One of the greatest challenges to the credentialing and privileging process is making sense of the various forms, regulations, and changing standards that those involved must follow. Who among us hasn’t wondered why all hospitals can’t follow the same rules, if only for simplicity’s sake?

While a standardized hospital rule book may be a long way off, standardized credentialing applications are a reality in some states and managed care organizations. Among those are Illinois, which has a state-mandated application for hospitals and some other facilities, and Iowa, which has a voluntary standardized application that is used by 18 managed care organizations and 56 of the state’s 116 hospitals. Those who are familiar with these applications report that they have multiple benefits, such as lessening the administrative burden on practitioners, and making it easier for MSPs at different organizations to exchange practitioner information.

The Joint Commission (formerly JCAHO) has no standard that speaks to a standardized application for medical staff membership, nor do they plan to create one. “Our standards are for the purpose of improving quality and safety of patient care,” says Kenneth Powers, The Joint Commission’s media relations manager. “While it might be argued that a standardized application decreases the burden of filling out multiple applications for a practitioner, this improvement in efficiency is not directly tied to the improvement of quality or safety of patient care.” However, Powers says The Joint Commission has worked with organizations who are interested in creating such a thing.

Guiding principals for standardized applications

Elizabeth A. Snelson, a healthcare attorney based in St. Paul, MN, works with medical staffs across the country and says that there are great advantages to using a standardized application, but there can also be a huge potential for abuse.

The greatest advantage, by far, is the reduction in paperwork for practitioners applying to multiple hospitals at once. MSPs can also benefit by linking the application to a software program that can help manage the verification process. Ironically, another advantage of a well-constructed standardized and uniform application is the ability to change or add to it when needed. Snelson says even if only some pages of an application are standardized it is still beneficial because “any little bit helps. It just needs to be very carefully crafted.”

“If you’ve got a bad uniform application that is going to be uniformly bad for every applicant, and it’s not like a doctor could walk away from a uniform application,” says Snelson. She says the application shouldn’t ask for information that an organization’s bylaws don’t require it to consider when evaluating an applicant, nor should it contain questions that are too general. For example, she says that it is acceptable for an application to ask an applicant to list his or her medical staff or relevant professional affiliations, but it is not acceptable to ask an applicant for an unspecified list of affiliations. This unspecified request could result in an applicant listing political or religious affiliations which should not be on an application.

“The other concern is asking about economic information, and that can range from how you run your practice to what your financial interests are, and those questions can be very overbroad also,” says Snelson.

Iowa takes the initiative

The Iowa Association of Medical Staff Services (IAMSS) decided in 2000 that it wanted to be proactive and develop a standard medical staff application for initial appointment before the state mandated such a document. At the same time, other groups in Iowa were looking at ways to streamline credentialing processes. (A standard application is still not mandated in Iowa, although it is a legislative proposal to mandate the use of a standardized application by health plans.)

Kathy Szary, medical staff services coordinator at Grinnell (IA) Regional Medical Center, was one of three IAMSS members who co-chaired a task force to develop the application. The diverse task force included representatives from the Iowa Medical Society, Iowa Hospital Association, Wellmark Blue Cross Blue Shield of Iowa, Iowa Board of Medical Examiners (since renamed Iowa Board of Medicine), Iowa Medical Group Management Association, an emergency department staffing company, and representatives from small, medium, and large hospitals.

“The task force established the goal of [reducing] paperwork for practitioners and providers through the development of a single uniform application,” says Szary.

By 2001, the task force had evolved into the Iowa Credentialing Coalition (ICC), finalized the application, and made it available in two Microsoft Word formats: a printable copy and an electronic template version that allows users to merge in data from their credentialing software programs. The electronic version is password protected and hospitals that post it on their Web site must sign an agreement promising not to change the application; applicants must also agree not to make unauthorized revisions to the application when they fill it out.

