Management and governance of senior medical staff is an increasingly complex task. Poor governance of credentialing and scope of clinical practice creates major risks for a healthcare organisation, including failure of accreditation, reputational damage and the possibility of Governing Board members being held liable for breaches in the event of major governance failures. Some hospitals have struggled to keep pace with the requirements of the National and State frameworks. Smaller hospitals may be at more risk of engaging doctors with problematic backgrounds or performance and hospitals that rely extensively on agency and other locums are often overly reliant on the agencies' governance processes. 

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Whilst a software solution greatly improves the process, it requires specialised knowledge to administer. This task often devolves to a clerical officer who does not have a clear understanding of the credentialing process and its role in clinical governance. Integration with HR recruitment and appointment processes is often poor.  Some hospitals have invested in electronic credentialing systems, but failed to do the background work of clearly mapping out the processes and procedures that are required. As a consequence, the credentialing system is not correctly configured and provides little value.

 

As a starting point, there must be robust policies and procedures to describe the credentialing and appointment process. These should include the mechanisms for review of practitioners where concerns about professional performance and/or conduct exist. Scope of clinical practice needs to be aligned to the capability of the organisation. A well functioning credentialing process, which provides robust governance of the medical staff and also functions as a single source of truth around the capabilities and contact details of the medical staff is a critical requirement for high functioning healthcare services. 

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Simon Woods has extensive experience in this field. He has redesigned and streamlined credentialing systems at multiple hospitals. He has written bylaws, medical staff rules and procedures to support this function. He can help you integrate your HR and credentialing processes and ensure you are obtaining value out of your systems.