When an OB-GYN’s first delivery after her own 5-year maternity leave resulted in a bad outcome for the baby, litigators immediately turned their attention to the hospital’s credentialing process. Their discovery? The organization had not assessed whether the physician was clinically competent after such a long absence. What happened next is every healthcare executive’s worst fear: The hospital was deemed liable because it hadn’t put guardrails in place to keep patients safe.
A strong Medical Staff Services Department supports the entire organization’s ecosystem—from revenue to safety of care. In times of financial pressure, organizations often cut back, which historically has meant reductions in staff and education for this department. But organizations fare better if they instead fortify the Medical Staff Services Department to prevent budgetary constraints from adversely affecting patient safety.
A single mistake completing a credentialing file—whether caused by understaffing or inadequate training—could result in devastating consequences for patients, reputational damage for the organization, and millions of dollars of expense.
In conjunction with malpractice lawsuits, many attorneys also bring negligent credentialing suits. We have seen an increase in these types of cases over the past 10–15 years. Organizations have no defense if they bypass credentialing requirements to expedite a provider’s path to patient care. They often find out the one verification they didn’t obtain would have flagged that the provider shouldn’t treat patients. Landmark legal cases support accrediting bodies’ requirements for an objective, consistent credentialing process to avoid such misses.
Healthcare organizations need a structured approach to ensure a high-functioning Medical Staff Services Department that grants privileges only to qualified and competent practitioners.
5 Essential Elements That Enable Medical Staff Services to Mitigate Risk
The Medical Staff Services Department is responsible for supporting the medical staff, as well as ensuring verification of credentials and clinical competence prior to clinicians providing patient care. Qualified medical service professionals (MSPs) also share critical information that enables greater efficiency and lowers the risk of medical care errors.
With the appropriate approach, the Medical Staff Services Department adds great value to the organization. Five elements are critical:
1. Implementing structure and standardization. Organizations must create a structure that enables them to grant privileges to individuals based on expertise, confirm new providers’ clinical competence, and establish ongoing professional evaluations. The Medical Staff Services Department can support and align with medical staff leaders to uphold rigorous standards. This enables healthcare organizations to reduce risks associated with provider incompetence, unprofessional behavior, and procedural errors.
A defined structure and processes for medical staff support allows organizations to easily address behavior issues that affect patient care. Years ago, The Joint Commission created standards regarding codes of conduct for employees and providers. Having a structure to address noncompliance with a medical staff code of conduct gives the organization and medical staff leaders the teeth they need to support compliance.
For example, a neurosurgeon had a history of disruptive behavior, including verbal abuse of nurses and ancillary staff, but the organization did not address it. Inappropriate behavior that goes unaddressed gives the provider the impression that this behavior is acceptable, which can lead to other avoidable circumstances. The potential for verbal abuse to escalate to physical altercations is real. Because his anger and behavior has gone unchecked, this physician could easily grab hold of a coworker. This becomes assault—which the organization can no longer ignore.
MSPs usually support the formalized structure for medical staff leaders and hospital administrators to address inappropriate provider behavior. MSPs help educate the leaders, document collegial conversations, and provide bylaw language to mitigate these situations before they escalate out of control.
2. Establishing credentialing and privileging processes. These requirements are essential for maintaining high standards of patient care. Verifying a provider’s education, training, licensure, and certifications should be basic expectations at any healthcare facility. A robust criteria-based credentialing process should verify providers’ clinical competence to perform specific procedures or treatments above and beyond what accrediting bodies require.
This helps the organization to entrust only qualified professionals with patient care. With the vital support of health system and medical staff leaders, the Medical Staff Services Department ensures these processes are established and remain in place.
