J Dent Educ. 70(6): 636-643 2006
© 2006 American Dental Education Association
Critical Issues in Dental Education |
Faculty Credentialing: A Survey of Forty-Six U.S. Dental Schools
Ronnie Myers, D.D.S.;
Angela J. Yoon, D.D.S., M.P.H., M.MSc.
Key words: dental school faculty, health professional credentialing, credentialing protocol
Submitted for publication 12/28/05;
accepted 03/12/06
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Abstract
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This study was undertaken in June of 2005 to evaluate the status of credentialing of clinical faculty in United States dental schools. A short survey on the process of credentialing was developed and emailed or mailed to all clinical deans. The survey contained a standard definition of health professional credentialing to which the respondent was to compare his or her school’s procedures. Of the forty-six respondents, only 46 percent were conducting credentialing as defined on the survey. Recredentialing of clinical faculty was occurring in most of these schools; however, 23 percent did not report a process of recredentialing. Each institution required different items in its credentialing application: 95 percent required information on licensure; 86 percent, educational background; 67 percent, academic appointments; and 67 percent, specialty board status, among other items that were included at lower rates. Health status was only requested by 29 percent of the institutions. Only 34 percent of those institutions doing credentialing verified the data collected during the application process. Given the legal implications of adverse outcomes, prudent risk management calls for a strong credentialing program. Results of this survey indicate the need for an ongoing effort to standardize credentialing procedures among dental schools and to select appropriate data to be included in the process.
According to an article in the New York Times on April 17, 1996, a chief physician at a prominent health clinic in New York was discovered to be someone who never attended medical school and whose only formal training in a health-related field was a bachelor’s degree in pharmacology.1 In the New York Times on January 14, 2001, an article entitled "The Great Pretenders" reported on the large number of imposters living in New York City and revealed that the pretender professions of choice, in order of popularity, were medical doctors, registered nurses, massage therapists, pharmacists, and dentists.2 This problem is not limited to the health care professions. A New York Times article on December 15, 2001 revealed that a major college football coach had exaggerated his accomplishments as a football player at the University of New Hampshire and falsely claimed to have earned a master’s degree in education from New York University.3
Cases like this are reported in the news because they are rare. It should be recognized that the overwhelming majority of practitioners are highly skilled, well qualified, and able to deliver appropriate health care. However, credentialing is necessary to identify the few practitioners for whom appointments or privileges should be denied or limited if the privileges requested go beyond their level of training and experience. Time and expense make the credentialing process challenging. Nevertheless, these difficulties are preferable to what can occur as a result of an adverse patient outcome. In addition to the human consequences, the institution could have significant liability exposure.4
Health care organizations are becoming increasingly aware of the importance of credentialing health care providers to protect patients and the organization. While no generic definition exists, credentialing has been described as a complete review and verification of all applicable documents including the specific skills that the provider possesses in order to determine if that individual will be authorized to teach, supervise, or practice particular procedures.4–8 While the efficacy of credentialing has not been formally evaluated, the strongest argument for credentialing is improved risk management.9 The parent organization is responsible for provider assessment and verifying the provider’s previous training and experiences and ultimately is liable for any adverse events attributable to its clinical staff.9 In this sense, credentialing improves clinical care and is one protective measure the organization can take to reduce exposure to adverse events and malpractice liability.
Physician credentialing has been a part of administrative protocol at hospitals, nursing homes, and managed care organizations for many years. However, a comprehensive credentialing process is not routine at dental schools. A noticeable difference between medical and dental education is that clinical medical education predominantly occurs in the hospital setting, while clinical dental education primarily takes place in university-operated clinics. Physician educators, as hospital-appointed medical staff, are required to be credentialed. No such requirement exists for dental educators within the university.4
Consequently, the goal of the survey was to assess the procedures used for the credentialing of clinical faculty at U.S. dental schools.
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Materials and Methods
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A brief survey consisting of seven questions was sent via email in June of 2005 to the clinical deans of the fifty-five U.S. dental schools. (See Figure 1
.) The following definition was provided on the questionnaire: credentialing is "a complete review and verification of all applicable credentials and a review of specific skills the faculty possesses in order to determine if they will be authorized to teach, supervise, or practice such skills." Questions on the survey were directly related to this definition. The first item asked if dental schools were requesting clinical faculty to complete a credentialing and privileging process. If there was a positive response, the clinical deans were asked how long their institution had been conducting this activity and how often recredentialing was performed. The next question asked who directs this activity. The final questions asked about the types of data collected, who verifies the information, and whether they consider credentialing to be an important activity.
