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Why does SCOPE for Women’s Health care about Credentials and Privileges for your providers?

When women come to your office, they expect a level of skill, training, and experience from all the providers they come in contact with.  Many of the providers may already have obtained privileges from the hospitals the practice is associated with and most hospitals now have fairly standard requirements.  However, some of the providers may NOT practice in that setting.  In addition, certain skills and capabilities are required in the outpatient practices setting that are not required in a hospital setting.  For example, doing a tubal implant for contraception is quite different with the anesthesiologist on call or giving anesthesia and an infection control and cleaning process as well as staff training well established for the equipment used.  How you manage a patient for the same procedure in the office requires that you have a different set of skills for managing the sedation of a patient, for oversight of the infection control processes, and the training of assistants.  Making sure that everyone has the right skills for the OFFICE setting is not the same as having the right skills for the hospital setting.  So it matters.

On the other hand, the process of credentialing and privileging is redundant in medical settings—and refilling forms over and over can be more than cumbersome; it can be downright frustrating.  One opportunity for the practice is to use the practice process to collect all the documentation that is also required for hospital or insurance credentialing and make it a resource to the providers rather than an added burden.  Then the provider can simply request a copy to be sent to other sites as needed and we provide additional support to lighten the load.  However, some procedures need separate observation and often training for in the office setting, and providing that proctoring and sign off in the practice assures women that everyone has achieved the skills required to safely provide that procedure or care in the office.

Remember, there are well documented examples of individuals who did NOT have the actual credentials or skills who have made it through clinic and hospital systems.  We don’t want that for our patients or our practices.

What does the SCOPE for women’s health reviewer look for?

• A set of requirements and skills assessment that the office/practice expects including a code of conduct and behavioral expectations
• Up to date copies of basic documents such as prior work history and malpractice history, education, licenses (State and Federal for DEA), Board status and maintenance of certification, BLS, immunizations, malpractice coverage
• Some way of verifying the information is correct (for example education).  If the hospital does this and is willing to provide confirmation to the practice, that might be considered acceptable.  Otherwise, a way of verifying information is a key element.
• Assessment of skills initial and ongoing assessment of skills:  proctoring systems in office for new partners or yearly skills labs (see Best Practices) for clinical staff are examples.  In addition, internal quality assurance audits of targeted office practices or procedures as well as satisfaction surveys provide a basis for ongoing assessment of skills.  How does the practice identify and deal with a senior partner who many recognize should not be doing x procedure any more?
• Available on site.  Some offices are part of large groups that have central credentialing.  If that is the case, however, the on site manager may not be able to quickly access whether Dr. A is credentialed to do office hysteroscopy or whether PA B is credentialed for management of contraceptive counseling in the practice.  So, these records need to be available on site for any questions that might arise.

Table 1:  Common elements of Credentialing in Office to consider:

1. Photo
2. Education history
3. Board Certification/ MOC/ and up to date
4. Medical or other licenses (with any voluntary or involuntary terminations or limitations)
5. CME history
6. Past Work Experience,
7. Hospital affiliations and status including any loss of privileges
8. Letter of Health status/ Immunizations (particularly for offices with OB or with immunocompromised patients this is a key element for patient safety)
9. Malpractice insurance and claims history
10. Any disciplinary actions at hospitals, health systems, educational programs
11. National Databank release/ information
12. References
13. Signed code of conduct or other instrument that defines expectations.
14. Attestation that above is true:  eg. Board certified/ licensed/ etc.
15. Release from liability for the facility for good faith peer review activities