December 6, 2023
Renovating a facility to accommodate the many spine procedures that can now be performed in outpatient settings often involves a digital makeover in the form of...
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By: Jeanine Watson, MSN, RN, CNOR(E)
Published: 9/14/2023
Recently I was asked to put together a presentation on avoiding common mistakes in credentialing, privileging and peer review.
As luck would have it, these are some of my favorite subjects. I enjoy connecting the dots in the processes, so I was eager to uncover the areas in which leaders were currently struggling. To do it right, I had to dust off my regulatory hat, open my accreditation resources and dive into the research. I was surprised how many of the most common mistakes haven’t changed much over the years.
In regulatory compliance, “loop closure” means completing tasks with documentation that each step was done according to policy. This requires a meticulous attention to detail — an ability to find and check off each requirement to avoid gaps. For instance, even if you have a great policy and are following it to the letter, if you don’t have the documentation, it doesn’t count. Lack of loop closure was a contributing factor in the most common errors leading to deficiencies.
The purpose of the credentialing and privileging process is to ensure applicants are legally and professionally qualified to perform the procedures requested. With the Peer Review process, the performance of providers on key patient outcome indicators is evaluated by other providers. These processes must follow established requirements which vary depending on the accrediting agency the facility uses. Most agencies require the policy to clearly define each step in the process from application to approval or denial of privileges. The process should be efficient and carried out in a timely manner and the specific privileges should be requested and approved as individual line items. Meticulous documentation should take place at every step in the process. Instead of including every specific mistake, I’ve identified the most common themes of the errors that facilities tend to commit:
Credentialing, privileging, and peer review are integrated processes, and loop closure to prevent deficiencies is best achieved through knowing your policy, having an organized plan to carry out responsibilities and documenting every step of the way.
If you want to learn more about how to avoid common mistakes in credentialing, privileging and peer review process, be sure to check out my recorded webinar, which can be accessed through this link: https://www.youtube.com/watch?v=s4pHT6csvcM OSM
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