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A Publication of WTVP

When a person presents himself or herself at a hospital or hospital emergency room it is generally with the assumption that the treating professional is trained and properly qualified to give the care required. Recent newspaper articles of untrained persons posing as physicians, and in particular the publication of Blind Eye, gives us cause to explain the mechanisms which hospitals use to assure physicians using their facilities are properly trained and qualified to give the care provided.

Credentialing is the process used to make sure the individual applying for medical staff status is properly trained and has an acceptable work record. We at OSF HealthCare, as do other health care systems, require a complete record of undergraduate, graduate and post-graduate education and a listing of where that training was obtained. The physician must list what specialty boards have been obtained or which boards they are qualified to apply for examination. They are required to give names of other physicians who can give personal and professional references as well as a chronological order of professional employment for at least the past 10 years.

All current and past state licenses to practice medicine are required as well as current and past hospital appointments. In addition, Drug Enforcement Administration (narcotic license) certificates are required. The physician must list malpractice suits filed or judgments made for a 10-year period, as well as any state board or hospital disciplinary actions taken against him or her or any criminal convictions.

We recognize the collection of this data does not insure its accuracy, so every detail undergoes primary source verification— medical school records are queried, information is obtained directly from state medical boards, and written references are obtained from professional peers. The National Practitioner Data Bank is a repository of mandatory practitioner specific reports of malpractice judgements, medical staff disciplinary actions, narcotic license violations or disciplinary actions of state boards of health. This database is routinely checked in the process of credentialing. Hospitals in which the physician previously practiced are asked for recommendations. We look for and ask for explanations or any chronological gaps in the records provided.

When data collection is complete, it is reviewed by the appropriate medical staff committees and recommendations are made to the hospital board. It is the governing board of the hospital which finally decides if a physician will be admitted to the medical staff.

Once physicians are given hospital staff status another process of evaluation is made to determine their privileges. This delineates what illnesses or procedures they’re qualified to care for or to perform. Again, these decisions are recommended by the specialty department in which a physician wishes to practice, taking into account training and experience.

Physicians are re-credentialed every two years, at which time the hospital, medical staff and hospital board re-evaluate the practitioner, including an evaluation of the quality and outcomes of patient care. Any changes in the original credentialing data are collected and considered, as well as continuing education and training, which may permit the granting of expanded privileges.

It is important for the community to understand the detailed collection and verification of data, as well as the continued monitoring of a physician’s activity by the hospital medical staff—and ultimately the hospital board—to assure the public is cared for by appropriately trained and qualified physicians when they seek care from our medical community. The process which has been outlined is monitored by the Joint Commission for the Accreditation of Hospitals (JCAHO) and the State Board of Health to assure compliance. IBI

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