Truth or Consequences

From the August 2001 Issue

Truth or Consequences

Credentialing is vital for the health of a hospital’s patients, and ultimately, the hospital itself.

By Peggy Bryant, business systems analyst for Alverno Information Service, a division of The Sisters of Saint Francis Health Services; and Martin Lebbin, vice president of quality services, SSFHS.

It’s like saving money or preparing your taxes—you know you should do a better job of it and what the consequences are when you don’t—but it is an activity we all dread. That’s credentialing, an activity all hospitals and managed care organizations (MCOs) must perform, but few receive the guidance or support necessary to do it well.

The Joint Commission on the Accreditation of Healthcare Organization (JCAHO) defines credentialing as the process of obtaining, verifying and assessing the qualifications of a healthcare practitioner to provide patient or resident care services in or for a healthcare organization. These qualifications include documented evidence of licensure, education, training and experience. An organization must credential all licensed independent practitioners. Basically, there are three fundamental reasons for credentialing:

To protect patients from fraudulent, unqualified or incompetent providers;
To protect the organization from malpractice allegations;
To satisfy regulatory agency and managed care requirements.

Sounds straightforward, but credentialing still spells trouble for many hospitals, MCOs and long-term care facilities because of the voluminous amount of record-keeping and updating that must be done to comply with JCAHO and NCQA accreditation requirements.

A Common Problem

At the Sisters of Saint Francis Health Services (SSFHS) system, located in Indiana, we needed to update our credentialing and quality systems. Ours is a 2,400-bed integrated healthcare system of six hospitals with 10 campuses in Indiana and Illinois, that include: St. Francis Hospital and Health Centers; St. Anthony Memorial Health Centers; St. James Hospital and Health Centers; St. Margaret Mercy Healthcare Centers; and St. Anthony Medical Center and St. Clare Medical Center.

We faced an immediate challenge. We had a homegrown mainframe system and the limitations of that system required users to create “workarounds,” that were not consistent among the hospitals. The “workarounds” led to the use of spreadsheets, manual processes, PC-based databases and redundant paperwork.

Once we reviewed our credentialing and quality systems, we found a great deal of key information was incomplete, such as physician profiles, and that we needed a replacement system. With the mainframe system, users could not generate ad hoc reports, the staff was inefficient due to the manual system and the quality of the data going to board members was, at times, problematic.

To identify and obtain a medical management system that would work with a number of departments, we sent a questionnaire to concerned internal users, requesting guidelines on their specific needs and their wish list for the perfect system. From that, we compiled an RFP and a total of 14 vendors responded. Through a process of product demonstrations, user voting, reference checks and site visits, the list was narrowed down until we finally selected Landacorp and its Maxsys II system.

We decided this was the best product for us because it incorporated the greatest amount of integration between the credentialing and quality modules, such as case management, infection control and risk management. Because of the advanced integration, it was also the most user-friendly system we evaluated.

Gaining Ground

SSFHS implemented Landacorp’s Windows®-based Maxsys II into all facilities during 1998-1999, allowing us to automate several critical business functions. The software suite included quality and resource management modules, workflow and process improvement applications and decision support capabilities essential to our healthcare system—and, of course, a credentialing component. Landacorp representatives came to our offices for a week and trained staff on how to seamlessly blend the new system into daily operations.

We needed a solution that could standardize reports and would provide consistency with these reports among various facilities in the system. “The credentialing module was a dynamic, real-time database, one that allowed us to add new information easily and let us use one server, but operate different databases,” says Lauretta Hapke, medical staff coordinator at St. Anthony Memorial Health Centers.

The credentialing module offers import/export integration of required physician details with the National Practitioner Data Bank. Based on access rights, hospital personnel may view physician privilege information online, eliminating dependency on the medical staff office personnel and permitting increased hospital compliance, while allowing staff to spend more time concentrating on medical issues and concerns.

“What surprised us was how quickly we were up and running. It took us six months from kick-off to goal to customize the system. Once it was implemented, we were trained and up and running within two weeks,” says Jan Buland, medical staff coordinator at St. Francis Hospital & Health Centers. SSFHS gained access to instant letters and reports, reducing the number of FTEs needed to complete various credentialing tasks and providing better tracking of expiration dates.

“We estimate we were able to avoid hiring one FTE per facility due to the implementation of this system—and we are more proactive than reactive, too. For example, ad hoc reports used to take from three days to a month to put together. Now we have instant access to specific information and we can print it on demand. This allows us to find problems and fix them before they become critical,” says Buland.

“We know that the system will provide the information needed to meet accreditation standards. I always knew we had some of the best physicians in the country. Now I can print it out and prove it,” says Buland.

One of the most attractive features of the credentialing module is that we will be integrating it with the other modules in the Maxsys II system. This will provide us with a real-time clinical quality database, that will include data from quality, risk, infection control and case management. With enhanced access to our data and more streamlined, standardized processes, we have already seen decreased costs and increased productivity in our medical staff offices. We’re very excited about the additional savings and efficiencies that the system will provide, especially in case management, once we implement the remaining modules.

We’re looking forward to reducing our denied days, or avoiding many denials altogether with the case management module that will allow us to effectively document and track patient information. We also look forward to a return on our investment by recovering those costs.

Liability Issues

Many people erroneously believe that when a physician treats a patient, only the physician and the patient need to agree on the course of treatment. Unfortunately, this perception might lead people to believe that doctors have the final authority on patient treatment.

However, it is the hospital’s responsibility to properly credential and privilege physicians, and therefore the hospital has decisive authority about treatments and procedures a physician may perform at that hospital.

According to hcPro, a healthcare education company, the need to establish credentialing and privileging as the highest authority is also evident in a number of court cases and state laws that establish a hospital’s ultimate responsibility for the care provided within their walls, regardless of doctor-patient agreements. In addition to fulfilling the obvious need to protect the public from incompetent practitioners, credentialing and privileging fulfill a hospital’s legal obligation to ensure that physicians are competent to practice and carry out specific treatments.

Hospitals must exercise due care concerning prescribed treatments and procedures, and in selecting clinicians that may perform treatments and procedures. The fact that a clinician is not an employee of a hospital, but contracts independently and directly with patients, does not absolve a hospital of responsibility.

Credentialing is necessary for more than meeting the requirements of regulatory and accreditation agencies; it is also imperative for the health of hospital patients, and ultimately, for the hospital itself.