If the email questionnaire was not successfully delivered (i.e., the email was returned), a survey was mailed to the clinical dean. If no response was received, second, third, and fourth surveys were sent either by email, where possible, or by U.S. mail. Consequently, responses were received by email, fax, and U.S. mail.
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Results
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Table 1 provides a summary of the responses to each of the seven questions. A total of forty-six responses (84 percent) were received. Of the forty-six responses, twenty-one (46 percent) indicated that the institution performs credentialing of clinical faculty as defined. For schools that perform credentialing, 43 percent have been performing this task for less than ten years (with a range of two to ten years), while 57 percent have been credentialing for more than ten years.
For those institutions that credential, 77 percent have a mechanism for recredentialing, and 23 percent do not. Of those that recredential, 42 percent do so every year, 29 percent every two years, and the remaining 29 percent every three years or more. For dental schools that credential, this activity is managed by different offices and individuals, including the associate dean and staff (43 percent), department chairman’s office (38 percent), the Office of Clinic Administration (33 percent), and others (14 percent). The sum is greater than 100 percent owing to multiple responses by some schools.
Wide variation exists in the credentialing data collected by dental schools in the United States. Most institutions require information on licensure (95 percent), educational background (86 percent), academic appointments (67 percent), and specialty board status (67 percent). Only about half of those schools collect information on DEA (Drug Enforcement Agency) registration (52 percent) and hospital appointments (48 percent). Forty-two percent requested references, and health status was collected by 29 percent of schools. An important aspect of the credentialing process is a review of the practitioners’ specific skills they will be authorized to teach, supervise, or practice. This is known as delineation of privileges and was requested by 33 percent of those dental schools that perform credentialing. Nineteen percent reported that they requested faculty to provide information on participation in continuing education.
Surprisingly, 66 percent of schools performing credentialing did not verify the accuracy of the information that was collected. Verification is a process by which the data collected is investigated using a primary source (direct contact or an outside agency). Eighty-five percent of those verifying the information reported that they directly contacted each source, while 15 percent used an outside agency.
Lastly, while only 46 percent of the respondents reported the existence of some form of credentialing, 100 percent of the schools responding to this question either strongly recommended (75 percent) or recommended (25 percent) the process of credentialing clinical faculty.
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Discussion
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Typically, in health care institutions, a standing committee of the professional board or medical board is responsible for the credentialing process in accordance with the institution’s bylaws, rules, regulations, and policies. This committee expedites the credentialing and recredentialing process. Such a committee can include clinic administrators, department chairs, faculty, and staff members. The governing body, i.e., the professional board, should retain the ultimate authority to render the final decision on staff appointments and privileges. That decision must not be arbitrary, capricious, discriminatory, or contrary to the bylaws.6 Membership on the professional staff or clinical faculty is a privilege and shall only be extended to practitioners who can demonstrate clinical and academic competence and good character and who continuously meet the qualifications, standards, and requirements of the institution. Professional staff are notified about the application process for appointment, reappointment, and the granting, renewing, and revision of clinical privileges. A written agreement clearly defines the bylaws for the participant. Most commonly, recredentialing and renewal of privileges occur every one to two years.7
The criteria for professional staff membership and clinical privileges are specified in the professional staff bylaws. These criteria help establish the applicant’s background and current competence and verify physical and mental ability to discharge patient care responsibilities and ensure that patients receive quality care from providers who are credentialed in their profession.4,6,7
A review of the pertinent literature outlines the core information essential to establishing and maintaining a qualified and competent staff. Items that are commonly recommended include but are not limited to the following:
- Current licensure: Verification of current licensure is obtained directly from the appropriate state licensing board, along with any challenges to licensure or registration or voluntary or involuntary relinquishment of such licensure or registration. DEA (Drug Enforcement Agency) and specialty board status may also be included.6
- Educational background: Relevant educational background is verified by copies of diplomas and letters from professional schools, residency, or postdoctoral programs and previous academic and/or hospital appointments.6,8
- Current competency: Competency assessment can be obtained from references. The individuals listed as references should be personally acquainted with the applicant’s professional and clinical performance, either in the context of a training program or as the member of the staff of a clinic or hospital. Continuing education should also be included as part of the review process.6,7
- Clinical privileges: Clinical privileges that are requested must be included in a delineation of privilege form, which is confirmed and signed by the provider’s clinical division chief or department chair. Privileging ensures that the patient care delivered by the clinician is within the parameters of that clinician’s current professional competence.4,7,8
- Health status: Health status must be documented to ensure that there are no health problems that could adversely affect the clinician’s ability to practice.
