Credentialing: Supporting Clinicians, Protecting Patients

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Credentialing plays a critical role in patient safety — but it can also affect whether clinicians feel safe seeking mental health care. In this episode, leaders from Michigan Medicine and the Dr. Lorna Breen Heroes Foundation discuss evolving credentialing practices, reducing stigma and supporting clinician well-being while protecting patients. The conversation highlights how thoughtful policy changes can help create a healthier, more compassionate health care system.

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Dr. Lorna Breen Heroes’ Foundation

Transcript

Dr. Liz Harry:

Welcome to today's episode of Well-Being at Michigan Medicine Podcast, where we will talk through the process of credentialing in health care. I'm Dr. Liz Harry, and I'm excited to be joined by Dr. Stefanie Simmons, the Chief Medical Officer at the Lorna Breen Heroes Foundation, emergency room physician and Michigan alum times three, undergraduate medical school and resident graduate, and a proud now Michigan mom of two, so deep roots. Dr. Nik Theyyunni, chair of the credentialing committee and associate chief of staff, also emergency room physician. And Amy Brant, an administrative director of medical staff services and RN, and all leaders passionate about creating a better, safer health care environment.

Today we'll unpack what credentialing really entails, explore clinicians' mental health concerns on disclosure and talk candidly about privacy, stigma, and ongoing advocacy. You all, thank you so much for joining me today.

Amy Brant, RN:

Happy to be here, Liz.

Dr. Nik Theyyunni:

Super excited to chat.

Dr. Liz Harry:

All right. Well, Dr. Theyyunni and Amy, can you tell us about what credentialing is and about the intention of the process in general? For those of our listeners that might be like, "Why are we even talking about this?" What is it?

Dr. Nik Theyyunni:

Yeah, I think let's zoom all the way out. Everything we do in health care is in some way we want to help patients and in the process of doing innovative and cool things to help patients, we want to keep patients safe. And at the same time, we want to make it as easy as possible for doctors and nurses and everyone else in the health care system to do those things. And so you can imagine, I don't know if you're, this may be dating me, you can imagine I'm just a bill for I'm just a file. And so you decide you want to work at a hospital. Cool. The hospital has to confirm that you're a doctor and they have to confirm that you're a good doctor and the kind of doctor you are, where you went to medical school, where you completed your training, and that you can do the kinds of things you want to be able to do to take care of patients. And that process of verifying who you are and what kind of practice you can have, that's credentialing.

After they do that, they can say, "And based on the credentialing we've done, here's the kind of medicine you can practice, what you can do to patients." The things you're allowed to do to patients are the privileges you hold. So the group that manages that process, that works for the hospital, is medical staff services. They're the group that kind of manages the process of what kind of credentialing happens, what kind of privileges doctors can hold. And at the same time, that process needs to have doctor's voices and the group of doctors that works not for the hospital, but for the medical staff, the doctors that work at the hospital, is the credentialing committee that then reports to some sort of governing body for the hospital, which for us we call ECUP, and many places is like a governing committee for the hospital. And we, I chair the committee that does that credentialing, work with medical staff services to make sure that we try to keep that process as safe for patients, but also as painless for clinicians as possible.

Dr. Liz Harry:

And give me just a little bit of nuts and bolts. So a provider does this when they're joining, and then with what regular cadence?

Dr. Nik Theyyunni:

Yeah, actually that's a new and changed thing since we've started talking about this. And so everything we do, I said, is to keep patients safe or to do innovative things. To do both those things, there's a bunch of regulatory requirements. And so one of the bodies that manages those regulatory requirements says that we have to do this when you start to work at a new place, because that new place has to verify what you can do. And then on some sort of regular cadence, has to reappoint or reconfirm that you can do those things. And so we used to do that every two years, now we can stretch that to up to every three years.

Sometimes we do it more frequently than that if there's stuff we have to watch out for, but usually we want to move towards that three-year cadence because again, as painless as possible for clinicians.

