Credentialing conundrums

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Medical administration is a rewarding profession, but it comes with challenges. So what is it like and what should you do if confronted with a monumental administrative difficulty? This is the podcast that takes unfortunate scenarios. and explores the essentials of clinical governance to find solutions.

I'm Dr. David Rankin, a very experienced medical administrator and lead fellow with the Royal Australasian College of Medical Administrators. And this is Safeguarding Healthcare, the essentials of clearing. Today, credentialing conundrums. I think there's a significant issue about making sure that the performance process is actually being adhered to.

That's Professor Andrew Wilson, the Chief Medical Officer at Safer Care Victoria, a practicing cardiologist who also holds an academic appointment at the University of Melbourne. And I'm presenting him with a difficult scenario. I think it's very challenging. It's uh I'm not gonna say it's easy. In today's scenario, your hospital runs a three-yearly credentialling cycle. This is usually a desktop exercise, particularly when the head of unit supports the application.

A surgeon about whom you have some concerns has come up for review. There have been several complaints from patients about the surgeon's poor communication skills. Their return to theater rate seems high, and they appear to place a disproportionate number of patients on the surgery waiting list. Their paperwork looks to be complete, including three glowing references. one from their practice partner, and two from specialists who you do not know, but who operate at a local private hospital.

You have an informal discussion with the head of unit who implies that you would be very courageous to decline their application for renewed credentials or place conditions on their practice. So I start by asking Professor Andrew Wilson what key issues arise in a credentialing scenario like this.

Well, I think one of the things we're hearing from that scenario is that there are some performance issues with that clinician. And I think it's how do we work with the performance process that we have at a health service? versus the credentialing process. And I think

things get blurred sometimes and we use the credentialing process almost instead of performance management, which should be occurring all the time. And so I think credentialing has a role to play here. But I think the first thing I'd be looking at is

supporting the head of unit to work with this clinician and look at ways that their performance is not up to the level that we require at our health service. And also understanding particularly the impact that this sort of clinical performance or behaviour can have on the team.

So not just on the overall performance from a clinical viewpoint, but also on the culture within the group. So I think there's a significant issue about making sure that the performance process is actually being adhered to through performance. PDPs or whatever structure is in place. And I think

particularly on the medical side, there's probably a lot of work we could do to improve those and explain to our colleagues why we do it. And it's for their interests to develop themselves professionally. So I think credentialing is a relatively blunt tool to address some of these issues.

That raises a really I think interesting question of what's the purpose of credentialing if it's not to identify and exclude poorly performing clinicians. So to me, and I think this is something we're obviously doing a lot of thinking about, that credentialing has traditionally been something that provides a minimum data set, if you like, about a clinician. It's about their qualifications. Are they actually qualified

to work as a a medical practitioner in this setting? Are they actually trained to do what they say they're doing? Do their peers support them working in that environment? But it really doesn't tend to speak traditionally to those areas we're talking about about behaviour and performance from a day to day work environment. So I think There is a significant role in checking for these things because they're the bedrock on which we work.

I think there's a limit to what credentialing can provide in this setting, but it provides consistency and increasingly we want it to provide a transparent way of addressing people's qualifications so that when people turn up to a health service They have faith and confidence that the person that's treating them is who they say they are and is trained in the manner that they expect. A lot of credentialing at the moment revolves around paperwork.

Have you got indemnity insurance? Are you registered? Do you have any conditions on your practice? And references. That as you say, is a very basic standard. for quality and safety. In that context, what value does credentialing really add? When m much of this material is available for someone to look up at any time?

framework, if you like, for looking at someone. And I think we do need to have improvements in the way we collect that information and collate it. Not all of it's easily available. Some of it is, some of it isn't. We'd like it to be more available. That's certainly something I feel strongly about. But I think what we're missing is that we're not going to be able some of those other elements that we've raised in that scenario, which are about leadership and

safety culture, behavior, the ability to work with others and and those things are not picked up in a credentialing process. I think the other area that we need to look at more strongly is Scope of practice as well. So there are elements of it that are picked up by most credentialing processes, but we certainly see in many health systems that Someone who's, for example, an orthopedic surgeon who has worked exclusively treating knees for 10 years and then moves to another facility and starts.

