Question

Prepare a email to Ms. Williams summarizing the key deficiencies, proposed solutions, and an assurance that the deficiencies will be permanently resolved.

Using the case study below:

You are the Credential Manager for Weeping Willow Medical Center. Recently, the Credentialing Department underwent a routine compliance audit whereby a random number of credentialing files were pulled and reviewed. When the report of findings was released, the following deficiencies were noted.

In early 2018, the Medical Staff Coordinator (MSC) did not follow the facility's policy to issue a 60-90 day preliminary notification to three providers that their privileges were due to expire in the coming months. As a result, three psychologists’ privileges lapsed.

One physician was privileged 5 weeks before the Medical Center Director (MCD) signed, dated, and approved the action.

One physician was privileged to perform bronchoscopies 2 months before the MSC received documentation of his experience and competency.

Two physicians were privileged to perform conscious sedation even though the Anesthesiology Director had not signed the approval forms.

Several physicians, due to staffing shortages, have been brought on board with incomplete credentialing files (to be completed at the earliest possible date).

We also found that the Acting Medical Director inappropriately signed, dated, and approved the March Professional Standards Board minutes for the Medical Director and for the Medical Center Director to renew the privileges of the Medical Director, who only occasionally sees patients.

The organization has frequent lapses in credentialing and re-credentialing staff. These are just a few instances.

Answer 1

Hello Ms. Williams, Hope you are doing good. I feel very privileged to write about few concerns of our Weeping Willow Medical Centre in regard to the credential department. As a concerned manager for the department I would like to maintain the standards I terms of compliance. On my random audits I found few concerned few deficiencies which were summarized below. S.No. Summarized deficiencies Identified Incident occurred in 2018: The due privileges of 3 psychologists were lapsed as Medical Staff coordinator did not issue preliminary notification. One physician was privileged 5 weeks before the approval and signature of Medical centre director and the other privileged to perform two bronchoscopies before Medical staff coordinator receiving documents of his experience and competency. 2 physicians were privileged to perform conscious sedation with out approval of anaesthesiologist. 4. Several physicians were on boarded with incomplete credential files and also acting medical director in appropriately signed minutes to review the privileges. I have few proposed solutions :

• Hiring process must be screened with proper subsequent standards and levels with the most honesty panel. Privileged standards and policies must be reviewed with a standard professional panel. Encourage the employees with annual rewards and recognitions. • Bi-annual appraisal system must be implemented. In the permanent continuous growth of the standards in the facilities, I can definitely assure the above proposals will better increases the standards of our credential department. I can also assure you that I take complete responsibility of things and will prove my self trying hard in all terms as a credential manager. Need your continuous encouragement, guidance and support. Regards, Name Credential Manager, Weeping Willow Medical Centre.