I am sure you have heard the phrase "trust but verify." That is what a healthcare organization, no matter its size, is tasked with to ensure patient safety is at its forefront. How do they do that? For starters, the organization must put its providers through a vetting process to ensure those individuals providing healthcare services to its patients are who they say they are and can do what they say they can. For most of us in the healthcare arena, we already know that this is credentialing, setting out to prove that those healthcare providers representing or affiliating with said organizations are competent and qualified.
But who is it that performs those tasks and what do they have to do with the administrative support and oversight of these actions? In other words, how can we trust that the people responsible for vetting those providers are doing it right? What are those people doing with the data they are collecting? And how do they know what to do with it? Soon, AI will access all the data at the drop of a hat. So, collecting the data won’t be a time-consuming process, capturing and downloading documents. The collection process will become instantaneous. But what happens when that data is dropped in a file, collected? Someone will still have to review it, assess it, manage it, secure it, and make appropriate decisions utilizing all that collected and verified data.
That someone is usually in the medical services profession and, most likely, that someone found themselves thrown into the fray of credentialing initially without proper training. But I am sure that someone has done what most of us have done, we have dug in, got copies of accreditation standards, studied state regulations, utilized every internet option to find the appropriate information related to the provider’s profile and what we were supposed to do with it. Some of us even became certified in our profession to continuously learn how to function in this area proficiently. However, we can’t say the same for most clinical and administrative leaders overseeing the credentialing process. Unfortunately, many still think the credentialing teams only perform rote tasks, clicking a few links online to see if a license exists and if other credentialing information submitted by the provider exists. At a minimum, those credentialing folks just build checklists, store documents, initial, and date the documents, get an appropriate signature of approval, and they are done.
Sounds simple? The misconception is totally understandable. But we all know that credentialing is not that simple. Those rote steps are just the outer scale of credentialing. There is a complexity in the decisions made with each collected and verified document. And these decisions are not totally dependent on the expertise of the credentialing specialist, the coordinator, the manager, or even the director. So, let’s skip the hands-on folks, the people I just mentioned, for now. Let’s consider the clinical leaders responsible for making the decisions to align the organization with qualified and competent providers. How do we ensure that those individuals have the critical skillsets required to continue to support operational success? Are those clinical leaders confident in assessing the okay provider that meets all the organization’s criteria and speaking up when the provider is not quite up to par, not quite meeting the organization’s requirements?
If there is any doubt, the confidence level of someone making those decisions related to other healthcare providers may be challenging. The leader may empathize with another member in their community who has undergone long years of education, or perhaps has had a documented lapse in clinical judgment, or a bad outcome considered to be that one mistake. Everyone is human, and no one wants to negatively affect another. But what if the decisions that need to be made are based on the lack of expertise, the history of sanctions or disciplinary actions, and other factors that identify negative credentialing issues? Is the leader automatically supposed to know what to do with these? Are they familiar with the organization’s policies and procedures, bylaws, and other regulatory requirements? Shouldn’t they be?
Wouldn’t you like to ask the leaders at Mohawk Valley Health System — the most recent case in the news where providers without the appropriate expertise were performing surgeries — if anyone had approved those activities? And if they did, why, who, and with what level of oversight? According to the lawsuit that has recently been publicized, a clinical leader with the knowledge of what should be done did do what she was supposed to do, she pulled the plug on these surgeries. But, instead of the support she needed and instead of educating all the clinical leaders to make sure it didn’t happen again, it appears she was punished. She was fired. Of course, I don’t have all the facts, just what has been reported in articles. But I can only assume that the organization’s bottom line was affected when the medical director pulled the plug. That made me wonder if these administrative leaders who fired her were familiar with regulations, whether state, federal, and accreditation standards. Did they realize their ultimate goal is to ensure patient care, and then make a profit for their organization? That is, if this is the true scenario. Too soon to tell, but it makes you wonder, and it makes you want to be more diligent in your organization to ensure everyone understands the importance of credentialing.
Maybe, I would suggest, every leader in a healthcare organization should receive orientation to credentialing. At the very least, they should have to take a class related to their policies and procedures overseeing credentialing. And yes, that includes chief medical officers, the credentialing committee chairs, and even the chief operating officer. They need to know the inner workings of credentialing to continuously ensure their organization's patients are treated and assessed by skilled and ethical providers.
With that said, I have one more recommendation. Recently, I attended a GAMSS meeting, the local state chapter of our professional society, the National Association of Medical Staff Services (NAMSS). Clinical and administrative leaders in healthcare would have benefited from the overviews presented. As usual, it was very informative, not only for those of us who are on the front lines every day, credentialing, enrolling, and licensing, but it was very insightful to anyone who must contribute to that final decision whether to accept, deny, or terminate a provider’s affiliation with a healthcare organization. The topics at the meeting ranged from malpractice litigation to regulations that an ambulatory surgery center (ASC) must adhere to and how to promote psychological safety in the workplace for all of us.
The healthcare world today is continuously evolving, managing, and tackling everything from nearly severe staffing shortages to political and religious interference with individual healthcare decisions, placing the providers' livelihoods at risk as well as the lives of patients. Ensuring that the patient care services run smoothly and effectively by always putting the patient first is a major juggling act. But, with the best training and support possible, the weight is slightly lightened. That's why it is important not only to continuously train the credentialing teams, but also the credentialing leaders and the collaborative teams in the organization. It's the only way to keep the patients safe. Credentialing is the first line of patient defense in all healthcare organizations. So, make sure those team members are highly qualified to make the right decisions for your patient’s safety.
Dilsa S. Bailey, CPMSM is the owner and principal consultant for The Right Credentials Network and an independent publisher and author. If your organization's credentialing and provider enrollment programs need assistance, contact The Right Credentials Network. We can help you apply for and maintain NCQA accreditation, build your delegation arrangements, and repair your existing credentialing program. And, if you or your staff needs additional training, let us create a package to fit your needs.
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