Operating on people's hips. It's relatively difficult to manage that situation. And so I think that those things would be picked up in an ideal world in a more robust credentialing process. And perhaps less of the paperwork, the tick and flick kind of credentialing, which is probably the dominant part of many of the credentialing processes.

There's a lot of informal knowledge in an organization. Nurses in particular form quite strong and often very correct opinions about medical staff, their attitude to patients. Their skills, whether they turn up on time, whether they're reliable and available. How much of that soft organizational evidence?

should be brought into the credentialing question. Well I think it's a really important question and I think it's where do we sit that within the overall review of someone's performance. And I think that's again goes back to that How much of that should come into a performance review and I would argue it should be there. Many organisations and craft groups around the world in many other areas undertake three sixty degree feedback. I think

It's fair to say the healthcare system is relatively challenged in many ways about giving feedback as supervisors or to colleagues and that's something we need to do better at. So I do think that certainly within the performance structure. there should be much more room for three sixty degree feedback. And I know that when we undertake reviews in lots of other scenarios, which are more about the impacts of healthcare quality and safety issues

We will always speak to everybody because we know that the whole range of the team have important inputs there. So I think people who are organizational psychologists and others will tell us that we should welcome three sixty degree feedback.

So I think it needs to have a place, whether or not it actually lands in the decisions at the medical advisory committee who are making those final credentialing decisions or perhaps is fed in earlier and if there's a significant issue raised by members of the nursing staff, for example, and there were significant performance issues raised. To me, that's then escalated into the credentialing process. Because if someone is not credentialed.

Not that it's irreversible, but it's a much more challenging process to reverse if the decision's made. So I think there's an opportunity to work earlier with people through performance management, which should include the feedback of a range of workers, not just people that they handpick. In this scenario, the surgeon that's been credentialed has very carefully selected his referees. One of his work colleagues and a couple of his mates that work in a private hospital.

How can you be sure that the referee's comments are accurate and impartial? It's very challenging, as we know. And I think the other area of conflict that I think we come across quite a bit is when clinicians are involved in the management of a health service or in the medical advisory committee and there's a small group, perhaps they're involved in the ownership of a private hospital, for example, and there's so there's a huge amount of potential conflicts there, or that the clinician is

A very key member of a staff or in a private hospital is a important driver of throughput through the hospital. There's a lot of difficulties there. I think part of the challenge we have is that we need to really emphasize the the accountability of someone who is writing one of these references to them. And to understand that it's not just going into a black hole. They are

a key feature of deciding whether or not someone's qualifications and professional standing and behavior is appropriate. And so I think we could do a lot more about helping people understand how serious a role that is. Just as we do when we write a medical certificate. We understand that it's a legal document and

It has important impacts on people's lives and can potentially come back to us. So I think there's perhaps a lack of uh understanding sometimes of the importance of those references and the need for people to be accountable when they write them.

One of the assumptions I'd always made is that the references have to be medical practitioners, but actually reading the national guidelines, it's not clear. I had an organization ask the other day whether nurses can provide references for medical staff. What are your thoughts on that?

As we talked about before, I mean, they know a lot more about someone when they're working with them. So again, I think uh need to check the rules myself very carefully, but I certainly in principle have no issue with a range of people writing references. And especially when they speak to those other features that we've been discussing, such as their behaviour and how they interact with the rest of the team, which

in many ways is as important, if not more important, than their technical abilities that they trained in something thirty years ago, they may or may not have kept up to date, but we know in real time how they've been performing. So I think

References from people who know and work with them on a regular basis are critical. So yeah, I I don't have a problem at all with y using a broader range of people. Take a step back and look through the technical processes of credentialing. Who makes the final decision?

as to whether or not the doctor can work or is appropriate to be working at that hospital. So usually it will sit at the level of the medical advisory committee or the some groups will have a credentialing committee that reports through depending on the structures of their governance. But I think one of the challenges we have in smaller facilities is that pool of people is very small. And I think that's why some of us anyway are looking at ways to make some of these decisions in a more

system wide way and there's lots of ways we can look to do that over time. But it usually sits at the level of the Medical Advisory Committee, have ultimate accountability reporting through to the board. Yeah, certainly as a board member of a large private hospital.

the board has ultimate responsibility in ticking off the advice that it receives from the Medical Advisory Committee. So what happens when the chief executive, for instance, Looks at the advice from the Medical Advisory Committee and says, No way, we can't survive financially without this doctor and therefore I'm not prepared to support the recommendation to the board.

