The Risk Manager’s
Role in Practitioner
Credentialing
WHO ARE THESE PEOPLE?
When you go to the hospital seeking medical care, how do
you know that the doctors are properly trained,
licensed, and qualified to take care of you?
Why Credential?

Patient Safety

Risk Management - Negligent Credentialing

Accreditation and Regulatory Requirements
Definitions
Credentialing – The process of collecting,
assessing and validating the qualifications and
credentials against established criteria.
Privileging – The process health care
organizations use to determine the specific
procedures and treatments each health care
practitioner may perform based on training and
current competence.
Judgment
Criminal
Education
Patient
Care
Background
Staff
Competence
Complaints
Communication
Skills
NPDB
Practice
Based
Learning
Patient
Complaints
Medical
Work History
Professionalism
Knowledge
System
Based
Practice
Training
Claims History
Technical
Skills
Health
Negligent Credentialing

Negligence is conduct that is culpable because it
falls short of what a reasonable person would do
to protect another individual from a foreseeable
risk of harm

Organizations can be found liable for negligent
credentialing
Negligent Credentialing Cases
Darling v Charleston Memorial Community
Hospital, 211 N.E. 2d 253 (Ill. 1965)
Hospital liable for negligent treatment resulting in
amputation of teenager’s leg. Nurses failed to monitor;
physician failed to consult; hospital claimed charitable
immunity doctrine-court ruled against hospital for
failure to provide proper supervision.
Errors in Credentialing Process
Information Errors
Process Errors
Decision Errors
Information Errors
Information existed that could have been known
but wasn’t, and the information would have
impacted a credentialing decision
Silos
MSS
Quality
Risk
Medical Records
Information Errors
Elam v College Park Hospital, 132 Cal. App. 332,
183 Cal. Rptr. 156 (Ca. 1982):
Hospital liable for podiatrist’s negligence; failed to obtain
malpractice claims data, even though medical records
department was aware of claims-court ruled negligent
credentialing.
Significant Court Decisions
Johnson v Misericordia Community Hospital, 294
N.W. 2d 501, 97 Wis. 2d 521 (Wis. 1981)
Hospital liable to patient injured by physician who had failed to
disclose pending malpractice cases and lied about privileges at
other hospitals; should have verified information-court ruled
negligent credentialing; failure of initial credentialing process
Process Errors

Failing to follow bylaws, regulations
and/or policies

Not consistently applying processes,
requirements and criteria

Adopting an unreasonable policy and/or
criteria
Lawrence R. Poliner, MD v. Texas
Health Systems, James Knochel, MD


Upon review, the advisory committee recommended a temporary
restriction of Dr. Poliner's cardiac catheterization lab privileges
for up to 15 days. Dr. Poliner agreed in writing after he was told
he would receive a summary suspension of all his privileges if he
didn't agree to the penalty.
Dr. Poliner brought federal and state antitrust claims, along with
tort and breach of contract claims, against the defendants. A
lengthy legal battle ensued, the result of which has significant
meaning for those administering peer review and the physicians
under evaluation.
Lawrence R. Poliner, MD v. Texas Health
Systems, James Knochel, MD

The jury determined the defendants weren't entitled to federal or
state immunity. Jurors awarded Dr. Poliner more than $360
million in damages, $90 million of which were for alleged mental
anguish and injury to career and reputation on Dr. Poliner's
defamation claims and $110 million of which were for punitive
damages.

The district court reduced the defamation damages to $22.5
million to comply with the law. Prejudgment interest added up to
more than $11 million, making the total award more than $33
million.
Lawrence R. Poliner, MD v. Texas Health
Systems, James Knochel, MD

On July 23, 2008, the 5th Circuit Court of Appeals reversed the
federal trial court's judgment and ruled for the hospital and Dr.
Knochel based on federal immunity for their actions.

Dallas attorney Lewis Lefko, JD, said the Poliner case sends a
message to entities conducting peer review that they should
make every effort to follow their bylaws and treat physicians
fairly.