- Liability: Information on voluntary or involuntary termination of professional staff membership and/or voluntary or involuntary limitation, reduction, or loss of clinical privileges should be collected.6,8
After all the requested information is collected, the parent organization must verify the information from the primary sources. Acceptable means of verification include directly contacting each source, obtaining letters or computer printouts, or verification through a primary source Internet site and/or by telephone.6 Submission of a copy of a license or board certification does not mean it is valid. The parent organization must ensure that the practitioner is truly certified for the requested privileges.8
In addition, verification may be accomplished with the use of outside agencies (known as designated equivalent sources), which maintain specific information identical to the information at the primary source. Two examples of such designated equivalent sources are Medical Verification Solutions (www.mvshome.com)10 and Credentialing Solutions (www.credsolutions.com).11 Use of these agencies can reduce paperwork and streamline workflow so that initial and subsequent credentialing is efficient, consistent, and accurate.6,8
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Credentialing Process at Columbia University School of Dental and Oral Surgery
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In 1996 the Columbia University School of Dental and Oral Surgery established a not-for-profit corporation to administer the operations of its dental clinics. Known as Columbia University Health Care, Inc. (CUHC), the entity was required to establish professional staff bylaws, rules, and regulations. These bylaws, rules, and regulations established a procedural outline for credentialing that identified specific core data to be collected.
1. Setting Standards of Credentialing
The standard items selected for credentialing were included in the CUHC professional staff bylaws, rules, and regulations. The delineation of privileges document was created with input from each clinical division within the school. The items in the credentialing process represent the minimum standards that must be met by the applicant.
Clearly delineating what is or is not acceptable for clinical appointments before the implementation of the credentialing process was paramount. Included in the application package is an acknowledgment form that clearly defines the importance of the credentialing program and the organization’s dedication to its implementation, as well as the importance of submitting the required accurate information in a timely manner. Applicants are required to sign and date the form, signifying their understanding of the process and their obligations.6,8,12
2. Selection of Requested Information
Verifiable information contained in a detailed and complete credentialing application is critical to the success of the process. The school’s application requested the following information:
- Licensure information: A New York State license or New York State limited teaching permit (which may be obtained if an out-of-state license exists) and DEA number (if applicable). In addition, the applicant is asked if he or she has a license in another jurisdiction and if his or her license to practice has ever been or is in the process of being investigated, suspended, or revoked.
- Education: Proof of baccalaureate degree, professional degree, and postdoctoral degree or other postdoctoral training (if applicable) is requested.
- Professional career: All university and hospital (past, present, and pending) appointments and promotions.
- Specialty board status (if applicable): Membership in all applicable professional societies (past, present, and pending).
- Continuing education: The applicant is to list all applicable continuing education programs attended over the past two academic years.
- Health evaluation: A health evaluation by a physician, which includes vaccination with antibody titers, PPD, and tetanus inoculation, is required.
- References: Each applicant is requested to list two individuals as professional references who have knowledge of their current clinical abilities, ethical character, and ability to work with others.
- Delineation of privileges: Each privilege requested is one in which the applicant is attesting clinical competence and educational training. Privileges requested outside the applicant’s discipline must be approved by the appropriate division director.
- Nomination for appointment: The application for appointment (known as a nomination) is completed by the applicant and submitted to the appropriate division director.
- Statement of confidentiality: All professional staff upon application must sign the statement of confidentiality in which they agree to hold all patient information in confidence.
- Consent and release form: This form is signed to extend immunity, to release any and all liability, and to agree not to sue Columbia University for activities in the application and credentialing process.
- Statement of acknowledgment: Signed by the applicant acknowledging the accuracy and completeness of the submitted information.
- Billing compliance training attestation: All professional staff must participate annually in the university billing compliance program. Before a credentialing package is complete and reviewed, the applicant must read the policy guidelines and agree to abide by the principles of the billing compliance plan.
- Infection control training attestation: Members of the professional staff are required to have completed an approved infection control course within the last four years.
- Curriculum vitae: A current curriculum vitae must accompany all applications.
