What a Proctor Isn’t

Hugh GreeleyDear Colleagues,

I have recently received a number of questions concerning “proctors,” their relationship to the medical staff, qualification, privileges and compensation. Before we delve into these questions, let’s take a look at just what “proctoring” means.

According to most dictionaries, proctoring, to proctor and (the noun) proctor generally relate to “a person appointed to keep watch over students at examinations, to supervise or monitor, a person who administers a test.”

In the course of either F or OPPE (focused or ongoing professional practice evaluation), medical staffs most often use the term “proctor” to mean a person with like or similar skills and knowledge who will observe the work of another in order to render a report to the medical executive committee concerning the overall quality of the work under observation.

A proctor is not an assistant during a clinical event, is not a trainer, is not a disciplinarian and is not a supervisor. He or she is simply present to observe and report. However, we could easily imagine a situation in which a proctor may feel the need to intervene or assist the person subject to proctoring because of imminent potential harm to the patient. While this situation rarely occurs, it is a distinct possibility.

The next issues of the Digest will address the proctor’s relationship to the staff, clinical privileges and compensation.

This edition contains another in Dr. William Cors’ important series on best practices in credentialing, this one about reference errors.

That’s it for now.



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From the Trenches: Best Practices in Credentialing: Reference Errors

WILLIAM CORSReference Errors

By William K. Cors, MD, MMM, FACPE

Two Scenarios:

Scenario #1: Your organization has just granted privileges to a new hospitalist, Dr. Shift. During her first month, there are three staff complaints about her professional behavior, two patient complaints about her communication and she was listed weekly on the delinquent medical record list. She has come to you from ABC Hospital, a reputable organization in a different part of the state. It had sent you a letter indicating “that due to a high volume of requests for information, ABC Hospital will provide the following information: Dr. Shift held an appointment to the active staff  from July 8, 2010 through May 16, 2014 and that at time of resignation there were no formal actions taken against privileges held.” She interviewed well. All of her other credentialing and privileging information appeared to be in order. What happened?

Scenario #2: After searching several years for a robotically-trained urologist to meet community need, a candidate from a top tier residency program has been recruited. Dr. Yurin is interested in your area because his wife has ties to the region. There are complications in six out of his first 10 cases being proctored. You are perplexed as to how this could occur and you review his credentials file once again. A letter in the file from his program director clearly states that “Dr. Yurin has good potential for the continued development of independent surgical skills; however, because of a low volume of cases overall accumulated during his training, it is recommended that his surgeries occur in a supervised setting for a 6-12 month period.”

Reference Errors

This series has made it clear that obtaining professional peer references is not optional. It has been shown that they are required to ensure the current competency of a practitioner to perform requested privileges at your organization. Further, best practice for a professional reference is a peer recommendation that includes written information regarding the practitioner’s current medical/clinical knowledge; technical and clinical skills; clinical judgment; interpersonal skills; communication skills; and professionalism.

An additional piece of information is that there are two types of errors that can (and do) occur in the credentialing and privileging process. They are:

  • Information errors. This refers to information that is available but you don’t have it. This is what occurred in scenario #1. You have the so-called name-rank-serial number letter from ABC Hospital. What you don’t have is that Dr. Shift had a long list of complaints about professionalism and communication from staff and from patients. She also was cited for chronic medical record delinquencies. It is factual that none of this led to a formal action against her privileges; however, she was referred voluntarily to sessions with a professional about improving behavioral interactions and communication. It is precisely for reasons like this that many medical staffs now consider this type of generic evaluation to be insufficient and require the applicant to provide additional information. Information errors can be very difficult to recognize and ferret out. Your thinking may also be clouded if the applicant is coming from an organization with a very good reputation. As a medical staff leader, this is where you really need to trust the instincts of a seasoned medical staff professional (MSP) and physicians on your staff who have experience in credentialing/privileging. These folks have an uncanny sense of radar, a well-developed sense of something that stinks and you really need to listen to their concerns.
  • Decision errors. This refers to information that you possess but you make a decision despite it. This is what occurred in scenario #2 with Dr. Yurin. Many organizations in their zeal over finally having recruited a key specialist overlook the most basic information staring them right in the face. So after six of 10 cases with complications, the letter that was there the whole time jumps out and knocks you over. This type of error is more obvious and definitely more painful because it was information you had the entire time but made decisions despite it. You might wonder how the program director could have allowed such a surgeon out of training and that certainly is a legitimate query. However, at the end of the day, you had the letter and made a decision anyway. Looking back, it is a sad day all around for your patients, this surgeon, the medical staff and your hospital.

