It’s hard to imagine a process more rigorous than a hospital hiring a doctor, but picture this:
A storm of electronic documentation, starting with more than 30 pages on the application form required by the State of Illinois. Dozens of emails and phone calls to verify every degree, fellowship and previous practice. Interviews with references. Then recommendations from department or service chairs, multiple committees and finally, approval by the hospital governing board.
The process can take months.
“Don’t you want your husband or wife, son or daughter to go to a doctor who has been fully vetted? Of course you do,” said Sue Goldhammer. “Everybody is a patient at some point. That’s what makes this real.”
Every provider requires vetting
Sue is the manager of Credentialing Verification Organization (CVO) for OSF HealthCare. She and her staff of 16 are responsible for scrutinizing every provider who practices in one of 15 OSF HealthCare hospitals in Illinois. (OSF HealthCare St. Francis Hospital and Medical Group in Escanaba, Michigan uses an independent CVO that is grounded in details of Michigan state laws.)
About 5,000 providers – medical doctors, advanced practice registered nurses, physician assistants, etc. – practice in Illinois OSF HealthCare hospitals. That includes directly employed providers in addition to others who receive privileges to practice in one or more of those hospitals.
“We are the front door for providers coming into our hospitals,” Sue said. “Our job is to help ensure providers who are taking care of patients are qualified to do so.”
The CVO staff lives by the journalism adage: If your mother says she loves you, check it out.
‘We check everything. We really do.’
So, CVO will verify the photo on a provider’s application. They go to the primary source to verify everything claimed in the application or curriculum vitae. They look at the dates and places the provider was in medical school, internship, residency and fellowship. Check every state license held, even if it’s no longer active. Dig up the complete history of malpractice claims – dismissed, pending or resolved – and whether there was a payment or settlement.
They use whatever tools are necessary, from old-fashioned telephone calls to web crawls and applications like CertiFACTS Online.
“We check everything. We really do,” Sue said.
They don’t pass judgment or make editorial comments on what they find. Instead, they literally red-tag every item that should be, or even might be, of interest to the department chairs and committee members who will make recommendations to hire.
“Medical staff leaders play a critical role,” Sue said. “Their integrity and willingness to make hard decisions make the process work. We can red-tag all day long, but if the leaders don’t stand up and say, ‘No, this is not a good person to take care of our patients,’ it’s all for nothing.”
Governing board has final word
Each hospital facility has its own standards for providers seeking privileges to practice there. The number of steps before privileges are granted can vary, often due to the size of the facility. But the final decision always is made by the hospital governing board.
Mary Kay Eccleston is executive assistant for hospital administration at OSF HealthCare Saint Elizabeth Medical Center in Ottawa, Illinois. She and her colleagues at the other OSF HealthCare hospitals play a vital role in the credentialing process.
When a provider applies for privileges at her hospital, Mary Kay supplements the CVO report by looking for day-to-day details within a provider’s background. For example, if an obstetrician-gynecologist (OB/GYN) seeks privileges to deliver babies at OSF Saint Elizabeth, Mary Kay will find out how many they delivered in the past 12-24 months and compare that number to the hospital’s requirement.
She also makes sure every physician practicing at OSF Saint Elizabeth maintains their board certifications, and every two years she verifies they’ve maintained competencies within their specialty, as required by The Joint Commission, the nation’s oldest and largest accrediting body in health care.
Once Mary Kay finishes her work, she submits the file to the credentials committee. (At a larger hospital, a medical staff department chairman likely would review the file first and include a recommendation.) The committee at OSF Saint Elizabeth includes five physicians, who must be past presidents of the medical staff or past committee chairpersons.
“They are not brand new. They are people who understand what and how things work here,” Mary Kay said.
The credentials committee makes its recommendation to the medical executive committee, a group of nine to 12 hospital physician leaders, including the credentials committee chair. That committee then makes its recommendation to the governing board, which decides to grant privileges – or not.
Patients are top priority
Sue and Mary Kay relish their work, painstaking though it may be.
They occasionally hear complaints about the length of the process – from the time a provider application is submitted until the governing board rules. But they are committed to taking whatever time is necessary to make sure everything is in perfect order.
“It doesn’t happen overnight, nor should it,” Mary Kay said. “Keeping patients safe is the bottom line.”
Last Updated: February 9, 2022