When Lester Salinsky, MD, applied for full surgical and orthopedic privileges at Misericordia Community Hospital in Milwaukee, everything seemed on the up and up. He was on the active medical staff across town at Doctors Hospital. He held consultant privileges at New Berlin Community and Northwest General hospitals. And his privilege record was clean: no suspensions, revocations, curtailments or non-renewals at any hospital. Or so he said.

After he damaged the femoral nerve of a patient's right hip during a procedure to remove pin fragments, the patient sued, and the truth about Dr. Salinsky was uncovered in court. He was facing 10 malpractice suits; his privileges had been curtailed, investigated or denied at other Milwaukee hospitals; and he had never been associated with New Berlin Community Hospital.

Worse yet, all this information was easily discoverable, but Misericordia had failed to request or locate any records on Dr. Salinsky. Court records say the hospital's medical executive committee had decided that his "training, experience, and demonstrated competency were sufficient to justify the granting of staff privileges and ? there would be no further duty on the part of the hospital."

Misericordia was also sued, and it fought the case to the Wisconsin Supreme Court, which upheld the lower court's 1981 decision that the hospital had been negligent in its credentialing practices. Although Dr. Salinsky was directly responsible for the injuries to the patient, a jury found him only 20 percent negligent and found the hospital 80 percent negligent. The jury awarded the patient damages of $315,000 for past and future personal injuries, and $90,000 for past and future impairment of earning capacity, according to court records.

That case, now 25 years old, has set the bar for facility responsibility in credentialing: If a physician lies and you don't catch it, you and your facility could be held liable for damages in a malpractice suit. Here are tips to make sure bad doctors don't slip through the gaps in your credentialing process.

1 Think your bylaws through
Your bylaws set the groundwork for your credentialing process. Bolster them with these rules.

• Require enough references. Experts suggest you get between three or four letters of reference. The fewer you require a surgeon to give you, the lower your chance of receiving enough personal testimony about him. "But you can't mandate more [references] than what's in your bylaws," says Anita Lambert Gale, RN, MES, the vice president of clinical services for HealthMark Partners in Nashville.
• Spell out the grounds for dismissal or application rejection. No. 1 among them should be lying. Write a bylaw that states that a surgeon's lying on his application is grounds for revoking of privileges - even after you've allowed him on staff, says Ms. Lambert Gale. "And beforehand, lying is grounds for automatic denial," she says.
• Set a timeline for board certification. Insist that your surgeons be board-eligible or board-certified in their specialty within two years of joining your facility, says Ann Geier, RN, MS, CNOR, CASC, a vice president of operations for ASCOA. She relays the story of a high-volume pediatric surgeon who, despite three tries, didn't pass his specialty boards. Years later, he was brought up on charges of Medicare and Medicaid fraud. The certification and the fraud charges were unrelated, she says, but "if the facilities had had that rule, they never would have had that problem."

2 Give yourself plenty of time
Credentialing can take four weeks to six weeks - so you can't just have physicians giving you their completed paperwork at the last minute. But that doesn't mean you should take the completion of the application on, just to get it done on time.

"It is essential for the practitioner to have the burden of completing the application - not the [surgery center's] administrative staff," says Phyllis Adams Donaldson, Esq., a member of the healthcare law department at Dykema Gossett in Ann Arbor, Mich. "If this burden is shifted to the facility's staff, there is an increased risk that problem practitioners may fall through the cracks and that the facility may be held liable for negligent credentialing."

At the Harford County Ambulatory Surgery Center in Edgewood, Md., nurse administrator Linda Terzigni, RN, BSN, CNOR, organizes one credentialing meeting for all of her docs. "All paperwork has to be in for that meeting," she says. "If not, we send out a warning letter. The biggest hassle is getting all the paperwork in to prove that they have the credentials to perform whatever procedures they're requesting to perform. You need to be a bit of a detective."

Include in your surgeon's application form a clear timeline listing all pertinent deadlines, says Ms. Adams Donaldson. She also suggests you create a flow chart that includes documents and timing (such as state license renewal due one month before re-credentialing date) for yourself.