Szary says that the new standardized application was welcomed by users because of the uniformity it offered, a point of view shared by Jeanine Freeman, senior vice president of legal affairs for the Iowa Medical Society. However, Freeman says that some users are less than thrilled about the length: 19 pages. “We say it might be long, but once you get used to the form, it will save you a lot of time,” she says.

A standard, but flexible application

Although Iowa’s standard application can not be modified, says Freeman, hospitals can add information to it, and that accounts for the different lengths of applications.

Szary says “If there are unique items that [individual hospitals] need, we ask them to address it in a cover letter to the practitioner and have those as additional documents that the practitioner needs to complete or provide.”

This is a policy that makes sense for many standardized applications, says Snelson. “If you’ve got a centralized application that’s based geographically, but you’ve got Catholic hospitals, they can append to their application the obligation for the applicant to adhere to the Catholic directives,” she says.

Iowa’s application is updated on an annual basis by the ICC, which evaluates the suggestions it receives. Any users, including practitioners, clinic staff, and MSPs, are welcome to submit suggestions. Some of the most recent modifications included adding:

• More space for applicants to list their licenses and hospital affiliations
• A line for the national practitioner identifier (NPI) number

Szary says the group recently received a request to add information about criminal background checks to the application, but not every facility conducts them. “I’m not sure how far that [request] will go, but we keep a running list of potential revisions and then when we get together we review them,” she says.

In addition to the initial application, the ICC also developed a standard application for reappointment that about 24 hospitals use, says Szary.

Green light recommendations

Freeman and Szary both said that that working on the standardized application was a positive experience and they recommend that other organizations who are thinking about developing one to go ahead with their plans. It may not be the easiest credentialing project to tackle, but when the people involved with it are enthusiastic about the work they are doing, it makes the task more pleasurable.

“I would give tremendous credit to everyone that’s at the table,” says Freeman. “They actually were quite willing to come to the table to improve credentialing.”

For Szary, the results speak for themselves. “I’m a strong advocate for the universal application because it really does reduce paperwork, and helps to make the credentialing process less cumbersome for the practitioner.” she says.

Sidebar 1

Who should help develop a standardized application?

Donna Goestenkors, CPMSM, a consultant specializing in the areas of credentialing and privileging for The Greeley Company, a division of HCPro, Inc., located in Marblehead, MA, says that organizations should consider the following criteria when developing a standardized application:

• If an organization decides to use a standardized application, it is imperative to include all involved parties in the planning phase of this project to ensure that their knowledge, experience, and nuances are a part of discussion and action. Generally these parties would include an MSP, attorney, medical society, CVO administrator, state licensing board, managed care organization administrator, etc.
• It is also critical that key members of medical staff leadership and/or the credentials committee have input and action on the standardized application before it is implemented.
• Lastly, communicating to the medical staff and/or providers regarding the standardized application development project, its objectives, the application’s content, and activation date is essential as these individuals are ultimately the primary users of the standardized application.

Sidebar 2

Opinion poll: Standard applications

Do you think there should be a standard application for medical staff membership?

“In the ideal world: yes. However, there are many factors that currently exist where this is not possible, i.e., state mandates, hospital or system requirements, managed care requirements, medical staff preferences, etc. The most important thing to remember when considering standardizing an application is to be sure that all required elements from any state or accrediting body are a part of the application.”

Donna Goestenkors, CPMSM, a consultant specializing in credentialing and privileging for The Greeley Company, a division of HCPro, Inc., located in Marblehead, MA.

“A national application, that would be interesting, [but] I don’t think we’d ever get there.”
Elizabeth A. Snelson, a healthcare attorney based in St. Paul, MN.

“[A national application] would make sense; we all essentially need the same information. The key factor would be to make sure that all required elements are included in the document. From that point I think it’s a matter of getting use to formats.”
Kathy Szary, medical staff services coordinator at Grinnell (IA) Regional Medical Center.

From: Briefings on Credentialing, March 2008,
Vol. 17, Issue 3 - Copyright 2008 HCPro, Inc.