Follow Your Policy

The role of experienced MSPs and physicians who become subject matter experts in credentialing/privileging cannot be over emphasized. But even in less than ideal circumstances, an explicit policy of what is required to be included in a professional peer reference (see the previous part of this series titled Professional Peer References) can be extremely helpful. Your policy can state what information is required to be in a professional peer reference and, if the name-rank-serial number reference is not sufficient, then the burden is on the applicant to produce or tell you where you might obtain the information requested. This will help to minimize the chances of an information error occurring.

Your policy should also require review of the materials obtained at multiple and different steps of the process. Reference letters should be read and a checklist provided to indicate that elements requested are present or whether additional information is required. Multiple reviews at different steps of the process—the MSP initially; the department chairperson or clinical service chief; a member of the credentials committee prior to the credentials committee meeting; a member of the medical executive committee (MEC) prior to the MEC meeting; a board member prior to the quality board meeting—will help to minimize the chances of a decision error being made.

Until next time, be the best that you can be.

William K. Cors, MD, MMM, FACPE, is chief medical officer of the Pocono Health System in East Stroudsburg, Pennsylvania.
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Best Practices in Credentialing – The Professional Peer Reference






By William K. Cors, MD, MMM, FACPE

As part of your credentialing and privileging process, you have requested that the new applicant provide three professional peer references to your hospital. As a result, you receive a letter from his pastor, his dentist and his best friend in medical school all extolling what a wonderful person he is and how lucky you are to have him applying to be part of your organization. So what happened here?

What Is Required?

Professional peer references are not optional. They are required to ensure the current competency of a practitioner to perform privileges requested at your organization. Many hospitals, however, merely list that “X” number of professional peer references are required without ever specifying what constitutes a legitimate professional peer reference.

The Joint Commission, in the medical staff privileging standard, MS06.01.05:EP8, clearly states that a professional reference is a:

  • Peer recommendation that “includes written information regarding the practitioner’s current:
    • Medical/clinical knowledge
    • Technical and clinical skills
    • Clinical judgment
    • Interpersonal skills
    • Communication skills
    • Professionalism
  • Note: Peer recommendations may be in the form of written documentation reflecting informed opinions on each applicant’s scope and level of performance, or a written peer evaluation of practitioner-specific data collected from various sources for the purpose of validating current competence.

Letters obtained should be as current as possible and from knowledgeable professionals who actually would have knowledge of the candidate’s performance, either by direct observation or from reports. Your obligation is to clearly state what you need and provide examples of who might be able to provide what you need. You cannot leave your requirements unspecified, thinking that the candidate knows what you want and need. Chances are he or she won’t.

After clearly stating what you require, you can provide examples of who might be able to provide that information. If the information you want is from a training program, it could be provided by the academic department chair or the residency training program director or the faculty member responsible for the resident’s performance evaluation.

In the case of a reference from another hospital, it could come from the department chair, the physician service line director, the physician assigned to perform the candidate’s proctored focused professional practice evaluation (FPPE), the employed physician group medical director or someone in a position to directly comment on all the above elements. A further example might be the chair of anesthesiology commenting on the performance of a surgeon. Or the medical director of critical care commenting on a medical specialist that uses the critical care unit. Or the medical director of the catherization lab might comment on the performance of an interventional or invasive cardiologist.