Dr. Liz Harry:

Great. Thank you. And Dr. Simmons, Steph, what did the data show about health care workers' perceptions of the credentialing process regarding mental health care? And could you tell us a little bit about Dr. Lorna Breen Heroes Foundation and the work you all do to preserve privacy around mental health care?

Dr. Stefanie Simmons:

Sure. I'll start with the history of the foundation and why this was elevated as an issue to us. So the Lorna Breen Heroes Foundation, we're actually just entering our sixth year. We were started in the summer of 2020 after the death by suicide of Dr. Lorna Breen, an emergency medicine physician, medical director at New York Presbyterian Allen Hospital in Manhattan. She had come back from vacation to care for patients in the first wave of the pandemic, and like many health care workers, worked long hours, 18 hour days caring for her community, but also for her team, trying to make sure that her team had PPE, had care guidelines available to them. I think we all have some visceral memories of what those first weeks were like in March of 2020. Lorna got COVID, she got quite sick with COVID. And when she came back to work, again, to those 18 hour days, 24 hours after her fever broke, like so many did, she was exhausted, physically exhausted, mentally exhausted, emotionally exhausted.

And her friends from residency, from medical school really evacuated her by car. There was still no air flights, right? Back to her home in Charlottesville, Virginia where she received mental health care. And she was very burdened after she was discharged from the hospital that the fact that she had received mental health care, that she had become unable temporarily to do her job, meant that she would be at risk of losing her license, losing her hospital credentials, losing her leadership position, and she expressed this to her family. And sadly, Lorna died by suicide. Now, what happened next about 12 hours later was that the New York Times published an article about her death. And first dozens, and then hundreds, and then thousands of health care workers reached out to, first, Lorna's family, and ultimately to the foundation that was started in her name, expressing that Lorna is not alone with these concerns, that questions on licensing, credentialing, applications, payer forms, malpractice insurance, disability insurance, really have a chilling effect on health care workers' willingness to seek mental health care when and if they need it, and their concerns about what that will mean for their career afterwards.

So along with the Federation of State Medical Boards, the AMA, the ANA, the AHA, it's like the whole A team, and making sure that we were consistent with best practices from credentialing and regulating organizations for hospitals, health systems, and states across the country, we put together a series of best practices for state licensing boards and hospital credentialing and peer reference forms that eliminate questions about a past history of diagnosis or treatment for mental health conditions. And in order to recognize organizations and states that meet all of those criteria, we developed the Champions Challenge badge.

Dr. Liz Harry:

And tell me a little bit about how that's gone and what sort of uptake you've seen and where you are now. Where are you guys looking towards next?

Dr. Stefanie Simmons:

Yeah. Well, I think one of the things we did early on was we formalized this anecdotal evidence that we were receiving from health care workers by doing a survey of physicians, nurses, nurse practitioners, and PAs about what their perceived barriers to receiving mental health care were. And the number one barrier was actually cost and time. Depending on your income, cost became more or less important, but time was universally problematic because there's not many health care workers who can keep a standing 3:00 PM, Thursday afternoon appointment, right? That's just not really in our purview. The second barrier was stigma, and that was in the form of what we think our colleagues will think about us and in the form of institutional stigma in terms of how questions about mental health care and substance use disorder care are used in our institutions.

So when we first did a survey of state medical boards across the country, we also, since then have looked at nursing, pharmacy and dentistry, by the way, there were only 17 states that were consistent with identified best practices. This was back in 2022. And at that point, Michigan was already identified as a best practice state for the medical board for medical licensing. Since that time, we've gone from 17 states being consistent with best practices for medical boards, to 43, and three additional states that are in progress right now of making those changes. So it has really been a national change in how these questions are asked in state medical boards.

We are also seeing adoption of these best practices in pharmacy, nursing and dentistry boards, so that there are over 70 boards across those four areas that have adopted these changes. We also have been doing these reviews and recognition for hospitals, health systems, and clinics. When we started this, there were zero who had been reviewed and validated, and now there are over 2000 across the country and growing. So that ranges from large health systems, private health systems, academic health systems, small medical groups, employers, really looking at their applications and making changes. And even more, I would say, making changes that are in the spirit of improving access.

