Quality oversight

Credentialing, Privileging and the Engaged Board

Education, preparation and collegiality are key to frank discussion and fair decisions

By Laurie Larson

Editor’s note: This is the second in a series of articles on credentialing and privileging (C&P). The first article described trends in the C&P process. This second article focuses on the board’s participation in that process.

Although hospital boards have always understood their legal responsibility for vetting and approving provider credentials — as well as granting, limiting or denying privileges — value-based care models have driven the point home. The models' requirements for more data gathering and quality measure reporting demand that board members communicate in greater depth with their credentialing and medical executive committees to make well-informed, thoroughly vetted credentialing and privileging decisions.

Within the board, those approvals require thoughtful discussions between physician and lay member trustees. These are two distinctly different types of board members, however, and finding a common and comfortable language to frankly discuss a board decision about which physician trustees generally have more knowledge can daunt nonphysician trustees. How can that common language be found and encouraged?

“It starts with the board chair,” says David Hasleton, M.D., senior medical director over emergency and trauma services and community hospitals with Salt Lake City-based Intermountain Healthcare.“ The chair is critical for empowered, fair [credentialing and privileging] decisions.” Among the system’s 23 hospitals, Hasleton is board chair of its five Salt Lake Valley hospitals, and chair of that division’s Professional Standards and Credentialing subcommittee.

“The chair sets the tone and climate of the boardroom,” agrees Charles E. Reiter III, founding partner of Chicago-based Reiter Burns, LLP, and former senior vice president, general counsel and secretary for Loyola University Health System, Maywood, Ill. “The best leaders create a safe space for conversations without immediate judgmental feedback and demonstrate a personal openness that makes trustees feel it’s okay to ask questions.”

Social activities that allow all trustees to get to know each other better outside the boardroom also can foster that comfort level, Reiter suggests. He further recommends regular individual and group self-assessments that ask board members whether they think they have received adequate education on credentialing and privileging, and if they believe they receive meeting materials far enough in advance to adequately prepare.

In his boardroom experience, Reiter has seen a higher ratio of lay board members to physician members — and he thinks that’s preferable. “Lay trustees bring varied experiences to all board discussions that they should feel comfortable enough to share,” he says.

Hasleton affirms that choosing strong, intelligent individuals to fill lay trustee roles is key — and that all board members should demonstrate mutual respect for one another. “There is very respectful interaction between all five of our hospitals’ board members, and the physician members actually often take a back seat to the lay members in discussions,” he says. “We’ve provided high-level education to our lay members, and our physician members understand that they also need to be able to explain and answer lay trustees’ questions about complex medical procedures and conditions.”

Michael Nussbaum, M.D., chair of Roanoke, Va.-based Carilion Clinic’s department of surgery, describes his board’s credentialing and privileging discussions as similarly collegial, with lay members asking physician members for advice on quality and safety issues, but still making their own decisions.

“In a malpractice discussion, for example, lay trustees will look to physician members to understand what an issue means, or how egregious a mistake was,” he explains. “Our physician trustees’ role on the board is to bring that understanding to the rest of the board.”

He adds, “The expectations for hospital boards have changed and become more important over the past 10 years. Our trustees understand that, and our lay members are not shy because they’ve had in-depth orientation — and they’ve been chosen for their knowledge and leadership in their own fields.”

What Trustees Should Ask

That understanding and dedicated preparation for every meeting makes for “a very involved board,” including its discussions about credentialing and privileging, Nussbaum says. “Our trustees take their responsibility seriously and err on the side of caution. They might ask, ‘Is this a patient safety issue? Is this disruptive behavior affecting patient care?’ We tell our lay trustees, ‘If you have a question, ask. You don’t have to have medical experience.’”

Steve Blanks, who chairs the Carilion Medical Center board and serves on the Carilion Clinic system board adds, “Our lay trustees know they are accountable to the community and are not afraid to ask hard questions.” Those questions might include asking why an exception is being requested for a physician’s privileges, or whether a difficult credentialing or recredentialing vote might have an effect on the quality of care delivery, he explains.

Reiter encourages board members stay up to date with their hospital’s community needs assessments to be aware of their patient populations’ most pressing care and service needs. Credentialing and recredentialing questions can then be framed by how well the organization is meeting those needs.