The key thing to make explicit is that the professional peer reference must be from someone who is or has been in a position to evaluate the applicant on the six dimensions of performance above and who can attest to current competency for privileges being requested. That leaves out the pastor, the dentist and possibly the best friend from medical school (unless that friend is now his “supervisor” and responsible for evaluating current competence).

Professional Peer References as the Rate Limiting Step in Privileging

It is almost axiomatic that the one guaranteed rate limiting step in getting an applicant credentialed and privileged is waiting for the professional peer references to be returned to the medical staff services department. Response times are slow, often agonizingly so. It is important to remember that the burden is on the applicant to provide you with the best contact information for his or her professional peer references. It may also be helpful to enjoin the candidate to become an active participant in this process by having the candidate personally contact peer references to expedite the process.

Future solutions may rest with new credentialing and privileging software systems that are being designed to capture these references more uniformly and using web-based products to secure the reference more expeditiously. One such web-based professional peer reference system is offered by SkillSurvey.

Follow Your Policy

Finally, since this step can bog down the entire credentialing/privileging process, what should you do if you have two outstanding and legitimate professional peer references but your policy calls for three? The simple answer is that you need to follow your policy…or change it. If it says three, then three are required. Additionally, your policy should clearly state that the burden is on the applicant to provide the information required by the medical staff to make a recommendation on privileges to the board. So, if that third professional peer reference is not forthcoming, then the applicant needs to ensure that it is received and/or provide a third legitimate alternate reference who can be contacted.

Until next time, be well.

William K. Cors, MD, MMM, FACPE, is chief medical officer of the Pocono Health System in East Stroudsburg, Pennsylvania.

Traditional vs. Necessary Credentialing Practices

Hugh Greeley




Dear Colleagues,

Can anyone reasonably argue that possession of a current unlimited license to practice medicine or osteopathy verifies that the bearer has completed a recognized course of study in an acceptable accredited medical school and has competed at least one year of residency training?

Every state takes great pains to verify that applicants for licenses have completed medical or osteopathic school and have completed at least one (in some cases two) years of an accredited postgraduate residency program. Why then do regulatory and accreditation agencies require that all health care organizations confirm completion of medical school with a primary source? Why is it not permissible for these organizations to rely upon the state, which grants the license, for confirmation of completion of basic medical education? Perhaps the reason is nothing more than tradition.

Can anyone reasonably argue that certification by a board recognized by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) indicates that the bearer has completed a recognized and accredited post graduate residency training program, or has been found by that board to possess equivalent experience and competence?

Every ABMS or AOA certifying board goes to great lengths to verify that applicants have completed an approved residency program and meet other important requirements for certification.

Why then do regulatory and accreditation organizations require that all health care organizations confirm residency completion?

In fact, they do not. Completion of an approved residency is not required by any hospital accreditation program or by the Centers for Medicare and Medicaid Services (CMS) or by any state hospital licensing regulation or statute. Many hospitals and managed care organizations do have such a requirement and it should therefore be up to the organization to determine how it wishes to confirm residency completion.

Why don’t medical staffs rely upon board certification as verification of completion of residency training (or equivalent grandfathered activity)? Tradition! (And outdated standards.)

As acquisition of a National Practitioner Data Bank (NPDB) report is mandatory, and since such reports contain information that confirms education, training, licensure, federal and state sanctions/actions and malpractice settlements, why is it not reasonable to permit hospitals and others involved in credentialing to rely upon such federally supplied representations?

Why is it necessary to duplicate this effort by requiring primary confirmation of these issues?

That answer is easy—because NPDB regulations explicitly state that health care organizations may not rely upon such federally provided representation. Why this is so is probably the result of concerns about competition with other proprietary data banks. And tradition.

Can anyone reasonably argue that the presence of a Medicare provider number signifies that CMS has verified education, licensure, and freedom from federal sanctions?

In fact, CMS will not issue a provider number without an extensive application and review process that includes verification of medical education, license and freedom from sanctions.

