acquiring a potentially life threatening illness due to our “right” to refuse immunization.  That said, what about religious convictions?  What about our right to decide what is “best” for us?

Who is responsible if a significant adverse reaction occurs to a healthcare worker that was “forced” to be immunized?  I believe the benefits of yearly influenza immunization far outweigh the risks.  Many of our employees who declined the vaccine earlier this year have now decided to get it.  I wonder what that means about their initial reasons for refusal.  What do you think?


New York State – the place to get really sick?

Is New York State the best place to be if you become septic?  Isn’t this the state that brought a bill to the assembly in 2011 that threatened to make “reckless infection of a patient with a communicable disease by a health care provider” a felony?  Now, the governor has mandated that all New York hospitals develop aggressive procedures for identifying sepsis.  Didn’t the “Surviving Sepsis Campaign” start in 2002?  So – better late than never, New York.

But wait – why is a state governor  mandating this?  Shouldn’t something like this come from the medical folks and not the government?  Could it be that N.Y. hospitals aren’t doing such a great job at diagnosing and managing sepsis?  As a physician I am embarrassed that the government needs to tell us that this is an issue.  I’m proud to say my hospitals have been following the sepsis guidelines for years, but I guess some hospitals haven’t.

Shouldn’t this evidence-based medicine approach to diagnosing and treating sepsis be a quality factor monitored by physicians, nurses, quality personnel, and medical staff professionals?  Should we be waiting for the government to tell us what the right thing to do for our patients is?  Should our hospitals’ credentialing and privileging process be more attuned to matters of life and death than to the number of discharge summaries not dictated in a “timely” fashion?  What do you think?

Call for submissions: Privileging forms, policies, and procedures

Want to help out your fellow MSPs and learn how other MSPs tackle their credentialing challenges?

Credentialing Resource Center is looking for member-submitted privileging forms, policies, and procedures to share with our subscribers. While we make every effort to keep our Clinical Privilege White Papers up-to-date, sometimes there are new procedures and technologies that we have not been able to address yet. Your forms could aid other organizations in solving their privileging dilemmas, and vice versa!

Whether it’s credentialing criteria for RNFAs or sample bylaws language for delineating medical staff categories, we want to see the forms that have helped your organization address credentialing issues. Examples of these member-submitted forms can be found when you log in at

To share your privileging forms, please email documents, along with a brief explanation of the contents, to Katrina Gravel ( Thank you!

Best regards,
Katrina Gravel
Credentialing Resource Center Blog

Happy National Medical Staff Services Awareness Week!

Did you know that in 1992, President George H.W. Bush declared the first week of November as National Medical Staff Services Awareness Week? In his proclamation, Bush wrote that the week honors MSPs for playing “an important role in our nation’s healthcare system.” The National Association Medical Staff Services (NAMSS) developed a press release for medical facilities to use in promoting this special week and explaining the role of the MSP. Let’s face it: many healthcare consumers are unaware of the medical staff services department. I will admit, I was one of those healthcare consumers who did know what the word credentialing meant before I started working at HCPro. Here is an excerpt from the NAMSS press release:

“MSPs are experts in provider credentialing and privileging, medical staff organization, accreditation and regulatory compliance, and provider relations in the diverse healthcare industry. They credential and monitor ongoing competence of the physicians and other practitioners who provide patient care services in hospitals, managed care organizations, and other healthcare settings.

“MSPs are a vital part of the community’s healthcare team. They are dedicated to making certain that all patients receive care from practitioners who are properly educated, licensed, and trained in their specialty.”

I think we can all agree that the role of MSP has expanded far beyond what can be summarized in a one-page press release. What I find amazing is how passionate MSPs remain about their work, even as their workload increases and they face greater resistance from physicians to complete all of these credentialing and competency checks. When I told two of my personal physicians what I do for work, they each responded with similar comments: “I hate that credentialing stuff. It takes up so much time and I have to fill out the same papers over and over.” I have to admit, I was kind of surprised to hear this. I guess I had hoped that physician resistance to credentialing was a myth. What I did not get a chance to ask either of my physicians about was their relationship with the MSPs at their hospitals. I will keep my hope alive that this answer would have been a lot more positive.

In honor of all that MSPs do, HCPro is offering you and your colleagues a 20% discount on all of our medical staff and credentialing products from Nov. 5-9. Visit the HCMarketplace and enter EB202434 during check out to receive your discount.

On behalf of HCPro, and as a patient who has always received great care from exceptional physicians, thanks for all of your hard work!

Difference of opinion in Texas

Public Citizen, a nonprofit organization that advocates for individual rights, says the Texas Medical Board needs to step up its game. The organization asserts that the state medical board has failed to punish many physicians in the state who have received sanctions from healthcare organizations. The Texas Medical Board disagrees, citing Federation of State Medical Boards data that often ranks Texas at the top for disciplining physicians.

According to an article from HealthLeaders Media, Public Citizen analyzed 21 years of NPDB data.The group found that almost 450 Texas physicians who had been sanctioned by a healthcare entity had yet to be disciplined by the Texas Medical Board. Public Citizen sent a letter to Texas Governor Rick Perry urging him to take “immediate action to improve the performance of the Texas Medical Board and thereby protect patients in Texas from physicians who should have been, but were not, disciplined.”

Public Citizen does not blame the medical board; it instead puts the blame on a lack of funding and staffing. In Texas, the money that is collected through physician appointments, reappointments, and fines is placed in the state’s general fund. The medical board than submits a request for funding to perform its functions.

Lee Hopper, spokeswoman for the Texas Medical Board, says the agency is not underfunded or understaffed. “Like anybody, of course we would always like more money. But we haven’t been dealing with a budget crisis so the agency is healthy and it’s effective,” she tells HealthLeaders Media.

In its letter to Perry, Public Citizen recommends letting the medical board keep more—preferably all—of the funds it collects. This raises some interesting questions to think about.

Should the medical board be entitled to all of the money collected through its processes? Should the medical board learn to do more with less, like many other businesses and citizens are currently forced to do?  Would more funding lead to more disciplinary action?

The question that really sticks on my mind is, as a healthcare consumer, how important is it that disruptive physicians be disciplined? I know the short answer is very, but at what cost? Do you want your state’s medical board to use all of the money it collects to fund its needs? Or would you like to see some of this money go into the state’s general fund to be used for other public services?