Healthcare Practitioner Credentialing Toolkit

Webinar

Credentialing Compliance: Documenting Practitioner Credentials and Competency Webinar

One of the biggest challenges of any medical staff is evaluating and documenting the competency of providers. In order to support this need, having an effective and efficient credentialing and prvileging system is vital. This webinar covers methods for documenting credentials, forms and processes for documentation of competency and the concept of negligence in credentialing.

Checklists

6 Common Areas of Liability Exposure During Credentialing

During the credentialing process, a medical facility may open itself to unwanted positions of liability if certain factors are overlooked. This downloadable resource discusses six common areas of liability exposure during the credentialing process to help prepare your team.

In addition to areas of exposure, the document also provides insights that explain how a plaintiff attorney uses this information and what administrators can do to protect their facility.

Guidelines/Recommendations

Dealing with Disruptive Physicians

Disruptive physician behavior negatively impacts patient safety, staff satisfaction and increases the likelihood of medical malpractice claims. Disruptive behavior poses a challenge for leaders in healthcare to address and it is important for leaders to have a plan in place to handle them when they arise. This article from MGMA addresses how to confront physicians with behavioral issues and how to develop an organizational plan of handling disruptive behavior that will promote a change in culture.

Guidelines/Recommendations

2019 Joint Commission Medical Staff Update PowerPoint

This 2019 Joint Commission resource provides a description of regulatory requirements as related to Medical Staff processes and compliance strategies, discusses new standards impacting the Medical Staff, describes common survey findings and provides a description of a successful OPPE/FPPE program.

Webinar

Negligent Credentialing Webinar

Healthcare entities are responsible for developing credentialing processes for physicians and physician extenders who practice in the hospital and managed care settings. These processes are developed to protect patients from harm. But when physicians are engaged in a medical malpractice lawsuit, the healthcare entity may also be included under the pretense of negligent credentialing.

This webinar provides an overview of a pre-application, initial application/credentialing and reappointment/re-credentialing processes along with the integration of FPPE and OPPE quality criteria. The processes include aspects of primary source verifications, applicant responsibility and how to identify potential risk management issues for review by various Committees and Board approval entities.

Webinar Slides

Negligent Credentialing Presentation

Click to view the presentation slides used in the Negligent Credentialing webinar.

Webinar Slides

Credentialing Committee Orientation Presentation

Provided below is a downloadable PowerPoint presentation on the responsibilities and related processes of the credentialing committee. This is a useful tool in the orientation and onboarding of new committee members, offering an overview of the expectations placed on the committee with regards to patient safety.

The information within the presentation should be used as a guide and edited as necessary to reflect your facility’s specific process.

Webinar Slides

Implementing an Effective Faculty Performance Evaluation Process (FPPE/OPPE) PowerPoint

This presentation provides information about OPPE/FPPE as it relates to a healthcare organization and the Joint Commission. It will:

• Review how different healthcare organizations manage OPPE/FPPE
• Discuss skills to implement policies, procedures and implementation tools

National Association Medical Staff Services

The National Association Medical Staff Services focuses on enhancing the professional development of and recognition for professionals in the medical staff and credentialing services field. The website provides NAMSS members educational, certification and regulatory resources.

Credentialing Resource Center

The Credentialing Resource Center provides resources related to processes involving the medical staff and credentialing services. Resources include featured articles, white papers, privileging tools and form, networking and events, career opportunities and membership opportunities.

Kathy Matzka, CPMSM, CPCS Writer/Speaker/Consultant

Kathy Matzka is a consultant, speaker and writer specializing in credentialing and professional staff resources for healthcare organizations. She provides services in the following areas: staff support and training, accreditation preparedness, process review, educational programs, newsletters and data collection tools.

Checklists

Sample Credentials File Chart Audit Form

Healthcare providers and facility administrators can use this sample credentials file chart audit to ensure compliance with hospital standards and policy. The downloadable form provides a comprehensive checklist field including necessary elements of review to ensure credentialing documentation is in place for physicians on staff.

Through thorough assessment using this form, you can determine which physician files at your own facility are out of compliance with proper credentialing procedures, helping to safeguard against accidental oversights and room for liability.

Checklists

Comprehensive Credentialing Checklist for Hospitals

The credentialing process is information-intensive, often requiring a multitude of components for completion. Staying organized and updated on what details you need is important in the successful implementation of the credentialing process.

To stay on target with your assessment process, use our Comprehensive Credentialing Checklist to ensure that all needed information has been verified prior to presenting for next level of approval or review.

Policy Templates

Sample Focused Professional Practice Evaluation Plan Form

While licenses offer a benchmark for the training of an employee, these hardly gauge how competent the physician may be at a particular skill. When onboarding new medical staff members, it’s essential to evaluate their individual competencies and professionalism to ensure it’s streamlined with your facility’s quality of care.

Use the sample Focused Professional Practice Evaluation (FPPE) form provided to quickly assess your new staff members.

Policy Templates

Hospitals Reference Request

Letter and form to be sent for reference of the applicant.

Assessment tools

Sample Peer Reference Request and Form

A request for peer review of a new applicant should include the following indicators: evaluation of the applicant’s experience, ability and current competence in the areas of medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills and professionalism.

Provided is a sample peer review request letter and evaluation form that you may use to quickly send and request assessments for new applicants to your facility. The download provides an introductory letter followed by an evaluation form to be completed by the selected peer.

Assessment tools

Sample Credentials Audit Report for Hospital Board

The Governing Board is ultimately responsible for credentialing and privileging activities of the hospital. It’s best practice to provide them with a yearly report of all credentialing activities that occurred in order to sustain continued process oversight.

The downloadable document provided is a sample credentialing audit that can be performed and presented to the governing board of your facility. New applicant activity and medical staff roster counts are included within the audit to provide a broad overview of the department or facility for review.

Policy Templates

Practitioner Worksheet for New Privilege Request

In the healthcare setting, practitioners may request new privileges as needed. Provided below is a downloadable request form to be used by the practitioner, which ensures that all necessary information is collected and documented prior to presenting to the committee for review.