Why then is it not permissible for hospitals to rely upon the presence of a CMS issued provider number to verify such basic credentials? Accreditation and CMS regulations, of course, but mostly tradition!

In today’s technological environment where information is readily available and is extremely accurate, it seems reasonable that the next revision of national credentialing standards would require the following:

  • Acquisition of an NPDB report that may then be relied upon to confirm licensure actions, disciplinary actions, medical education, malpractice settlements, Drug Enforcement Administration (DEA) permit, etc.
  • Confirmation of state license (which provides a second confirmation of professional school completion and, in many cases, provides significant additional information about the licensee.)
    • If the applicant is certified by a recognized board, confirmation of this fact, which could then be relied upon as a third confirmation of successful completion of medical or osteopathic school, and residency completion or equivalence.
  • Confirmation of the presence or absence of past criminal history (none of the above confirmations assure that the practitioner does not have a criminal record that would be of interest to the organization.)
  • Confirmation of the ability to legally order certain medications, as shown by a DEA permit if this is not confirmed during one of the above checks (where needed.)

The above could be completed with a few strokes of the computer keyboard in a matter of hours, leaving the medical staff office time to gather information confirming current clinical competence, which undoubtedly is the most important step in the entire process.

Remember the competency equation: competency=actual practice + evidence that such practice is acceptable to peers and co-workers.

The following verifications are essential:

  1. Current, recently completed professional references from qualified peers or others.
  2. Verified recent volume data showing actual recent clinical practice (number and types of patients treated.)
  3. Relevant recent work history.

The following activities add no value and could safely be discontinued:

  1. Obtaining copies of documents such as license, certification certificate, diploma, etc.
  2. Contacting additional primary sources to confirm medical school or residency.
  3. Conducting a sanctions search of federal data banks.
  4. Contacting all past practice sites to confirm absence of disciplinary actions.
  5. Contacting all past affiliations to confirm presence.
  6. Contacting all past malpractice carriers to verify settlements. (Unless the staff is interested in the number of actual claims filed against a practitioner.)

No more digging to confirm medical education, residency completion, past licensure actions, all past practice affiliations, etc., needs to be done.

Regardless of how it is evaluated, the current process that hospitals use to verify qualifications and competency is archaic. The field seems, as a result of CMS and accreditation requirements, to be caught between a past that relied upon photocopies of documents and the use of snail mail and a future that promises to reveal nearly everything necessary to make informed decisions available with a stroke of the keyboard.

Many hope that the future is not distant, because the hospital and its medical staff have far more important jobs to do than needlessly chasing credentials that already have been subject to excellent vetting. Some, however, will stand in the way with their arms raised as if to stop the wave of change, for they see this change as disruptive of tradition.

This issue of the Digest features another of Dr. William Cors’ excellent articles on best practices in credentialing, this one about the factual reference. And our latest installment of “For MSPs Only” offers another savvy tip for improving communication skills.

That’s it for this month.


Hugh Greeley Signature



For MSPs Only: Adjust Your Style to Your Audience

Vicki Searcy Peggy Greeley






By Vicki L. Searcy and Peggy A. Greeley

This month’s tip deals with communication skills.

Learn how to communicate most effectively with your chief executive officer and chief of staff and others whom you deal with frequently. Some executives prefer verbal communication; others prefer short, bullet-point memos. The only way for you to find out is to ask their preferred method of communication.

Great communication requires that you care deeply, listen carefully, send your message effectively and adjust your style appropriately.

This month’s tip was taken from “101 Smart Things Every Medical Staff Services Professional Should Do“, by Vicki L. Searcy and Peggy A. Greeley.

Questions about this month’s tip may be addressed to Vicki L. Searcy by clicking here.

The Evolution of the Medical Staff

Hugh Greeley




Dear Colleagues,

The medical staff structure and function might have evolved differently had circumstances been different. Let’s take a look at the rise and fall of the fictional “Organized, Self-Governing, Community Medical Staff” and then consider possible parallels to today’s confused and evolving medical staff model.

