Hendrickson: An anxious time of year for residents, med staff offices

This is a time of year when many medical staff offices are extremely busy with the credentialing of residents who are in their last few weeks of completing their residency programs. As anxious as the residents are to complete their education and land the job of their dreams, the same basically holds true for medical facilities who are anxiously waiting to get them credentialed and working at their facility as soon as practicable! Recently, a question came up regarding the approval of medical staff applications pending receipt of information. This is commonly found in the credentials file of a resident applying for medical staff membership at a medical facility. 

 

TJC Standard MS 4.10 states: The hospital collects information regarding each practitioner’s current license, training, experience, competency and ability to perform the requested privilege. Further clarification of this standard was interpreted by the TJC as follows: An application cannot be processed until it is complete. It is not complete until the training has been completed. It cannot be processed before completion of the training. 

 

For those facilities that have a credentials committee and/or an executive committee, it appears to be common practice that if there are one or two items “pending” at the time these committees meet, the file will pass contingent upon receipt and/or verification (as the case may be) of the pending item(s). The real approval is granted by your board of trustees, thus all information will have to be 100% complete and in the file prior to presenting it to your board.  

-- Diane Hendrickson