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Striving toward transparency in credentialing and privileging decisions.

Transparency in the credentialing process refers to allowing the general public access to the processes the organization uses to ensure that only qualified, competent individuals are allowed to provide patient care, treatment, and services.

It does not mean that all materials received in the process of credentialing and privileging are available for review by the general public. Peer review statutes enacted by most states assign strict confidentially to these materials. For instance, in Illinois, the Medical Studies Act states that:

"All information, interviews, reports, statements, memoranda, recommendations, letters of reference or other third-party confidential assessments of a health care practitioner's professional competence ... shall be privileged, strictly confidential and shall be used only for ... improvement of quality care, or granting, limiting or revoking staff privileges. ..." (1)

Most patients have little or no understanding of the credentialing functions performed by the organization. Rather, the community relies on the administration and governing body to employ a reasonable standard of care to ensure that employees and physician leaders perform functions in keeping with the expectations of community.

Organizations that operate in such an environment of public trust hold a high degree of accountability. While a medical services professional (MSP) typically performs credentialing and privileging functions in conjunction with medical staff leaders, the ultimate legal accountability for the organization lies with its governing body.

Publishing the credentialing and privileging policies and processes will cause a greater degree of accountability within the organization, which can lead to a stricter adherence to these policies.

Providing public access to the credentialing and privileging processes utilized by the organization ensures that potential patients receive important information they can use in making informed health care decisions. This can boost public perception of the credibility of the organization. It can also be used as a marketing tool.

Avoiding confirmation bias

When striving for transparency, it is important that organizational leaders avoid confirmation bias. Confirmation bias is a tendency to seek out and to interpret information in a way that confirms one's own beliefs or preconceptions. Raymond Nickerson describes this phenomenon as follows:

"There is an obvious difference between impartially evaluating evidence in order to come to an unbiased conclusion and building a case to justify a conclusion already drawn. In the first instance, one seeks evidence on all sides of a question, evaluates it as objectively as one can, and draws the conclusion that the evidence, in the aggregate, seems to dictate. In the second, one selectively gathers, or gives undue weight to, evidence that supports one's position while neglecting to gather, or discounting, evidence that would tell against it." (2)

Confirmation bias can be dangerous in the credentialing and privileging processes because it can lead people to make poor decisions based on debatable information. Consider the following scenarios:

Scenario #1

The board has charged the hospital CEO with responsibility for recruiting an orthopedic surgeon. A candidate who recently completed an orthopedic surgery residency is interviewed by the CEO. The CEO makes a few phone calls and receives positive verbal recommendations from physician peers whose names were provided by the candidate.

The CEO reports at the next board meeting that the recruitment efforts were successful and a well-qualified applicant has been identified. The board congratulates the CEO on his efforts and recommends that a contract be offered to the new recruit. The hospital expends a significant amount of funds and resources in negotiating a contract and relocating the surgeon to the community.


When conducting the credentialing activities for medical staff appointment, the hospital receives a letter from the candidate's residency program director that states that the physician's surgical skills in some areas were "marginal," and that there were some "behavior issues" that occurred during the training program.

Taking into consideration the resources that have already been expended by the hospital, the CEO decides to put more weight on the discussions he personally had with the peers than on the written recommendations of the program director.

In addition, he is concerned about being embarrassed in front of the board if he has to recant his previously held belief that the applicant was well qualified. He strongly recommends to the medical staff and governing body that the new recruit be given a chance to prove himself.

Scenario #2

The criteria for granting privileges as documented in the medical staff bylaws require that all medical doctors must be board certified by a member board of the American Board of Medical Specialties or the American Osteopathic Association; or for newly trained physicians, that they achieve this board certification within five years of completing their residency.

The hospital has a critical shortage of emergency physicians and is actively recruiting. A recruiter contacts the CEO regarding a "board certified" physician who is interested in the opportunity. The hospital contracts with the physician and the CEO grants temporary privileges pending completion of the credentialing process.

During the credentialing process, it is determined that the board that granted certification in emergency medicine is not a member board of the American Board of Medical Specialties or the American Osteopathic Association. No other concerns are identified during the credentialing process.

As the physician has been working for several weeks, the CEO asks the emergency department director's opinion regarding the physician and is told that the physician appears to be providing appropriate care. He also asks for a review of patient records, which does not turn up any concerns.

