December 19, 2019

QUESTION:        We have nine hospitals in our system.  We are not ready to have a unified medical staff (and maybe never will be) but we need to find a way to have more uniformity in our documents and decision-making.  Do you have any suggestions?


ANSWER:            There is no single right answer to the question of whether medical staffs within a system should form a unified staff.  Although CMS changed the rules in 2014 and allowed hospitals with separate CMS Certification Numbers (CCN) to have a unified medical staff, unification may not be the best choice for your system.  It is important, however, for medical staffs within a system to strive for uniformity and consistency in their documents and decision-making.  Take it from us, it is a problem when one hospital in a system decides to deny reappointment or imposes a precautionary suspension and the physician shifts his practice to a sister hospital.  Fortunately, there are ways to avoid that disaster short of unification of the medical staff.

Most systems we work with have started with a uniform application form and uniform peer reference forms.  This helps ensure that each hospital in the system is asking the same questions and getting the same responses both from the applicant and from the peer references.

Many systems have gone to the next step and created a credentialing verification organization to gather and verify information that is then forwarded to the physicians and other practitioners involved in the credentialing process.  This helps to ensure that each medical staff has the same primary source information to use in making credentialing recommendations.

As a next step, many systems have developed a system credentials policy.  This helps to standardize the standards and the key credentialing processes.  Each medical staff will then have the same threshold eligibility criteria for appointment, the same way of dealing with misrepresentations and omissions, and the same investigation and hearing processes.  This approach can also be taken for other key documents such as the professionalism policy, health policy and peer review policy.

Once your standards are aligned, you might next want to consider the development of key medical staff committees that would function at a system level.  Many systems have done this with the credentials committee.  Representatives from each medical staff typically serve on the system credentials committee.  This helps ensure that the same people are applying the same standards.  This should drastically reduce variation in recommendations at least at appointment and reappointment.

Good language in your credentials policy can also address those situations where one medical staff in your system has developed a performance improvement plan, commenced an investigation, or recommended revocation of appointment and privileges.  The key is to have language which allows these actions to be effective at all hospitals in the system without having to redo all the hard work that has already been done but, at the same time, to allow some discretion when a different outcome would be warranted by the facts.