Your policies should require that you close the application file if a practitioner fails to complete the application in a timely manner, says Ms. Adams Donaldson. "A practitioner's inability to complete the application in a timely way may be a red flag for quality," she says.

3 Look into a CVO
Everything in an application for privileges - education, state licenses, malpractice records - must be primary-source verified. Doing all that on your own can be both overwhelming and time-consuming; if that's the case, credential verification organizations may be an option.

"I talked the administrator of a new center into using a CVO because there was no way, with everything else she was responsible for, that she'd have time for that," says Ms. Geier.

Verify that the application is complete, and that you have copies of state licenses and any other documents that need to be included, then send the packet to the CVO. The facility paid $125 per application (rush service costs an extra $30), Ms. Geier says. In a few weeks, you should know whether each doc checks out. Another tip from Ms. Geier: Use a CVO that's approved by your accreditation body, or it won't count come your next inspection.

4 Pick the right staffer
If you'd rather keep the process in-house so you have more control, assign the duty to the proper person. Ms. Lambert Gale suggests you add the responsibility of credentialing to someone's duties. For example, maybe your part-time infection control person could handle credentialing. Or in states that require radiology techs to operate the C-arm, you might not have sufficient volume to keep them busy, but they can manage your credentialing and re-credentialing files as a side project.

"Once you have the system in place, it's just a matter of keeping up with it and having reminders set up regarding when documents are due," says Jerry Henderson, RN, BS, CNOR, CASC, the executive director of the SurgiCenter of Baltimore, who has assigned her administrative assistant the task.

Regardless of whom you choose, it's important that you "get the most obsessive-compulsive person in your facility," says Ms. Lambert Gale. "It's a lot of detail: You have to check off every box and read every inch of every document."

While helping a facility review its records, she pulled the file of a physician who was prohibited from performing certain procedures until she had further training. "The physician had failed to disclose that, and the facility had failed to read it," says Ms. Lambert Gale. "Thankfully nothing bad happened, but it's an example of why you must read every document. It can be tedious, but you have to do it."

5 Use the Internet to your advantage
Credentialing is actually easier now that almost every resource you need for fact-checking has gone digital. Most states have put information regarding licensure and disciplinary actions on the Web. The National Practitioner Data Bank, AMA Profiles and OIG sanctions are also on the Internet.

Use the AMA physician profiles to verify medical education, residency, fellowships and board certifications. The price: about $26 per physician. "In my experience, you get the results within two hours," says Ms. Lambert Gale. One caution: Similar verification mechanisms are not available for foreign-trained doctors, so give yourself extra time.

6 Go to the source
Primary verification is the rule, but not all primary verification methods are created equal.

The most accurate source of a physician's malpractice insurance claims history is the malpractice carrier itself, says Ms. Lambert Gale. The National Practitioner Data Bank only records substantial lawsuits. But the carrier will, with a copy of the physician's signed release, provide a complete history of all pending and settled lawsuits, she says.

In addition, she recommends not just double-checking that the physician holds a valid license in your state, but checking on his licenses in all states in which he's practiced.

7 Watch for red flags
Here are six red flags that merit further investigation above and beyond regular protocols, says Ms. Lambert Gale:

• An incomplete application. Always give the physician the benefit of the doubt and give him a chance to fill in the blanks, but be cautious and extra-thorough with those parts of the application.
• Discrepancies in fact-checking. Again, give the physician a chance to explain why what he wrote doesn't match with what you found out. Then go back and do some more digging. If you really can't reconcile the discrepancies, it's grounds for denial of privileges.
• State-hopping. If it appears that a physician has moved from state to state without a good reason - such as multiple fellowships or residencies, or working in a metro area (such as Washington, D.C.) that might necessitate licensure in several states - that should tip you off that something might be amiss.
• Gaps in practice. Some are due to normal life events - a woman might have taken off time to raise children, for example - but others are cause for concern, such as time off to go into rehab. If that's the case, check the physician's DEA registration.
• Inordinate number of malpractice claims. Most everyone at some point will get sued. Be alert for those who've been sued frequently or for an event you might not expect.
• Unresponsive references. If a physician's references won't respond, it might be a case of "if you can't say something nice, don't say anything at all." In one instance Ms. Lambert Gale recalls, she twice sent requests for a letter of recommendation to a reference. After the second time, she asked the physician to ask the reference to respond. On the third try, she got a response: "I'd prefer not to."