Think it's very challenging. Yeah. It's uh I'm not gonna say it's easy and we certainly see that where there's conflicts between boards and executives and that as again Not always in private hospitals at in rural settings where the clinicians may well be very well entrenched and well established.

these things can become extremely challenging. So I think one of the elements of my role is I I see what happens when those decisions aren't made, that someone's been able to continue working in an environment where they're perhaps

should have been managed or I think the issue about mitigation of behavior is probably something we need to do a lot more work with. People are sort of essentially re credentialed and not really managed And that the impact that has on the the health service and the the culture and the other staff members can be profound.

So there may well be a short term price to pay to deal with a very problematic clinician, but there's another price that's a bit more hidden and a bit more insidious that often ends up being bigger. So I mean I think that's it is very much an issue of

How does the board make their decision? Are they getting the right information? What are the influences on their decision making? But at the end of the day, they're accountable and that's why they're on the board. So we I think that's the way the system is set up. That's the governance that's been set up. Not being declined credentialing can have extraordinary impact on the doctor, not only their income but their reputation, their ability to practice. Is there an appeals process?

Yep. Usually there'll be an appeals process either usually within the health service or Obviously there can be legal challenges, which we do see every now and again. And I think there's enormous concern at health service levels about this. I I think it inhibits some of the decision making at times.

So any decision making should have an appeals process and that's absolutely appropriate. And I think we probably underutilise independent peer reviewers to look into these issues either about the original decision where it's contentious or when it has been difficult, or we anticipate it's difficult.

I certainly think that if I was in a health service and there was going to be a contentious issue, particularly about someone losing credentialing, I think it would be sensible to involve an independent person to come in up front.

and anticipate the problem rather than I think what happens is people are nervous about going down that road so they tend to make the more conservative decision which is to re credential because they don't perceive they want to go down that road, which is understandable. But I think we are seeing health services be a little bit more proactive about this than they have been in the past. So but I again I think something I'm really passionate about is the opportunities to address these issues.

further up the food chain or earlier in the process. I think once we get into not credentialing people or asking them to resign, which is often what happens, there's a huge missed opportunity to have mitigated some of the issues. So I think there's an opportunity to address these things ahead of time and also if in doubt, involved some independent thinking.

I think that goes to a fundamental issue. I'm really keen to see incorporated into clinical governance and that's coaching rather than policing. Absolutely. Taking the clinician aside, getting them to reflect and working with them in a constructive

coaching context as early as possible. Yeah, absolutely. One of the issues is volume. And you briefly mentioned earlier that knee surgeons starting to do hips. There's a clear correlation between the number of procedures that you undertake and the outcome for those procedures, particularly for some of the more complex procedures but also quite routine procedures.

We've seen some development in Australia particularly around colonoscopies, GP obstetrics and other procedures where doctors have to demonstrate a minimum number of volume procedures. It seems to be something we've been hesitant to pursue. Can you talk briefly about this idea that clinicians should be undertaking sufficient volumes to maintain their scope of practice and credentialing?

Yeah, thanks David. It's a really important question. I think we've done in our organisation a significant amount of work about volume outcomes relationships at a health service level.

