Three credentialing steps help ensure competency

[In this second part of a two-part series on new technology, we discuss how to handle credentialing in this story and how to respond to errors. Last month, we discussed training and informed consent issues regarding new technology.]

How do you credential physicians who want to perform procedures with new technology? If they are credentialed elsewhere or appear to have their documentation in order, do you wave your magic wand and rubber stamp their credentials? If so, you may want to rethink that policy.

"The facility is expected to perform its own credentialing and privileging for every physician on staff," says Stephen Trosty, JD, MHA, CPHRM, director of risk management and continuing medical education for American Physicians Assurance Corp. in East Lansing, MI. "If they do not do so, then they can be held liable for negligent credentialing. The courts have made it abundantly clear, as has [the Joint Commission on Accreditation of Healthcare Organizations], that it is not acceptable to accept the credentialing from another facility."

There has been an increase in the number of malpractice actions in which negligent credentialing is one of the allegations, Trosty warns. "There also has been an increase in the number of these legal actions being won by plaintiffs," he says.

Consider these suggestions to reduce liability and ensure patient safety when credentialing for new technology:

• Involve one or more committees.

At Ingham Regional Medical Center, a credentialing committee is chaired by the co-leaders of the professional staff and includes representatives from the hospital specialties, some administrative staff, and Michelle Kelly, CPMSM, supervisor of medical staff services.

Physicians requesting credentials give the committee an overview of the technology and are quizzed on their proficiency and experience, their interpretation of the outcomes with the technology, potential complications and how they are addressed, the basic science on which the technology is based, and needs for staff training and equipment. The physician also usually addresses any reimbursement for the procedure. The committee determines if the physician is qualified to use the new technology.

The next step is for the physician to submit a formal request for privileges accompanied by a proctor’s recommendations. The request is reviewed by the appropriate department chairman.

At The Surgery Center of Nacogdoches (TX), the physician requesting credentials submits information to a medical executive committee including an outline of the procedure, training, costs, reimbursement, and an anticipated number of procedures, says Jeanie Suhor, RN, director. Five physicians are on the medical executive committee, including the medical director and the vice medical director, and the administrator.

"Once the medical executive committee gives its approval, the physician submits a request for privileges to the credentials committee, which determines competency by training and/or certification," Suhor says. The credentials committee is made up of five physicians.

The request then goes back to the medical executive committee and then the governing board for its approval.

"This does sound like a lengthy process, but requiring approval of several committees is a better assurance of competency, management of equipment purchases, and patient safety," Suhor says.

• Assess the training and proctoring.

Just because someone performs surgery doesn’t mean they’re competent to use new technology to perform surgery, Trosty points out.

"Make sure they have gotten adequate and sufficient training from verifiable and legitimate sources," he says.

At Ingham Regional Medical Center, physicians have these options:

  • attend a program accredited by the Accreditation Council for Graduate Medical Education or attend an American Osteopathic Association-accredited residence program;
  • attend continuing medication education programs in one of these accredited institutions;
  • complete testing or certification by a certifying board;
  • provide documentation of training or practice under direct supervision of a recognized authority in the field.

Find out more information about the course, such as whether there was an assessment to evaluate the physician’s skills and judgment, suggests Richard J. Croteau, MD, executive director for strategic initiatives at the Joint Commission.

Ensure the physician understands the principles behind the technology and how the technology works, advises Bruce C. Hansel, PhD, executive director of forensic services at ECRI, a Plymouth Meeting, PA-based nonprofit health services research agency that focuses on technology, risk and quality management, and environmental management. "Too often, the training focuses on how to use the device, he continues. "As long as nothing goes wrong, knowing how to use it is enough. But when things go wrong, having a good understanding of the technology and how it works vastly improves the user’s ability reason through what is happening and troubleshoot the situation," Hansel explains.

Use proctoring or monitoring the first few times physicians use new equipment to make sure they’re competent in what they’re doing, Trosty advises.

• Recognize credentialing is an ongoing process.

Credentialing is not something you do once and the physician is credentialed forever, Croteau emphasizes.

"That position doesn’t recognize that skills change over time," he says.

Regularly revisit the physician’s credentials as required by law or facility rules, say sources interviewed by Same-Day Surgery.

"Look at the individual’s experience with particular types of procedure, what their results have been, and get input from others who have firsthand knowledge of the individual’s practice, ultimately to make recommendations on whether privileges should be continued or not," Croteau says.

When an accident does happen, you want to ensure that nothing has happened that could anger a jury, says Lori G. Cohen, Esq., partner at Alston & Bird in Atlanta. "The last thing you want a jury to believe is that the new technology is being trotted out as a means of testing or experimenting," she says. "You never want a jury to feel like anyone is being treated as a human guinea pig."


For more information, contact:

  • Michelle Kelly, CPMSM, Supervisor of Medical Staff Services, Ingham Regional Medical Center, 401 W. Greenlawn Ave., Lansing, MI 48910. Phone: (517) 334-2290. Fax: (517) 346-4865. E-mail:
  • Jeanie Suhor, RN, Director, The Surgery Center of Nacogdoches, 4948 N.E. Stallings Drive, Nacogdoches, TX 75965. Phone: (936) 558-3708. Fax: (936) 568-3591. E-mail:
  • Stephen Trosty, JD, MHA, CPHRM, Director of Risk Management and CME, American Physicians Assurance Corp., East Lansing, MI. Phone: (517) 324-6808. Fax: (517) 332-0262. E-mail: