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Avoid the most common Type 1 recommendation: Learn to credential physicians, staff properly

Simplicity and standardization create strong credentialing process

SDS Accreditation Update

Keeping up with credentials and privileges for 85 physicians plus the staff members of a busy four-operating room multispecialty center is not an easy task, but the staff at Salinas (CA) Surgery Center has developed a system that works. "Our surveyors have always complimented my staff and me on our process for credentialing staff members and physicians," says Christine S. Gallagher, RN, BSN, CNOR, executive director. That’s quite an accomplishment, because the most common reason for Type 1 recommendations for ambulatory programs from the Joint Commission on Accreditation of Healthcare Organization (JCAHO) surveyors relates to credentialing standards, and those standards are the reason for many recommendations from the Accreditation Association for Ambulatory Health Care (AAAHC) in Wilmette, IL. The Joint Commission reports that almost 22% of ambulatory care facilities surveyed during the first six months of 2002 did not meet Standard HR.7.1, which relates to credentialing criteria.

Failing to apply credentialing criteria in the same manner to all physicians results in the most Type 1 recommendations following a Joint Com-mission survey, says Stephen C. Anderson, RN, MBA, a consultant with Chicago-based Joint Commission Resources. "This standard [HR.7.1] requires that credentialing criteria be applied uniformly. This standard is not met when your medical director signs off on his or her own privileges just as he or she did for all other members of the medical staff." Another physician must review and approve the medical director’s privileges, he adds.

Remember that when you are first credentialing a physician, check primary sources of information about the physician’s training and licenses, says Anderson. Seeing the physician’s diploma or having a copy of the diploma does not qualify as verifying the diploma, he says. "You must contact the organization that granted the diploma and receive verification from that organization," he explains.

Another option is to use American Medical Association’s Physician Profile Service but be sure that you read the report correctly, says Anderson. (See "Resources" at the end of this article.) "Be sure that you see the word verified’ next to the physician’s name," he says.

One aspect of credentialing that is harder for freestanding centers is the peer-review requirement for re-credentialing, says Jerry W. Henderson, RN, CNOR, executive director of the Surgicenter of Baltimore in Owings Mill, MD. "When you have a single specialty center and one group of physicians involved, it is tough to get the physicians to evaluate each other’s outcomes, complication rates, documentation, and other patient care issues," she admits.

One way to make the process easier is to appoint a peer-review committee, says Cheryl Munsinger, RN, BSN, CNOR, director of clinical services at First SurgiCenter, Kearney, NE. "The members of the peer-review committee review charts on a quarterly basis and handle any problems that are identified," Munsinger says. If the members of the committee think they need an objective opinion, they call upon a respected physician who is not a member of the surgery center’s staff to review the issue, she explains. Using an outside, objective physician removes the personality issue from review of a colleague’s performance, she adds.

Even with the challenges of peer review, freestanding centers do have an advantage over hospital-based programs in credentialing, Henderson says. "I think that it is easier for freestanding same-day surgery centers to make sure they are up-to-date with credentialing information because everything is in the center and the manager is not relying upon another department within the hospital," she says.

Gallagher improved her facility’s credentialing process by centralizing everything. All of the licenses, list of privileges, Drug Enforcement Agency (DEA) numbers, and physician’s information is kept in one place, in one file for each physician, she says. "We have a standard format for each file as well, with all of the information placed in the same order in each file," she adds. This standardization makes it easy for anyone to find needed information, she says.

When The Surgery Center at Nacogdoches (TX) opened, there were three people responsible for different parts of the credentialing process, says Jeanie Suhor, RN, CNOR, director of the center. "There was just too much for one person to handle, but it also made it more important for each of us to thoroughly know our bylaws and policies related to credentialing to make sure nothing was missed," she says.

Now, that the center has been open for a couple of years, staff members are not having to credential large groups of physicians at one time. There is now one person to oversee all credentialing and re-credentialing activities, and the process goes much more smoothly, she adds.

Munsinger also has one person responsible for maintaining the credential files. "Each credential file is in a portfolio file, with each section labeled clearly so the surveyor can find information on source verification, educational information, and licenses," she says. "We try to make it easy for the surveyor to find the information and to see how our process works."


For more information on accreditation tips, contact:

Stephen C. Anderson, RN, MBA, Consultant, Joint Commission Resources, and CEO, Healthcare Information Access, P.O. 17940, Seattle, WA 98107. Telephone: (206) 795-2831. E-mail:

Jerry W. Henderson, RN, CNOR, Executive Director, Surgicenter of Baltimore, 23 Crossings Drive, Suite 100, Owings Mill, MD 21117. Tele-phone: (410) 356-0300. E-mail:

Christine S. Gallagher, RN, BSN, CNOR, Executive Director, Salinas Surgery Center, 955-A Blanco Circle, Salinas, CA 93901. Telephone: (831) 753-5800.

Cheryl Munsinger, RN, BSN, CNOR, Director of Clinical Services, First SurgiCenter, 3500 Central Ave., Kearney, NE 68848. Telephone: (308) 865-1462.

Jeanie Suhor, RN, CNOR, Director, The Surgery Center of Nacogdoches, 4948 N.E. Stallings Drive, Nacogdoches, TX 75965. E-mail:

American Medical Association’s Physician Profile Service. You can access the service on-line at From the home page, click on "physicians," then choose "products and services," then choose "credentialing products." Cost for a search is $26 per physician name. You can pay by credit card or establish an account. You can set up an account on-line or call (800) 665-2882. If you want to order a search by fax, send the request to (312) 464-5801. Send mail orders to: AMA Remittance Control Area/PPS, P.O. Box 109054, Chicago, IL 60610.