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Hardenbergh Group

Negligent Credentialing: Are You at Risk?


Every medical staff office, Credentials Committee, and Medical Executive Committee (MEC) responsible for renewing physician privileges.


Every two years, medical staff offices must complete a credentialing process to renew their physicians’ and surgeons’ hospital privileges. The credentialing process typically includes background checks, confirmation of continued Board Certification, validation that the physician has met Continuing Medical Education requirements, peer references, and other steps.

But these requirements may not be enough. A physician may be practicing below standard of care, but poor outcomes, concerning trends, or lack of current competencies have not yet been brought to light. If a negative event occurs, this could expose the hospital to claims of negligent credentialing – a serious threat with deep financial and other repercussions.


In addition to the minimum required verifications and validations, one of the best ways to ensure physician competence is to maintain a robust internal peer review process. Tracking individual physician performance metrics through Ongoing Professional Practice Evaluation (OPPE) and results of specific case reviews can verify current competency or raise a flag of concern.

Too often, hospitals fail to coordinate their credentialing process with peer review. It is essential that the internal peer review process regularly communicate its findings with the Credentials committee in order to support the validity of the MEC’s recommendations to the Hospital Board of physician privileging.

If your internal peer review process becomes compromised by conflicts, lack of expertise, or other needs for an unbiased review, external peer review should be your next step. An in-depth, detailed external peer review provides insight regarding the physician’s decision-making, care practices, documentation standards, communication with peers, and more. Such reviews offer clear validation that a physician is well qualified – or it may reveal a previously unidentified problem that needs to be addressed.


Failure to properly ensure physician current competency during the credentialing process can leave a hospital vulnerable to potential litigation. If a physician’s privileges are renewed without complete vetting, the hospital board, CEO, CMO, and other personnel can be held liable. If the credentialing process is deemed negligent, the legal ramifications can be catastrophic — both for the hospital as well as the responsible individuals.


Robust and transparent internal peer review, and external peer review when indicated, should be considered essential steps in the physician credentialing process. Particularly if there have been any questionable outcomes during the prior year or two, or any hints of a concerning trend, the medical staff office should include external peer review as a routine part of its efforts to assess the physician’s qualifications.