"The Poliner case says that if you don't do it right, it may not look
reasonable to a physician or to a jury," he said.
Decision Errors

The necessary information was known, but
medical staff leaders failed to make a wise
decision.

Failure to address concerns identified in the
credentialing & recredentialing process.
One red flag may not be a problem or concern in
itself but more than one suggests closer scrutiny.
Kadlec Medical Center v. Lakeview Anesthesia
Associates, 2005 WL 1155768, 2 (E.D. La. 2005)
Dr. Berry was known to have diverted controlled drugs
for personal use at an Alabama hospital and appeared
to have been under their influence when on duty. He
was fired and lost privileges. Hired in Washington State.
Harmed a patient (a young women in a non-responsive
vegetative state) as a result of drug abuse problem.
Kadlec Medical Center v. Lakeview Anesthesia
Associates, 2005 WL 1155768, 2 (E.D. La. 2005)
Kadlec Medical Center v. Lakeview Anesthesia
Associates, 2005 WL 1155768, 2 (E.D. La. 2005)
Best Practices



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Provide correct information when responding to
verification requests
Don’t omit key information when providing
verifications
Address letter to Credentialing and/or MEC
Sign as Agent of MEC
Best Practices
In addition to viewing a government
issued photo identification, send the
applicant’s picture with reference and
training requests.
Why?
“Dr.” Gerald Barnes legally changed his name in
the 1970’s to Gerald Barnes, the name of a
licensed physician who was practicing in
Stockton, California. He obtained copies of Dr.
Barnes’ records and medical credentials and used
the documents to obtain employment at
numerous medical clinics and offices in
Southern California.
Best Practices

Verify all clinical work history
(when possible).

Request information from past
groups as well as hospitals
Why?
Michael Swango, M.D.
In 1985, he was convicted of aggravated battery for the
non-fatal poisoning of co-workers at an ambulance
service. He spent 30 months in prison and lost his
medical license. Despite his record, he was able to get
jobs at hospitals in South Dakota, Virginia, New York
and Zimbabwe. He is believed to have killed as many
as 35 patients and is suspected in more than 60 deaths.
“Blind Eye: The Story of A Doctor who Got Away with
Murder” by James Stewart.
Best Practices

Include practitioner’s picture in notices to
departments.

Clinical areas should have access to privileges
granted to each practitioner

Pictures included with privileging information
Best Practices
Why?
“Dr.” Ofari Mays
October 2005, Orlando Florida – Mr. Mays was
arrested and accused of impersonating a doctor.
He spent days at Orlando Regional Medical
Center dressed in scrubs and lab coat. He had
access to the hospital, reviewed patient records
and discussed treatments with nurses and other
doctors.
Best Practices
Sharing of information between hospitals
MS.06.01.05 EP 9
Before recommending privileges, the organized
medical staff also evaluates the following:


Relevant practitioner-specific data as compared to
aggregate data, when available
Morbidity and mortality data, when available
NAMSS PASS
NAMSS PASS™ is a secure, online database
that provides quick, easy, and inexpensive access
to the affiliation history of practitioners and is
the first and only universal resource for tracking
practitioner affiliation history.
NAMSS PASS
NAMSS PASS
NAMSS PASS
Best Practices

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Google applicants
Sharing of information medical staff, quality and
risk management within organization
Self query NPDB
Don’t deny privileges –table requests
pending documentation.
NPDB Continuous Query Program
Additional reference
Document current competence at
reappointment.
Risk Managers




Advocate for education and training for medical
staff professionals and medical staff leaders
Encourage networking with other medical staff
professionals
Champion certifications for medical staff
professionals
Open communication with medical staff
professionals
Risk Managers



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Review credentialing policies and processes
Review reference, affiliation, and training
verification forms
Review and collaborate on wording of sensitive
topics and discussions in meeting minutes
Review and collaborate on sensitive affiliation
verification responses