The time was from the mid-1960’s to 1973, and communities throughout the country were being served by growing numbers of well-trained physicians interested in providing patient care services to the sick and injured. These practitioners prided themselves on prevention, maintaining their patients’ health and keeping those patients out of the small hospitals that dotted the land. Community-based ambulatory services evolved to the point where patients could receive nearly any needed service without entering the hospital. There may have been a few physician- or community-owned surgical centers, urgent care centers and imaging centers. And, of course, there were dozens of private offices serving patients though out the community. Hospitals played a small part in the nation’s health care delivery service.

There was a growing concern that the nation’s health care system did not adhere to any set of reasonable standards or guidelines and that there was no reasonable organization through which community-level decisions could be made about physicians’ qualifications or expertise or the actual quality of the medical services provided.

To answer this concern, a multi-disciplinary group self-organized into the Accreditation Commission for Community Care (A3C, as it became known). This commission eventually established standards mandating that the physicians in each community form themselves into a “community benefit medical staff” and that this staff then organize in order to best manage and supervise the care delivered within the community. Many groups of community physicians attempted to gain formal accreditation because that designation provided a simplified route to reimbursement under the newly-created Medicare program.

Unfortunately, the community staffs that were self-created did not always measure up to the standards created by the A3C, and some were denied accreditation. This created quite a stir within organized medicine and the A3C felt the need to provide a model organizational structure and operational guidelines that community staffs could emulate. The model called for the staff to be open to all qualified practitioners, organized, if desired, into departments such as pediatrics, general medicine, and obstetrical, surgical, and diagnostic services.

The model also suggested that categories be created to provide for orderly self-governance of all practitioners providing care within the community. Thus was created an active category for all actively practicing private physicians who had offices in the community. A second category was created for visiting practitioners. And a courtesy category was created for those few doctors who lived in town but had accepted employed positions in small hospitals to provide care for those without a private physician, the needy and the otherwise underserved.

For a few decades, all was idyllic. The community grew, additional physicians moved into town to join existing practices and services expanded to meet the needs of patients. But the urgent care centers that previously had been staffed on a rotating basis by volunteer physicians were struggling as increasing numbers of patients had no ability to pay. Soon the small hospital was forced to assume burden of providing emergency/urgent care and so hospital-based emergency rooms were created. Physicians were hired to staff these new services on a fulltime basis.

Obstetrical services, which previously had been provided at home or in freestanding delivery centers, also were unable to cope with changes in reimbursement and patient complexity. Advances in medicine now permitted the birth of babies in need of round-the-clock care, and the centers were unprepared to offer such services. Thus the small hospital took on this responsibility as well.

Next were the surgical services. No longer was surgery confined to simple fractures, suture of lacerations, repair of hernias and gallbladders. Modern medicine could now repair hearts, hips, complex trauma injuries and multi-organ failures. Equipment was costly and the previous cottage industry of surgery centers collapsed, thus forcing the small hospital to organize and manage a growing advanced surgical service working in conjunction with the freestanding surgical centers owned by private physicians. The advent of advanced medicine and an increasingly elderly population created the need for additional round-the-clock inpatient care, and this created the need for additional physicians to attend these patients at all times because private physicians had little interest in disturbing their ambulatory practices with frequent trips to the hospital.

While these cataclysmic changes raged through the community, the community medical staff continued to operate as if business was unchanged. The active component consisted of a declining number of private community physicians. More physicians than ever before were providing care exclusively in the hospital as employees. The straw that broke the proverbial camel’s back was the fateful day a highly respected private general practice group approached the growing hospital seeking a merger or acquisition. Eventually the group and hospital merged, with the physicians continuing to provide care in the community, but under the hospital’s license.

Now that they were employed by the hospital, the physicians no longer qualified for active staff status in the community medical staff organization and they were relegated to second class citizenship. Soon other physicians followed suit and became employed by hospitals. Within a short time, the hospital (now called the regional medical center) provided much of the community’s care through its growing number of previously private community physicians.

