Were there a few credentialing errors in your last inspection? Don’t dwell on the mistakes, failure happens in accreditation inspections. It’s how you move on that determines your center’s success in the future.
Failed accreditations can happen for several reasons:
- There are holes in the infection prevention protocols
- The required safety equipments are missing or unusable
- The medical staff credential records do not meet the standards (this was the #1 ding in 2015 The Joint Commission inspections)
A big responsibility of credentialing coordinators is to have a successful and smooth credentialing record inspection. Even with time to prepare for the inspection and a given window, things may not always go as planned on the actual day.
The AAAHC inspector arrives and asks to review 10 credentialing records but due to a recent internal shift that left the center’s credentialing department in a mess, the files provided do not meet the standards. There have been scenarios in which the credential manager could only retrieve 8 out of the 10 files, or some of the providers had outdated state licenses.
It’s not the end of the world, but a corrective protocol must be in place to show that your center is taking notes on the credentialing errors and is making improvements. In this article, we’ll go over some best practices for moving forward from credentialing errors on your credentialing inspection.
You Need to Establish a “Corrective Plan of Action”
Successful healthcare facilities will swiftly and effectively implement required changes to overcome mistakes in their accreditation inspection. Following the first inspection, there needs to be a “Corrective Plan of Action” if your center is considered out of compliance with the standards.
A corrective plan of action is a formal plan that defines the problem, desired outcomes, and the tasks to be completed to achieve the outcome. The goal of the plan is to improve your center’s credentialing so that it meets the standards of AAAHC, The Joint Commission, etc. Some important details to include in the plan are:
The problem and pain points
- The desired outcome
- Necessary activity to resolve the credentialing errors
- Responsible individual(s)
- Resources needed to achieve outcome
- Constraints
- Metrics for each task or outcome
- Due date for tasks
- Notes
During the revisit, the inspector expects to see the center’s progress based on the plan. If it is successful, the credentialing department is expected to follow the same protocols moving forward.
Note: We’ll be releasing a Corrective Plan of Action template in the near future. Subscribe to our newsletter to be the first to know once it’s out! In the meantime, check out our available free resources.
Consistency is Key
Accreditation inspectors look for consistency in the credentialing process. Did your credentialing process stay consistent with the tasks in your corrective plan? Did you consistently record the verifications across all 10 files? Is everything dated and signed accordingly? All of these factors matter when the inspector revisits because they would rather see consistency, which is a sign of improvement.
Credential managers have found that inspectors are more forgiving when credentialing protocols are extremely consistent across every file inspected even when there are a few small errors. That is not to say that you should rely on consistency completely. As the credential manager, you should be making sure that all files are compliant in addition to maintaining conformity.
Start Your Credentialing Cycle Earlier
Maybe the last minute scramble didn’t work out for you because what was left to credential required much more time in reality. A great piece of advice is to start your credentialing process earlier because it creates room to fix errors or for unresponsive providers. Plus, there is no harm or risk in starting early.
Instead of contacting a provider about a document expiring in 30 days, push it forward and reach out to them 60 days in advance. You never know when the provider or their assistant may be out of office for extended periods of time… or if they take weeks to hear back from.
Starting the cycle earlier reduces inspection errors, especially if your current credentialing process has a slow turnaround time. It will also improve your relationship with certain providers because 5 phone calls spread through 3 weeks is better than 5 phone calls in a week.
At Silversheet, we believe that credentialing should be simple enough so that it becomes a year-round responsibility, rather than a rushed job right before the inspection time. Because our software makes maintaining compliant files an easier job, our customers have experienced a decrease in credentialing errors.
Establish a Quality Check Program to Catch Credentialing Errors
If you’re familiar with the process for building software, you know that quality assurance or QAing is crucial for creating any successful and function product. It’s how our engineers and product team make sure that Silversheet is a seamless credentialing experience for our customers.
Quality checking also works for credentialing. By creating a workflow that requires the credentialing individual or team to review credentials in the workflow, it adds another layer of safety to the credentialing process. It’s an effective way to catch errors or missing items before an inspection. After defining the problems behind the credentialing errors from the initial inspection, those tasks or items should be highlighted in the quality checking process.
We created a Credentialing Checklist that allows credentialing managers to check-off, date, and mark progress on individual files. The quality checking process can be as easy as reviewing the status of each checklist, or something more complex like going through the files completely. Our team wants credentialing to be as painless as possible, so we take quality checking very seriously. Users can use our dashboard to see what is expired, about to expire, or missing for individuals… or across the entire facility in our customizable reports.
If you’re reading this article, you might have failed a previous inspection, are worried about failing one, or maybe you’re just interested in the steps to recover from credentialing errors. Our biggest takeaway for you is to establish a bullet-proof credentialing process that yields a low risk of errors.
We’ve helped healthcare centers across the country pass their accreditation inspections in a breeze. Interested in what our software looks like and if it’s a right fit for your center? Schedule a quick live demo with us:
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