“The first item on any board agenda should always be an assessment of how well the hospital is doing in providing needed services — and that will inform the number and types of physicians needed,” Reiter says. In evaluating a new physician candidate’s credentials and privileges, trustees should ask the medical executive committee representative such questions as: “Why do you recommend this physician? What will he/she bring to the medical staff? Will they fill a current gap in services? Do we need more of this specialty?” Physician board members should also be asked if they know or compete with the applicant. “It’s worth thinking about any possible conflicts of interest,” he adds.

“We’ve all come to understand that credentialing and privileging are among the most important things we do as a board,” Blanks says. “They have a significant impact on our reputation, clinical effectiveness, patient safety and our quality of care.”

Education Matters

With that in mind, Carilion Clinic provides thorough trustee on-boarding through two extensive orientation sessions, including case studies to illustrate board roles in action, along with a full list of legal rules.

“We work hard to get our trustees up to speed quickly,” Blanks says. “If you teach the fundamentals well and set high expectations, you will have a cohesive group who are all on the same page, and you can get to work.” Ongoing board education always includes an annual presentation on credentialing and privileging, he adds.

Hasleton says he always urges his Intermountain lay board members to think and speak candidly in credentialing discussions. “They might ask ‘If it was your family member, would you want this physician treating them?’” he says. “I encourage them to speak up, and I ask them pointed questions, different from those I ask physician trustees.”

As an example, he says he might ask lay trustees how they think an operating room should be run in terms of its demeanor and tone — a real-life issue the board recently addressed in deciding whether to recredential a surgeon with ongoing professionalism issues.

Hasleton adds that his division’s Professional Standards and Credentialing subcommittee asks for “a lot of factual opinions” in turn when weighing a difficult credentialing, recredentialing or privileging vote. “We lay out a timeline of all events in the situation in a nonemotional way, and I moderate that presentation,” he explains. “The presentation is made by a physician who understands the complexities [of the case] but who is not biased. The way a presentation is made can sway board members, so it has to be totally fact based.” A rebuttal to the presentation is then allowed, followed by a discussion and time for questions.

In his additional role as chief of surgery at Carilion Medical Center, Nussbaum reviews and votes on requests for surgeon credentialing, recredentialing and privileging through several rounds of approvals.

“If there are issues or problems, I’m aware of them before [a potential exception] goes forward to the hospital medical executive committee or to our board,” Nussbaum explains. He also reviews surgical behavior SafeWatch reports, Carilion’s event-reporting program, which is used as a peer review and patient safety tool and as part of its recredentialing process. “Our medical executive committee can often vet and handle credentialing or privileging issues before they need to go to the system board,” he says. “There are multiple layers of checks and balances, which provides the opportunity to hear about and have input on potential [credentialing and privileging] exceptions at multiple levels.”

Because of those checks and balances, “it’s virtually impossible for [a practitioner] with significant problems to get past the credentialing and privileging process,” Nussbaum adds. “But we also try to give physicians a fair shake. It’s a big deal to deny a physician privileges, so if there are concerns, our process is to seek additional information before making a final recommendation.”

Resources to inform that deeper dive into questionable credentialing or privileging cases might include gathering data from: The Joint Commission’s Ongoing Professional Practice Evaluation (OPPE), a summary of ongoing data collected to assess practitioners’ clinical competencies and professional behavior; the Focused Professional Practice Evaluation (FPPE), for more specific reviews in particular specialty areas; or the National Practitioner Data Bank (NPDB), a web-based report repository documenting medical malpractice payments and adverse actions. The NPDB prevents practitioners from moving from state to state without disclosure or discovery of previous damaging performance.

“For surgeons, we supplement this information with the American College of Surgeons National Surgical Quality Improvement Program, which covers all surgical specialties and provides a robust data set for comparing outcomes among individual surgeons with the national cohort,” Nussbaum says. “Boards are provided with all of that information, and as you give trustees more data, they will use it in their decision making.”

He is certain Carilion’s trustees make serious use of those resources as needed. “Our health system is an important part of the communities we serve, not only as its major employer, but because we provide the medical care for our families and friends. Our trustees know Carilion’s [quality of] care affects them personally.”

Blanks agrees. “Over many years, we’ve developed a culture at Carilion with high standards for our credentialing and privileging process — our leadership, physicians and lay trustees have all evolved together.” He adds, “Everyone’s intention is to do good. The real, frank question board members need to ask about credentialing is, ‘If this was your company, what would you do to be the best of the best?’ It makes them stop and realize how important credentialing and privileging are.”

Laurie Larson is a contributing writer to Trustee Insights.