We've all heard the stories of patients suffering at the hands of unlicensed practitioners. Some might blame lax administrative processes. Possibly, but if it was an accredited facility, you have to wonder how someone without the proper credentials could be granted privileges. Could it be that these facilities are on their best behavior only when the surveyor comes calling?

Fracturing a few rules
Those who bend the rules are forgiven, sometimes even rewarded, if a desirable outcome results. Case in point: A physician expresses interest in joining the medical staff. Facility administrators are delighted, and many will do whatever it takes to help the process along.

It's not uncommon for credentialing staff to complete most of the application on behalf of a new physician and to grant the new doc privileges before the process is complete. The staff might decide to supervise new physicians while their credentials are verified. Slight departures from policies such as these, however, expose even a well-run center to unnecessary risk.

Unfortunately, until something goes gravely wrong, most healthcare providers regard administrative checks and balances as a burden rather than as a safeguard. Many of you are taxed by the demands of caring for patients and simply lack the time necessary to stay on top of administrative duties. It's not at all surprising that completing forms and evaluating staff are often a low priority for administrators.

Cram session
Things change as your survey date nears. Documentation that demonstrates compliance with accreditation standards becomes a top priority. Staff frantically work as the mad dash for accreditation begins.

Surveyors use prior results and the results of other centers to focus their efforts. They always review credentialing files, but lately surveyors are spending more time reviewing the credentials of ancillary staff, particularly those not employed by the center. It's not uncommon for credentialing staff to overlook a surgical tech brought in by a physician, especially if the physician is routinely accompanied by sales reps. The more people allowed in the ORs, the harder it is for staff to know who does what.

Staff competence is another area of surveyor interest. Surveyors are expecting more than just completed evaluations. They want to see evidence of improvement. That means staff need to have clearly defined and easily measured responsibilities. Specifying expectations for staff and developing meaningful job descriptions is time-consuming, but the process typically reveals ways to streamline processes and free up the resources needed to improve care.

Not only will keeping up with administrative tasks and standards changes make the survey process a lot less stressful for all, it will reduce the risk of errors and ensure your facility delivers the highest quality of care.