3. Verification
Verification of the submitted information is a crucial step in the credentialing process. The organization must contact the original source and obtain confirmation of the submitted information. Verification can be by letter, Internet, telephone, fax, or other acceptable means of communication.6,8,10 Because of the time-consuming nature of the verification process and the complexity of source-specific rules and procedures, CUHC hired an individual to coordinate the credentialing process. Approximately 25 percent of her responsibilities are devoted to the credentialing process. Verification of references, education, and training is managed by mail contact. Licenses are verified by online Internet access using the New York State Office of the Professions website.
4. Evaluations and Action
Once the application has been completed and signed, the applicant’s division director must review and approve the requested privileges. The completed application package is then forwarded to the standing Committee on Appointments of the Professional Board. This committee reviews the application, specifically requesting assistance from the applicant’s division director if needed. Once reviewed, the committee’s suggested actions are then presented to the Professional Board of CUHC. The board then makes recommendations to the CUHC Board of Directors. The CUHC Board of Directors reviews the Professional Board’s recommendation and informs the applicant of its action. The bylaws of CUHC have methods of appeal in the event that privileges are denied.
5. Periodic Recredentialing
A recredentialing process to assess the faculty member’s performance over time and identify any credentialing changes was also instituted to determine continued appointment and privileges.8,9 In the recredentialing process, the candidate is supplied with all of the previously submitted information. All expired documents must be updated and verified along with the submission of a new health status document. The application is reviewed by the Committee on Appointments, who will then make their recommendation to the Professional Board. This is accomplished every two years. In addition, an internal system that can simultaneously manage data and workflow common to different divisions, schools, and hospital departments was required for the timely and cost-effective processing of applications.
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Conclusions
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The results of this survey suggest that credentialing at dental schools in the United States is neither standardized nor is it viewed as essential. Less than half of the responding dental schools credential their faculty, only one-third of those delineate teaching privileges, and only one-third verify the collected information. Less than 30 percent review health status.
Dental school clinics have been described as dental hospitals. An ongoing effort to standardize credentialing procedures and to select appropriate data to be included in the credentialing process is therefore needed. As the volume of patient care increases, the governance and compliance of dental school clinics must be comparable to other large health care facilities. In addition, given the legal implications of adverse outcomes, prudent risk management calls for a strong credentialing program.
Lack of participation in the credentialing process by a large proportion of dental schools in the United States necessitates further discussion and review. A dialog is needed that considers the effectiveness of credentialing and the cost-benefit ratio, as well as different approaches dental schools might take, including partnering with other members of their health science campus.
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Acknowledgments
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The authors would like to thank Dr. Ira B. Lamster, Dr. Allan J. Formicola, and Dr. Robert Lewy for their support and insight into the development of such an important course of action and Ms. Carolyn Emeric-Wilmoth for her dedication to the process.
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Footnotes
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Dr. Myers is Associate Dean for Clinical Affairs, Columbia University College of Dental Medicine; Dr. Yoon is a third-year resident in Oral Pathology at Columbia University College of Dental Medicine and the New York Presbyterian Hospital in the City of New York. Direct correspondence and requests for reprints to Dr. Ronnie Myers, Associate Dean for Clinical Affairs, Columbia University College of Dental Medicine, 630 West 168th Street, New York, NY 10032; 212-305-5199 phone; 212-305-2964 fax; rm36{at}columbia.edu.
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REFERENCES
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- Crow K. The great pretenders. The New York Times, January 14, 2001.
- Fountain JW. Notre Dame coach resigns after 5 days with a few lies. The New York Times, December 15, 2001.
- Payne DE. Credentialing and privileging ensure skilled care. Nurs Management 1999;30:8–10.
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- Joint Commission on Accreditation of Healthcare Organizations. Comprehensive accreditation manual for hospitals. Chicago: Joint Commission on Accreditation of Healthcare Organizations, 2000.
- Cooper E. Credentialing and privileging nurse-midwives. J Nurs Care Qual 1998;12(4):30–5.[Medline]
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- Hernandez AM. Trends in health care practitioner credentialing. J Health Care Finance 1998;24(3):66–70.[Medline]
- Medical Verification Solutions. At: www.mvshome.com. Accessed: March 6, 2006.
- Credentialing Solutions. At: www.credsolutions.com. Accessed: March 6, 2006.
- Schachter W. The role of provider credentialing in quality-of-care improvement and clinical risk reduction. Behav Healthcare Tomorrow, July/August 1995:1–73.
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Abstract
Materials and Methods
