Verification of Hospital Affiliations

Have you ever walked through the grocery store and spied that piece of chocolate you have been craving?  Then comes the internal conversation…”do I want this piece of chocolate or do I need this piece of chocolate? After all chocolate has some documented benefits (especially if it’s dark chocolate), but it also comes with some calories that maybe I don’t need or require. And although it may come with some dietary benefits in small portions, I’m not sure I can put chocolate in the health food category.”  Darn.  I wish chocolate was necessary to our human existence.  Wouldn’t that be a great world?

Hospital affiliation verifications seem to be in the same category as chocolate.  You may want them but do we need them?  And if we do need them how many do we need or require? Let’s explore that question.

I believe this approach to hospital affiliation verifications can be summarized in two categories:  1) the culture of the health care facility and 2) the depth of verification needed to establish current clinical competency.

Let’s address the culture first.

1)    Verification of all hospital affiliations has been a traditional component of credentialing for many years.  It has only been in the past 5-10 years that health care facilities have considered verifying some –but not all- affiliations.

2)    Health care facilities originally verified hospital affiliations to identify any gaps in practice.

3)    Many health care facilities believe verification of hospital affiliation is required by regulatory/accreditation agencies.  That simply is not the case.  In March, 2010, The Joint Commission (TJC) posted the following answer to the question of hospital affiliations:

Q. Are organizations required to verify affiliations at other health care organizations, and if yes, for how many years back must the verifications be done?

A. There are no standards requirement to verify hospital/other healthcare organization affiliations or privileges/clinical responsibilities or work history for any applicant. The hospital MS.06.01.05 and MS.06.01.13 and the HR.02.01.03 requirements are to evaluate:

  • voluntary or involuntary relinquishment of any license or registration
  • voluntary or involuntary termination of medical staff membership
  • voluntary or involuntary limitation, reduction, or loss of clinical privileges

Now let’s move to depth of verification.

1)    Practitioners have many more hospital affiliations than in previous years because of managed care plans. In many cases, practitioners have affiliations they never or rarely use.  This is why we are increasingly addressing the need for “low volume practitioners.”

2)    Applications promoted and/or mandated by states increasingly ask for only more recent history related to an applicant’s current/previous hospital affiliations.

3)    Health care facilities are now credentialing practitioners who may have hundreds of current/previous affiliations because they are involved in telemedicine or provide locum tenens services.

My take a-ways:

1)    Because the missions of credentialing is to document current clinical competency, health care facilities should carefully consider the value of verifying some – or all- current/previous hospital affiliations.  What depth of verification is required to document current clinical competency?

2)    Current clinical competency is also documented by professional peer references and so maybe we should consider how many professional peer references should be required (current industry standard is 3).

3)    MPR will continue to meet the need of each client individually in recognizing the culture of each facility and the depth of verification defined to document current clinical competency.

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