One of the challenges is there's lots of areas where there's it's a data free zone or the data isn't very strong. So the evidence, although my personal bias is towards having smaller number of people doing more of various procedures, but sharing that around so that it's not all conglomerated around one or two individuals, which tends to can happen and

disenfranchises the others. So I think there's a way to do it in a more collegial, collective way. But I think we should be looking for evidence of it. There it's not just I think part of the issue is There's clinical outcomes and they can be difficult to determine as well because of the way we measure them or they may be so infrequent in within a particular setting.

that it's difficult to show. And so the absence of data doesn't mean that it's not a an issue, but it's hard for us to show that. But I think there's other issues about training and convenience for people and we know that if you do the procedures more often in a setting, they may well become more efficient and you can develop up a whole lot of other systems around that. So I think it's a nuanced discussion.

I think in the past we have set numbers, but they were pretty arbitrary. And certainly in my training as a cardiologist, it was all numbers based. how many angiograms I had to do, how many echocardiograms and so on. But that wasn't necessarily linked to quality outcomes. And I think sometimes it can also be used to limit um access to care for others so that

The professions, the subgroups within the professions need to step up a little bit here as well. But being a high end echocardiography expert, you may well need to do a lot of echos and see a lot. But if you're someone who's providing an outreach service to a local community as part of your role, I think we don't need to do the same volume, but equally you need to understand your limitations and perhaps refer in the more complex cases to someone who does have that expertise. So

I think it's very nuanced. I think it's one of the features But equally I think we don't do a lot of retraining or re credentialing in Australia. I think there's other ways to assure someone is up to speed, doing enough work. I know with colonoscopy, as you said, One of the things they do, which I think is really impressive, is the professional body Geezer tracks how many polyps you are taking off per the number of

colonoscopies you do as a as an index, a surrogate marker of the quality of your work. I think that's quite an interesting approach. So I think appropriateness is equally as important as volume and Certainly in cardiology that's an issue. So that if you're doing a whole lot of inappropriate procedures, your numbers may well be adequate. But I'd definitely like us to turn our minds a little bit more to

How many of your procedures are appropriate as an index of quality? The flip side of that is a clinician's proclivity to intervene. And interventional cardiology. We all hear rumors about interventional cardiologists that will operate on anything that moves, while others will be very conservative about the approach to intervention.

How do we determine quality in the context of threshold to intervene? No, I agree. I think there's a benchmarking opportunity here that we definitely can look at. It has to be largely driven by the peer group in many ways, because they're the experts on that. But I think That's where I very much get down to appropriateness criteria. So cardiology is a good example of where there are really well defined indications for procedures and intervention and

We're working with V Cor in Victoria for our registry to pull out some of that data and there is some interesting data already. The difference of indications is really important. So, for example, to do an angiogram Most of us would generally believe the patients need to have symptoms or and or have an evidence of ischemia, either on a stress test or on blood tests and ECGs.

But there's a significant number of patients who don't meet any of those criteria. And I think that's the target area to look at is what's the proportion of cases that you are doing. that are appropriate. I think when you make it a black and white rule, which we do sometimes, that becomes difficult because there's always exceptions to the rules and our colleagues all speak to that. But certainly setting a benchmark

on what and I think that's what the Giza process does. It largely says you should be this percentage of your colonoscopies should find a polyp if you're have a very low proportion, you're doing too many inappropriate colonoscopies. I think I'd like that way of thinking. I think it's relatively early days in our profession, but

I think what will happen is you'll get the obverse situation where I'm the only person who can do these procedures and people are sent to me and that type of thing. Well, I think if that's the case, then you should be very open about your your figures and your outcomes. And I think part of the problem is the accusations that you're raising, often those clinicians are very opaque about their outcomes and that's part of

They may well be highly skilled and more effective than their colleagues, but their colleagues don't get to see because the data isn't available. So I don't think you can say that without showing your data to other people. It can't be based on hearsay. So I think moving to a system where we look at appropriateness is something I'm very supportive of.