The book The Blind Eye details how many facilities did not complete the credentialing process on Michael Swango, MD—ultimately allowing a serial killer access to victims. Swango’s criminal activity dates to the late 1980’s and has raised questions about the medical profession’s ability to detect and prevent abuses of trust by healthcare professionals. But if those organizations had completed the credentialing process, they could have saved many lives. Instead, they relied on interviewing Swango, during which he appeared to be the “all-American” physician. As a result, he was allowed to work at several facilities throughout the country, adding to his list of victims.
3. Supporting a positive culture of peer review and performance monitoring. Continuously assessing clinical performance through Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) processes further strengthens the integrity of patient care. These mechanisms promote accountability and encourage adherence to best practices.
Routine evaluations can detect deviations early on, enabling corrective measures before issues escalate. Additionally, interdisciplinary collaboration and effective communication ensure seamless coordination between medical staff services, clinical teams, and hospital administration. Practicing constructive peer review and data-driven performance monitoring fosters a culture of excellence, minimizing risks and enhancing overall patient care.
Objective peer review with a defined structure reduces the risk of tolerating harmful behavior, builds trust, and allows mitigation before issues become too great to manage. The unchecked behavior of the neurosurgeon in our example could cause numerous risks to patient care. For instance, his behavior patterns could cause so much fear that the nursing staff might not call him when they should to get patient care orders, hoping to avoid getting yelled at. As a result, patients might not get the medication or care they need in a timely manner.
Peer review committees can no longer shrug off this type of behavior because “that’s just the way he/she is.” Organizations must be willing to conduct a fair and honest peer review process, even when doing so might conflict with financial interest. This may be difficult when low-performing practitioners bring in substantial revenue, but building trust and mutual respect among health professionals is vital. A solid peer review process that is supported by the organization and medical staff leaders holds everyone accountable to the same rules.
4. Ensuring regulatory compliance. This is a crucial responsibility of an effective Medical Staff Services Department. Adhering to requirements by the Centers for Medicare & Medicaid Services (CMS) and standards set by accrediting bodies (e.g., The Joint Commission, DNV, ACHC) ensures that healthcare facilities meet national safety benchmarks.
Regular audits and compliance checks enhance transparency and reinforce institutional commitment to patient safety. This ultimately builds trust between healthcare providers and the communities they serve. When qualified MSPs support these accrediting bodies’ standards, they deliver immeasurable value.
Every MSP can share stories about the calls they have received from chief executive officers, chief medical officers, and medical staff leaders about getting privileges for a friend or colleague who wants to return to practice but hasn’t provided patient care in several years. A solid process based upon accrediting bodies’ requirements is the best response to these requests. MSPs can cite these objective standards and follow them. Without these safeguards, anyone could obtain privileges.
5. Leveraging technology. Technology platforms have revolutionized medical staff services, making processes more efficient and reliable. Automated credentialing systems integrated with electronic health records (EHRs) and artificial intelligence (AI)-driven analytics can significantly improve provider monitoring and risk detection.
Standardized reporting systems for adverse events also contribute to proactive error prevention, allowing organizations to address potential risks before they impact patient outcomes. Departments should optimize these tools to streamline administrative tasks, reduce human errors, and enhance decision-making. This ultimately creates a safer environment for patients and reduces the risk to providers and the facility.
Using the medical staff credentialing software as a single source of truth for the organization has a downstream effect directly linked to patient care. It also impacts reimbursement.
By optimizing the interface between the credentialing software and the EHR, organizations ensure clinical areas have accurate information about a practitioner’s privileges. The operating room can review privileges electronically, giving them assurance the surgeon can perform the procedure he/she has scheduled. It also allows staff to make appropriate documentation in the patient record, enabling accurate procedure coding and billing at the highest level of reimbursement. Siloed systems create a disconnect between patient care and financial stability.
Optimized Medical Staff Services Departments Save Lives
The role of medical staff services in patient safety cannot be overstated. By embracing these five core elements, healthcare institutions can uphold the highest standards of patient care. Investing in effective medical staff services is not just a regulatory requirement—it is a moral and professional commitment to safeguard lives.