The CEO weighs the importance of having a competent physician to provide patient care against the fact that the physician does not meet the eligibility requirements of the medical staff and decides that it is more important to have a physician--even one that does not meet criteria--than to have a shortage. He decides to ask the board to waive the board certification requirement.

In both of these scenarios, the GEO gave more weight to information that supported his beliefs or preserved his image, than to information that was negative in nature. Author Upton Sinclair observed that, "It is difficult to get a man to understand something, when his salary depends upon his not understanding it."

Applying critical thinking skills

One way to avoid this confirmation bias is to apply critical thinking skills in credentialing and privileging decisions. Instead of only looking at one opinion, both views should be evaluated carefully.

Consider the implications of the decision. Play the devil's advocate. Try to come up with ail rationales that do not support your decision.

In order for an organization to meet a reasonable standard of care, its credentialing and privileging practices must be based on applicable; accreditation standards and state and federal regulations and these practices must be followed.

Most organizations have bylaws, policies, and procedures that address these practices, but many fall short in strictly adhering to the established requirements.

Medical services professionals, physician leaders, administrators, and governing body members must be provided adequate training so that they understand their responsibilities in credentialing and privileging. This training should be an ongoing process that continues throughout their career.

Those responsible for credentialing and privileging must keep abreast of accreditation standards and regulatory requirements. A process should be developed where access to these documents is readily available. When changes occur, policies and procedures should be evaluated to determine if changes are necessary to keep practices current with standards and regulations.

Another significant aspect of accountability is development of a process of audit or evaluation to check that procedures are being followed and standards upheld.

In auditing credentialing and privileging processes, this evaluation should include:

* Strict adherence to the application of criteria for appointment and privileges

* Meeting timeframes for review and approval

* Meeting proctorship and monitoring requirements

* Having all necessary documentation in place prior to making a credentialing or privileging decision

The emperor's new clothes

Hans Christian Anderson wrote a famous story entitled "The Emperor's New Clothes" that illustrated how people are unwilling to state an obvious truth out of fear of appearing stupid or unfit for their job.

The story involves an emperor who was very fond of new clothes, being taken advantage of by two swindlers, who claimed to be able to make a material that was not only beautiful, but that the clothes made from it could not be seen by someone who was stupid or not fit for his post.

The emperor thought this was a great idea, as he felt he could use the clothes as a tool to determine which of his underlings were stupid or unfit. Although no one, including the emperor, could see the non-existent clothes, none would admit to this as they did not want to appear stupid or unfit. Instead, they all exclaimed of the beauty and magnificence of the material.

The emperor decided to wear his new "garments" in a great procession around the town. He took off in grand style with his courtiers holding up the non-existent train of his cape. All the townspeople raved about the new clothes as they did not want to admit that they couldn't see anything or it would be known that they were was either stupid or unfit.

The procession went on in this manner until a small child suddenly said, "But he hasn't got anything on." This comment spread like wildfire, and it eventually got to the emperor. Although the emperor had the uncomfortable feeling that what they were saying was true, he felt he had to go through with the procession.

Anderson ends this story with the comment, "So he drew himself up and walked boldly on holding his head higher than before, and the courtiers held on to the train that wasn't there at all."

Sometimes mistakes are made in the decision to grant privileges or in the credentialing and privileging process. It is important to identify and correct these mistakes internally before they affect patient care.

This may mean taking the unpopular stance on an issue, having to admit that a decision was wrong, or confronting a superior about a decision made. Although these can be uncomfortable actions, failure to admit and correct mistakes can lead to public ridicule and can cause distrust of the organization's ability to provide safe, effective patient care.

All credentialing and privileging decisions should be made in such a way that the organization can be proud of putting them on display to the public.


(1.) 735 ILCS 5/8-2102

(2.) Nickerson R. Confirmation Bias: A Ubiquitous Phenomenon in Many Guises, Review of General Psychology, 1998, Vol. 2, No. 2, 175-220

(3.) Sinclair U. (1935 (reprint 1994)). I, Candidate for Governor: And How I Got Licked. University of California Press. pp. 109


By Kathy Matzka CPMSM, CPCS

Kathy Matzka CPMSM, CPCS is a speaker, consultant, and writer with over 20 years of experience in credentialing, privileging, and medical staff services.
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Title Annotation:Credentialing and Privileging
Author:Matzka, Kathy
Publication:Physician Executive
Geographic Code:1USA
Date:Mar 1, 2010
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