And the underlying foundation of data. Yeah, absolutely. And coming to clinical opinions rather than anecdotes or hearsay. The scenario implies that the doctor's raising a threat. Against the organization. How do you m handle the threat of retaliatory action if you don't comply with what the doctors require? That's a really good question. I mean I think the reality of those of us who work in executive or governance roles are dealing with threats.

fairly regularly from a wide range of people. I certainly fundamentally, principally don't see why we should take threats from surgeons more or any other clinician more seriously than if it's a patient or a family member or a lawyer from another hospital or whatever. So I think

It comes down to governance about having systems that are appropriate, that are defendable, that are processes that are defendable. Listening to people, I think people should absolutely have a chance to make their case. But I think A lot of this is about making sure that your systems are defendable to any kind of

Retaliatory action. I think if we're going to beef up the processes, there needs to be that remediation, that coaching element built into it so that we don't leave it so late and then take a very drastic step. I think there's a lot of opportunity to work on the way forward.

If someone is not able to engage in that remediation or it's not effective That's important information when you make that credentialing decision that they're not able to change because then if you're accepting that their behavior or their performance is not adequate for your facility and they've no evidence they're going to change. What are you saying to the rest of your service and to your patients? You're accepting a lesser, lesser outcome.

A large hospital might have a thousand or more medical staff. On a three yearly reaccreditation cycle, that's ten or more a week. Credentialing's an incredibly important step in just confirming. the doctor's clinical skills and scope of practice, would you expect a credentialing process to involve an interview and confirmation of their practice? So I think the whole burden of credentialing is really a critical issue to deal with and I think there's an element about this that

Looking at ways we can streamline credentialing, particularly the the clerical parts that you were referring to earlier. So I think if we could create some space. by having that more streamlined approach that would then focus on these issues. And I think we should think about having some sort of interaction with the clinicians, whether or not it's an interview that's stronger than we do now, at least for some of them, particularly if it's contentious. There's lots of

ways we could prioritize some at least some of the staff. I think that's probably the other way to think of it, that if someone has been in place for a very long time or a very short time, you might interview them, but perhaps not Some of the others. But it would be nice to look at ways that it wasn't all paper based for every single person. That's a really interesting challenge because I I often find the high performing specialists that you'd whistle through accreditation.

are the ones that most value sitting down with the senior medical administrator and just talking about life and their career goals and where they're going and how they're keeping their skills up. So

Risk rating credentialing interviews can be problematic in itself. Yeah. And I think that's perhaps something about the role of the medical leader in a health service that Where I was in the US, well I was told that if you were the chair of division of medicine or so and so, that you spend fifty percent of your time every week talking to the clinicians and on a regular basis.

And certainly if you were a head of department, you would have a monthly meeting with the head of medicine and so on. So That would be nice to look at away, not aside from credentialing. that there was that was factored into the role of a medical administrator that we probably don't have today and it does tend to fall back into being a little bit more of that clerical paperwork elements of performance and so but even

Performance meetings can sometimes or performance reviews can sometimes be fairly cursory at times as well. So even when we have the structures, they're not always that effective. Andrew, thanks very much for your time. Today would you like to outline some of the things that you'd like to see improved or enhanced about the credentialing process in Victoria in particular?

Thanks, David. And very kind to invite me and very happy to be here. But I definitely would like us to do more work on streamlining of credentialing. So looking at ways that we can recognise particularly the more administrative elements of our credentials across services. So During the pandemic, we were able to get some reform agreed to in the short term that all hospitals essentially could recognize each other's credentialing. So I think that's something that would really assist

the process and then you could focus on these other areas that we've been discussing today, such as are they really trained in what they're doing? Does that really work for that health service? And some of the more clerical elements we could make much more streamlined. So we're definitely trying to work on that at the moment. And as you've you and I have discussed. I'm really passionate about looking at better ways for us to

coach or remediate challenges. So I think having a very robust credentialing system, if it's too much about compliance and having a hard edge without that coaching, you're missing a huge opportunity because the large majority of our colleagues are trying to do their best and they're very good at their role. But all of us can improve and I think to have ways of doing it better. That's Professor Andrew Wilson, the Chief Medical Officer at Safer Care Victoria.

And that brings us to the end of this episode of Safeguarding Healthcare. I'm Dr. David Rankin. Follow safeguarding healthcare free on Apple Podcasts.com. Google Podcasts, Spotify, or wherever you listen to podcasts. This podcast is produced by Sound Cartel for the Royal Australasian College of Medical Administrators.