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Credentialing - Who Cares?

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​Credentialing is a core part of the function of a medical staff. It is the means by which the medical staff ensures:

  • That only qualified physicians are given medical staff privileges;

  • That physicians’ membership on the medical staff is reviewed regularly (typically every 2 years) to ensure they are practicing at or above the expectations of the medical staff;

  • That physicians are treated fairly when asking for new or additional privileges; and 

  • ​That there is a way in which the medical staff can clearly establish the educational, training and experiential requirements for each privilege that is granted to a physician.  

If you think about it, it is really a tremendous privilege we’ve been given as physicians to have potential competitors review one another’s performance data and make decisions on what they will be allowed (or not allowed) to do.  


It is hard to think of a single other example where that degree of trust has been placed in a person by the federal, state or local government. You certainly don’t see all of the fast-food chains in the city getting together and deciding whether a new store can open up, but that is essentially what doctors are allowed to do at a hospital.


That degree of trust, though, has a price, which is important to keep in mind. Basically, the price is that privileges must be given to physicians in a fair, standard, unbiased manner based on criteria adopted by the medical staff. Those criteria reflect an overall goal of improving the care of patients, protecting them from unnecessary or poorly-provided care, and ensuring that only competent practitioners provide care in the institution. As we know, meeting these expectations creates a process that can, at times, be frustrating, prolonged and certainly inconvenient.


BayCare has invested considerable resources to assist the different medical staffs from our hospitals to carry out this process. The first is our electronic application and database system called Cactus. This is where every physician’s official credentialing record resides, where the electronic application that new applicants have to fill out resides, and where the many details about each physician are stored. 


While Cactus is a huge step forward from the old paper and pencil systems we used to use, it is far from perfect, and not at all flexible. Changes to the software that might seem to be simply common sense are neither simple nor common when it comes to adjusting the software to reflect some of our own traditions and expectations. The CVO (Credentials Verification Office) has done an incredible job, and spent lots of time and money working with the Cactus vendors to customize the product to our needs, but again, it is far from perfect, and will unlikely ever be perfect given the constraints of time, money and logistics involved in modifying it.  


The CVO is the department charged with collecting the initial information on new applicants and making sure that the information meets our requirements before sending the application to the individual hospital credentials committees for action. While there have been many complaints about how much time it takes to get an application through the CVO, and we would all agree these delays can be costly and are almost always frustrating, it is important to realize that the CVO has no authority or permission to deviate from the rules it has been given. If a hospital’s rules require references from two doctors in the same specialty, and the applicant submits references from doctors in another specialty, or one of the doctors doesn’t complete a reference, the CVO can only remind the doctor of the problem.  


Often this reminder goes to whoever the applicant has designated as their go-between, like their new group’s credentialing secretary, and at times, there is a breakdown in communication with the doctor. The CVO processes hundreds of applications a month, and tries to be as customer-friendly as possible, but it only has the resources to interact with each applicant on these issues at a finite frequency.  


Another source of frustration for many of our applicants is the variation in rules and expectations among our various hospitals. Each hospital in BayCare has been doing credentials since its inception, and thus has long traditions around the credentialing process. Unfortunately, these traditions are invariably different from one hospital to another. The Medical Staff Advisory Council is working with the various service lines, collaboratives, Medical Executive Committees and physician leaders to find opportunities to standardize our credentialing process to make it more physician friendly, remove some of the barriers to efficient credentialing, and also remove some of the opportunities for errors that occur when an applicant has to meet multiple requirements for the same privilege at different hospitals.


In summary, credentialing is an obligation we have as physicians to ensure our patients receive excellent care (and that we stay out of trouble with our colleagues, regulatory bodies and civil courts). To be effective and safe, it has to be done in a reproducible, fair, data-driven way. Because of the different traditions, bylaws, and rules and regulations at our various hospitals, processing credentialing applications is a complex, time-consuming process.  


We ask for your help, support and patience in making sure that we do it correctly, and that we continue our journey to standardize the process as much as possible among our various hospitals. We want to be not only the best place for our patients to receive care, but also the most physician-friendly place for our colleagues to practice!



Credentialing - Who Cares?