The traditional community medical staff’s governing structure was dominated by private community physicians unwilling to share decision-making with employed hospital doctors (who now provided both inpatient and ambulatory services). Yet in many instances, it was virtually impossible to tell the difference between an employed internist and a private one unless one had access to their W-2 forms.

The community medical staff, which had been propped up by protective A3C standards no longer represented the majority of doctors in the community. This vacuum was quickly filled with the creation of a hospital medical staff, with the rapid development of a division within the A3C called The Joint Commission (TJC), which began to accredit hospitals along with their medical staffs. Soon the community staffs crumbled into meaningless inaction, and eventually they were absorbed into a special category of the hospital’s staff called “inactive community division.” They were accorded no vote.

This month’s Digest includes another of Dr. William Cors’ excellent articles on best practices in credentialing, this one about the factual reference. We also have a new installment of Dr. Richard Thompson’s series, “In My Day.” This time he reminds readers about how poorly-conducted applicant interviews can be pointless. We also have two short pieces referencing important subjects, one containing accurate past predictions about credentialing and the other illustrating the vital difference between mere licensing and true verification of credentials. This month’s “From the Archives” entry is about Ignaz Semmelweis, who pioneered antiseptic procedures, and “For MSPs Only” offers another tip for improved communication skills. Finally, our website’s “Facts in Brief” post cites just how costly credentialing delays can become.

That’s it for this month.


Hugh Greeley Signature




For MSPs Only: Clean Up Your Language

Vicki Searcy Peggy Greeley






By Vicki L. Searcy and Peggy A. Greeley

This month’s tip deals with communication skills.

Never use profanity. There are more effective ways to express yourself.

It is better to remain silent and be thought a fool than to speak up and remove all doubt.” –American Proverb.

This month’s tip was taken from “101 Smart Things Every Medical Staff Services Professional Should Do“, by Vicki L. Searcy and Peggy A. Greeley.

Questions about this month’s tip may be addressed to Vicki L. Searcy by clicking here.

From the Archives: A Pioneer of Antiseptic Procedures

Ignaz Semmelweis (1818-1865) made big waves in the medical community back in the 19th century when he suggested that doctors might actually be giving patients infections with their dirty hands. A large portion of the medical profession was insulted by the theory and accused Semmelweis of slander and mental illness. His theory would go on to save untold millions of lives, but Semmelweis himself would die in an asylum—possibly of an infection that was improperly treated.

Source: Semmelweis Society International.

Licensure vs. Verification

Hugh Greeley




By Hugh Greeley

Licensure gets a doctor into the vestibule. Progressing beyond that point requires careful verification of qualification and competency.

Hugh’s Credentialing Digest urges its readers to recognize that licensure confers upon the licensee only the right to practice in the state. It often says absolutely nothing about the competency of the physician or any important details about his or her background.

This article about a doctor accused of sexually assaulting patients illustrates this point. Readers may draw their own conclusions. However, we hope they include realizing the importance of the points listed below.

  • The necessity of conducting criminal background checks when processing initial applications.
  • The necessity of contacting or otherwise verifying each and every license held by the applicant, regardless of state.
  • The critical importance of professional references sought and provided according to established institutional policy. (Such policy should include a requirement that the organization select references based upon the specialty and type of practice involved.)
  • The importance of conducting a simple Google check when completing the application package.
  • A simple and inexpensive FACIS (Fraud and Abuse Control Information System) search should be part of every completed application package.

Physician Licensure and Quality of Care

Paul B. Ginsburg and Earnest Moy published an informative and interesting article addressing “Physician Licensure and Quality of Care: The Role of New Information Technologies” in the fall, 1992 issue of Regulation.

While the article is now 22 years old, it contains material that may interest anyone involved in credentialing activities. Readers may note the authors’ many accurate predictions about licensure, certification, technology and the federal government’s interest in promoting quality initiatives.

You can read this article by clicking here.