12.17.2007

The Hospital Credentialing Process Dog and Pony Show!!

So, I've been filling out multiple hospital applications lately. It's not uncommon for physicians to have hospital "privileges" at multiple hospitals, you know? And it's *crazy* what's involved in this process. Addressing this issue would be the perfect 'lifestyle, morale boosting, lovey dovey project' that our professional organizations could tackle, that will validate the membership fee (and PAC contributions) to those of us who are too busy to really get involved in the mundane, ever-changing politics of healthcare. Isn't that their purpose?

Okay, here's how it goes -

First you get this huge packet, maybe 70-100 pages of...who knows what. A piece of paper for everything...completely unnecessary and purely a hospital CYA. Read, sign, read, sign. They ask for accompanying documents, such as a CV, copies of your medical license, DEA, ACLS, PALS, board certification, diplomas, health clearance, etc.

There's a credentialing fee...which is a crock of shit. Aren't these people paid by the hospital to do this job? Why am I being charged a fee? Are other people charged a fee to apply for a job? The nurses....the techs? Everyone wants to be 'treated equal', yes? Where am I supposed to get this fee money? I have no money, hence the application for a *job*!! The fees range from $200 to over $500. Then, you want *me* to gather all the information....and pay the fee to boot?!! If I pay the fee....seems only right that you gather the information. Isn't that what I'm paying for?

The application - requires the standard info like name, address, etc. Then they ask for work history, educational history, and references. It's all on the CV. But they write "do not write see CV". Why not?!! Why ask for the damn thing? My CV has my work history, my references, contact info....all the basic stuff.

Then they ask you *again* (as if to catch you in a lie...as if you're that stupid), your work history....just to be sure there are no gaps. What they really want to know is if you've ever been committed to a psych hospital, or drug rehab...or otherwise MIA due to being "weak" or "crazy." It would be much easier to just write "I have never had a problem with drugs/alcohol, nor am I crazy" than to do this song and dance, that in the end proves nothing.

There's a sedation packet with a quiz...because this makes you "safe" to administer sedatives (can you feel the sarcasm?)

There's a core privileges packet, where you request which privileges you'd like. What the hell? I would like to do everything I'm trained to do, please. ACGME doesn't accredit residency programs, and ABEM doesn't allow one to graduate from a residency program, without showing competence with basic EM tasks. So, by being a graduate of an approved EM training program, I shouldn't have to pseudo-justify my competence in basic shit....like sedation, and ultrasound. Nor should I have to request privileges one by one. Even if I've never done a cric....I need permission to do one if needed. And if you tell me "no", how can I do my job? So...this packet could be eliminated if I'm an ER doc asking for ER privileges only.

Then there's a background check. Makes me wonder what is the Medical Board for, and why do I pay them almost $700 every other year if they can't vouch for me, and their 'blessing' isn't enough to practice medicine in my state's hospitals. It's insulting, and unnecessary.

References - are a joke. I give you 3 doctors....of the 100+ I know. So, what does that prove? Not that I'm a good doctor. Even the worst docs can find/pay 3 people to fill out a form. Then they call these 'references' (over and over and over again) and ask stuff like "would you say she's competent at LPs?" As if they'd know. They are not standing over me...ever...watching my LPs. ER docs don't stand over each other, and honestly have no idea what our colleague is doing 99% of the time.

Then there's the residency verification. Again, board certified should be sufficient to demonstrate my competence in my area of specialty. So why go thru contacting my residency program...and how long do they do that? I mean, my program director is an old guy already...

Then contacting every employer? I don't understand this either. Obviously, by the questions that are asked of them, there is that concern (again) of drug/alcohol use, and mental health issues. It's not like they're interested in "was she a good person....did she work hard?" Nope, the hospital doesn't care about that (the Group might, but they don't contact all prior employers). It's a CYA thing, again...no real value. Again, if I'm okay with the medical board, and my professional organization....board certified and a clean record (which is public and could easily be obtained by the medical office staff , which may begin to justify that $500 fee)...I should be okay to work (from the hospital's point of view).

I thought was ahead of the curve by saving all of my 'important documents' (LoR, malpractice certificates, employment letters, board scores, etc). Not. Get this...the information has to be "primary source information." This means, *they* have to contact someone other than you to get this information. (yep, crazy, I know). But, if they are unable to contact these people (people such as secretaries of departments to "confirm" you actually worked there, and weren't in rehab), they blame you: "I couldn't contact Doctor's Office up the street so we can't verify your credentials." Okay. I know I worked there. You're the one who wants "first hand proof." What the f*ck do you want me to do? You offer up the letter of recommendation from the medical director of that clinic. "Oh it's not addressed to us specifically....and we need to talk to him directly." Seems to me my letter is far more reliable than whomever you happen to get on the other end of the phone. Besides, I think he's probably dead by now....

Then there's the medical malpractice questionnaire. "Please list all of your malpractice carriers for the last 10 years." WTF? I could understand asking about any pending lawsuits...but even that doesn't concern the new job...until the outcome is known. We need a HIPAA for malpractice insurance companies (to protect us from the sharing of sensitive information which would be used to exclude us from being insurable. Afterall, isn't that the original intent of HIPAA? But we've allowed it to go as far as preventing us to obtain vital medical information from the PMD of our comatose patient...who cannot, and I repeat (to the person in charge of the pencils) *cannot* for the love of God, sign a authorization to release medical records right now!!) But I digress.

We have been successful in eliminating the ACLS/PALS/ATLS requirement for board certified ER docs. I mean, what the hell? I'm board certified as an emergency specialist, and you want a little red/white card saying I can complete an online open-book quiz...is that supposed to prove something?

Then they ask for your passport, social security card, drivers license, shoe size...and a strand of hair for DNA testing!!

The process takes a few hours of actual work time to complete...and that's if you have everything readily available at home. It's ridiculous!!

I'm all for interventions that contribute to actual improvement of safety or security. But many of these hoops are akin to the prohibition of lotion and chapstick on airplanes. It's just a hurdle that penalizes "good" people, and does nothing to increase safety or security. It serves to increase the cost of healthcare, and aggravates those of us who are on the front line.

I say, ACEP or AAEM should help us lowly grunt docs streamline this process. Maybe help us implement policies that will allow ABEM to be enough certification of our training and ability by virtue of being board certified. Our medmal should be private. The Medical Board issuance of a license should be sufficient to practice medicine in any hospital in the state. If I have a drug/alcohol problem that's significant to prevent secrecy, the Medical Board should know about it, and my licensure should be adjusted accordingly (understandably the Medical Board needs to be held accountable, which currently they are not). A CV should be sufficient to explain our professional lives (afterall, it's not like I'm writing something 'different' on the application. It's not more 'sacred' or 'accurate' because I write it twice...just more believable). And a 'central databank' would be excellent. One that could be referenced, and taken to be accurate by 'all the bullshit people who interfere with healthcare' (i.e. joint commissions, CMS, etc).

85 comments:

MY OWN WOMAN... said...

My daughter told me that getting admitting privledges is a pain in the a$$, but I had no idea how much of a hemmorrhoid it really is.

Bostonian in NY said...

Holy crap...and I thought the MCAT and admissions criteria for med school were a bunch of flaming hoops for us poodles to jump through.

I can't wait to suffer through for the boards, the match, residency, state licensing, and board certification just to pay someone else to shuffle my papers around and rubber stamp them to keep the hospital lawyers and JACHO bureaucrats happy.

Anonymous said...

So, sarcasm may be lost on me today. Tell me the shoe size and DNA testing was not a legitimate part of the process?

Rita Schwab - MSSPNexus said...

I am a fifteen-year hospital credentialer. Unfortunately, most of what you say is true. Okay, maybe it's not QUITE as bad as you make it sound, but close.

The process is difficult both for you the applicant, and for the people on the other side who are trying to follow all the laws, standards and regulations that govern hospital appointment and privileges.

If it's not done well, organizations end up with physicians like John Anderson King, the now infamous Putnam WV credentialing-gone-wrong case.

Can it be improved - you bet. Some of the changes need to be done at a high level (CMS, Joint Commission, etc.) but some improvements can be made at a local level.

I always encourage docs to communicate with the Medical / Professional Staff Affairs personnel in their organizations. Even better, collaborate with them on ways to make the process effective and yet as painless as possible.

