This week, CRC Daily covers medical staff leadership and governance. When new medical staff leaders step into their new roles, one of the many duties they take on is playing a part in the credentialing process. Although a physician has been on your medical staff and has gone through the credentialing process as an applicant, it is a mistake to assume that he or she understands the behind-the-scenes workings of credentialing. The following are four credentialing truths that new medical staff leaders need to know.

“There is a running joke that physicians spend years of grueling and intense medical training to end up clicking their mouse or signing piles of paperwork rather than seeing and caring for patients.”

About one-half of physicians reported feeling burned out, according to a recent Medscape survey. The survey found some variation in burnout rates based on physicians’ race and ethnicity. With this in mind, JudyAnn Bigby, MD, a senior fellow with Mathematica Policy Research, who has researched physician ethnicity and professional satisfaction, shared three takeaways for healthcare leaders.

The basic work of the credentials committee will depend on the credentialing process model the organization uses. Regardless of the process, the roles and responsibilities of the credentials committee need to be laid out either in the medical staff bylaws or policies and procedures. This chart is a quick cheat sheet that the medical staff can use to assess the roles and responsibilities of each committee member.

Understanding the tenets of credentialing, privileging, and peer review are key to being a successful medical staff leader. However, there are also some general elements that new medical staff leaders should keep in mind (and follow) in order to keep their sanity while serving in a leadership role. The following are 10 survival tips for medical staff leaders.

Medical staff leaders often step into their new role with a desire to help improve processes at their organization but without training to do so. Expecting medical staff leaders to learn as they go is a mistake, according to most physician leader experts.

This month we explore the answer to a seemingly straightforward question. Should medical staff leadership positions be elected (by the organized medical staff) or appointed (by the hospital administration)? Depending on the culture of your organization and its medical staff, this question is either easily answered (rarely) or the subject of great discussion and debate (commonly). The good news is that your organization ultimately decides how it will be answered. There are no accreditation prescriptions in this area. The bad news is that there is no one size fits all answer. Even in the same organization, different variations of answers to this question may exist. Each organization decides for itself.

The Appellate Court of Illinois for the First District (the “Court”) affirmed a circuit court’s judgment that documents produced by Loyola University Medical Center’s Medical Care Evaluation and Analysis Committee (MCEAC), which conducts peer reviews of hospital deaths to reduce morbidity and mortality, were privileged under the Illinois Medical Studies Act (the “Act”).

Without a thorough credentialing process, medical staff leaders and MSPs may allow underqualified or undesirable practitioners to receive clinical privileges. Loss of licensure, significant malpractice activity, and poor clinical references are obvious targets of scrutiny. But what about the subtler inconsistencies and deviations that can surface on a medical staff application? Swift identification and targeted action can assuage concerns about these "pink flags" early in the game, promoting patient safety and preserving the integrity of the vetting process.

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