8 Observe the surgeon in action
Ms. Geier recommends that peers in the applicant's specialty proctor a candidate as part of the credentialing process. It might be awkward to have to contact the administrator at a competing facility to coordinate the observation of a physician performing cases, but it will give you a feel for the physician that you just can't get on paper.

"See him do three shoulder arthroscopies, three knee arthroscopies - whatever he'll mostly be doing in your facility," says Ms. Geier. "A facility I know didn't do that, and they got a physician who takes 45 minutes and longer to do cataract cases."

9 Make it easy for your board
No matter who does the legwork, your board is the final arbiter on decisions to issue privileges, so make it easy for board members to make the right decision. Ms. Lambert Gale offers these tips: sticker everything that you want to make sure the board knows and compose a summary sheet for them with any red flags or discrepancies you've noted.

10 Delineate privileges
Grant privileges for specific procedures (carpal tunnel surgery) or a type of procedure (hand surgery), but not for a specialty (orthopedic surgery). Just because a physician is trained to perform laparoscopic cholecystectomies doesn't mean he can do them in your facility, says Ms. Geier.

"Make sure everything you're going to grant privileges for can be staffed, and that you have the equipment in your facility," she says.

Keep in mind that credentialing applies to advanced nurse practitioners, physicians assistants, even that scrub tech the surgeon brings from his office - anyone who comes to your facility whom you don't employ, says Ms. Geier. "You must be able to say that, to the best of your ability, you have verified that these people are fully qualified to practice in your facility," she says.

11 Keep two files
As a means of protecting the facility should you ever be sued, keep two ongoing files on all your docs: discoverable and non-discoverable information, says Ms. Lambert Gale.

In the discoverable file should be things like the physician's application and education - anything that could easily be public knowledge. Anything that would trigger a peer review should go in the non-discoverable file. Most states have specific laws protecting this information, so if you keep everything together, it increases the chance it will be brought out in court. There's no guarantee a pile of unfavorable patient-satisfaction surveys will stay out of court, but keeping separate files improves the chance they will.

12 Determine follow-up practices
Key to ensuring that problem practitioners don't slip through the cracks of your process is to have well-drafted documents governing your credentialing and privileging processes, says Ms. Adams Donaldson. Be prepared for mid-stream glitches. Know what happens when a doc's license expires during the term of a two-year appointment.

"If you fail to follow-up and confirm that the practitioner's license was renewed, you could end up having a practitioner with a lapsed license practicing at your facility, which would clearly violate accreditation and Medicare requirements," she says.

Your bylaws should set down the events that would set the peer review process in motion, as such incidents will be important to the re-credentialing process. Know what will go before the medical executive committee, and make the criteria specialty-specific if need be, says Ms. Lambert Gale. In ophthalmology, an inordinate number of unplanned vitrectomies or cases of endophthalmitis might be the cause, she says. What about transfers to the hospital? Returns to the OR?

Other factors to track: number of infections, number of adverse drug reactions, behavioral issues and whether the physician completes medical records within the identified timeframe.

Ms. Donaldson recommends that you also require each applicant for reappointment to complete an application form that updates all information supplied since the last appointment, including information as to any new malpractice claims and resolution of previously disclosed claims. In addition, you should re-verify key credentials, such as licensure, when processing the request for reappointment.

"You have to have an organized system, and everyone has to know how it works," says Ms. Henderson. "You need to be able to address issues as they go along - re-credentialing shouldn't be the first time you're hearing about a problem with behavior or clinical practice."