I write a blog which is largely about these and related healthcare administrative issues.

You may be particularly interested in The Ugly Truth About Credentialing and Privileging posts. (Click on Most Popular Posts on the sidebar and scroll down.)

Our responsibility is heavy; work to protect the public from unsafe physicians and other healthcare providers. However, I agree that the methods currently in use can certainly stand improvement.

Rita Schwab, CPCS, CPMSM
http://msspnexus.blogs.com

Anonymous said...

Don't forget the hospitals that make you go get fingerprinted like a common criminal. Oh and the "random" drug test.

Ten out of Ten said...

Fantastically snarky. The push/pull between patients who demand immediate attention/results and the beauracrats who cannot be hurried and couldn't care less was driving me insane back when I was in the middle of this process.

jennfurr said...

Beautiful! I agree with (almost) every single thing you said! Unfortunately, as a credentialer, it's also a pain in the a$$ on this side of the wall too. Go talk to the Joint Commission, Medicare, and the various States, and make them change their rules, and I'd be glad to help streamline the process!

It's my dream to have ONE central clearinghouse for all physician information, so as to easily tell what's going on.

Not surprisingly, there are some heinously bad doctors out in the world ::gasp::!! And I have had the unfortunate task of running across some exceedingly unethical ones who have lied about current drug/alcohol issues (he's now in jail for manslaughter) and excessive malpractice cases (can we say 33 legitimate cases in the span of 10 years anyone??) etc. It's these bad doctors that ruin it for all of us and make the rules the way they are.

I try my darnedest to make the credentialing process go as quickly as possible, while following all the rules that are placed upon me. So remember - those of us in the Medical Staff Office are just the messenger!

ER doctor said...

Rita and Jennfurr, thanks for your perspective. I do completely understand you're just the messenger, doing your job. And I understand that the application fee is just another way for hospitals (CEO, stockholders, etc) to make money on our sweat (i.e. I understand that you don't get to keep the money for yourselves).

My gripe is with those who wear suits, who are not involved in direct patient care in any way...making asinine rules that really serve no purpose. As mentioned, if the hoops we jump thru really amounted to improved safety, I'd understand. But that is not the case.

I know (boy do I ever) that some doctors are bad people, or have other "negative human qualities/issues." And if they are unable to uphold our profession with respect and dignity, it is to my (and all other doctors) benefit that we call them out. But this process isn't very effective, and is easily manipulated...especially if a physician is creative and 'a really bad person.'

A central database is key. As is more involvement of our professional organizations, and the Medical Boards. If doctors, one day, take their profession back...things will improve...for everyone!!

p.s. I was only exaggerating a tad (maybe the DNA sample and shoe size were a stretch ;o)

jennfurr said...

er doc - thanks for your response! And... I have been known to tell a doctor during the process "we just need your blood type and first-born child to complete the process"... so DNA sample and shoe size aren't TOO far off!

CresceNet said...

Gostei muito desse post e seu blog é muito interessante, vou passar por aqui sempre =) Depois dá uma passada lá no meu site, que é sobre o CresceNet, espero que goste. O endereço dele é http://www.provedorcrescenet.com . Um abraço.

CresceNet said...

Gostei muito desse post e seu blog é muito interessante, vou passar por aqui sempre =) Depois dá uma passada lá no meu site, que é sobre o CresceNet, espero que goste. O endereço dele é http://www.provedorcrescenet.com . Um abraço.

Vitum Medicinus said...

I found this post fascinating, as a med student who will perhaps end up in ER someday.

This post is a great example of the real-life things we'll probably never learn about in med school...so I'm grateful to you for taking the time to explain it in such detail!

I wonder if it's different in Canada...?

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David said...

Great attitude! Credentialers do what they do because there are incompetent docs out there. We have patients to protect. Some of the paperwork is burdensome and doesn't seem to contribute much to the process, but we have standards that must be met.

BTW, we use the three references you give us, but we also contact a few more docs of our choosing.

We charge application fees to cover the costs of querying the NPDB, malpractice insurance companies, criminal background checks, etc.

I really hope you don't apply at my hospital.

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