Did You Prepare a Credentialing and Privileging Summary Report for 2019?

Did You Prepare a Credentialing and Privileging Summary Report for 2019?

Mar 16, 2020
  • Author:
    Vicki Searcy
    Former VP, Consulting
    Vicki has managed several credentialing and privileging practices, led a national healthcare accreditation and compliance consulting practice, was a surveyor for the NCQA, and a former president of NAMSS.

Does putting together an end-of-the-year report on credentialing/privileging sound like work that you would like to do if only you had the time (and you don’t)? If you didn’t find time to complete a report summarizing 2019 credentialing/privileging activities, you have missed a great opportunity. Here is why:

  1. You have the opportunity to identify metrics that will showcase the credentialing/privileging function – and demonstrate how your organization compares with other organizations (if you have access to those types of metrics). Note:  CredentialStream customers that use CredentialStream and Privilege have access to Credentialing and Privileging Insights (a wealth of comparative data). You will also find some comparative metrics in the upcoming 2020 Annual Medical Staff Credentialing Report (to be released in May, 2020 – the webinar on this topic is planned for May 14 – registration will be available soon).
  2. You can interpret the data positively and constructively – focused on solutions (when applicable), rather than finding blame.
  3. You can use the report to acknowledge individuals in your department or physician leaders who are deserving of recognition.
  4. You can get your Credentials Committee involved in the report so that this becomes a report from them, rather than you (and when it comes from the Credentials Committee it typically carries more weight and is more thoughtfully received).
  5. You can use a report of this type to educate your Board of Directors about the credentialing and privileging process – particularly on key metrics that contribute to quality patient outcomes.

The focus of the annual report should be an analysis of what was excellent (and why), what was good (but can be improved), and identification of opportunities for improvement, along with recommendations for how those areas can be improved. Comparison of actual performance or goals with target levels of performance are excellent to include in an annual report, along with an analysis of why the targets were met, not met or exceeded.

The annual report might provide data about how many times a file was returned to the medical staff office for additional information after the evaluation and decision-making process was initiated. Initially, it might be assumed the reason for returning a file was that the medical staff office did not do a thorough job of verification. The real issue, however, might be lack of qualified staff. Or the issue might be that the medical staff organization has not established concrete privileging criteria, which leads to indecision about whether an applicant is qualified for specific privileges.

Designing Your Annual Credentialing Report

The following outline shows how an annual credentialing report might be organized.

Title page
  • Name of report
  • Time period covered
  • Prepared by: (include names of credentials committee members and director, medical staff services, etc.)

Table of contents

Major purpose of the report

Comparison of actual performance or goals with target levels of performance:
  • State each goal (e.g., decreasing the length of time it takes to process applications, transitioning from paper applications to electronic applications, transitioning from laundry list privileges to core privileges, etc.) from the previous annual report and provide a synopsis of whether the goal was reached.

Summary of audits and audit findings:
  • Include a list of the types of audits conducted, what was learned, and any changes made as a result of the audits (or refer to the recommendations section of the report if changes are proposed).

Summary of important credentialing events:
  • Include information about denials that were made for appointment, reappointment, and privileges; hearings held and the outcome; negligent credentialing lawsuits filed and the current status; etc.

  • Include any recommendations made as a result of the analysis of credentialing processes during the year. These might include the following suggestions:
    • Provide credentials committee members and department chairs with more education about the credentialing process
    • Increase the number of credentialing staff
    • Purchase new credentialing software
    • Add resource information (e.g., newsletters, books, etc.)
    • Change the composition of the credentials committee
    • Eliminate verifications from the process that are not required and have not been found to yield information that makes a difference in decisions made

Goals and objectives for the coming year (may include a work plan):
  • You may need to defer part of this section, based on concurrence of the MEC, administration, and board, with recommendations made in the preceding section. Include here any goals and objectives that the committee can implement without “permission” of the MEC and board, as well as those actions that can be taken after first securing funds that will have to be included in the next budget.

Take advantage of the opportunity to spotlight existing functions and identify the factors that cause these functions to be ineffective or inefficient. Work with your Credentials Committee to analyze the information and then forward the report to the Medical Executive Committee and the Board. Preparation of an excellent, concise PowerPoint presentation would be a great idea for these venues.