Dr. Liz Harry:

Well, and what I love about what you're both saying is the service spirit behind it, right? So Nik, you really nicely outlined the purpose of credentialing, and specifically, and just to put a sort of finer point on it for our listeners, credentialing is at the hospital or health system level, licensure would be at the state level, Steph, you were talking about both in this circumstance, and a lot of times they mirror each other very close to one another. And Nik, you did a really nice job sort of explaining the goal to protect the patients. And then Steph, thank you for sharing what a powerful story about Dr. Breen and her experience and then the experience of all the health care providers that reached out to you. And I think inherent in this discussion and why I think this discussion is great is this, how do we meet both?

How do we keep our patients safe and make sure that we are making sure that the people that are caring for them are safe to do so in that moment, and how do we create an environment that allows providers to feel safe receiving care? And so Steph, if I can ask you a little bit to riff a little bit on the nuance around current impairment and why that's important to try to strike this balance.

Dr. Stefanie Simmons:

Yeah, absolutely. So I think it's actually really helpful to look at the history of some of these questions because this section on the licensing application and on many credentialing applications used to be called the moral fitness section. And there were questions like, "Have you been convicted of a felony? Are you a pedophile? Have you ever been diagnosed or treated with a mental health condition?" And it's like, wow, one of these things is not like the other, right? Being diagnosed and treated with a mental health condition is no different than being diagnosed or treated with a physical health condition. Both can be chronic, both can be potentially impairing, but we only ask about one because of the history of viewing mental health and substance use disorders through a lens of morality as opposed to of health. On the one hand, we want to make sure that we are not differentially stigmatizing mental health and substance use disorder. On the other hand, we want to make sure that health care workers are able to perform their duties in a safe way for patients.

And so rather than eliminating a question about impairment altogether, we encourage organizations and we recognize organizations who move from a look back question about diagnosis or treatment, or even a question about current treatment, and focus instead on a question about current impairment for any reason, be that physical health impairment, mental health impairment, substance use disorder impairment. We know that you can have a chronic condition without impairment. In fact, most people will, at some point in their life, have either a substance use disorder, or mental health or a physical health condition that can become impairing. And so by focusing on a single question about all cause impairment, we are making sure that we have a safe clinician population, but we are also not stigmatizing diagnosis or care because patients are safer when health care workers are getting diagnoses and care for the conditions that they have.

Dr. Liz Harry:

Yeah, that makes a lot of sense. And actually, it's sort of the ideas that it kind of strikes the balance. So part of what I love about this is that so much of the spirit of this is in care, and it is in seeking health care and making sure that our patients that seek health care are getting the best care that they can, and that the people that are caring for them are as healthy as can be because they're getting the care that they need. And so really trying to figure out how do we set this process up to ensure that. And Nik and Amy, I know that Michigan's done a lot of work in this space and has a long history here. Can you tell us a little bit about what's been done and the history at Michigan Medicine?

Dr. Nik Theyyunni:

Am.

Amy Brant, RN:

I would like to start by saying a big thanks to our predecessors in this work. As this work began many years ago, back in 2018, they had the foresight to start reviewing our disclosure questions and making modifications to make sure that they were supportive of our clinicians. So some of the changes that were made were really to try to really get at current conditions that may be impacting, and then really focusing around the mechanisms of support for our clinicians if there were to be a yes disclosure on a question.

So questions related to health recovery programs, whether in Michigan or outside the state, if there happens to be a yes response, making sure that there was appropriate support for that clinician to get the care they need within Michigan.

Dr. Nik Theyyunni:

Yeah. I mean, I want to riff on this concept, which is that the point of responding to a disclosure with yes is so that we can take care of our doctors the way we take care of our patients. A colleague of mine had shoulder surgery on their left arm. As an emergency physician, there are procedures you need your left arm to be able to do. And before we return them to practice where they might be unable to do something that was important for them to be able to do their job, we made sure that as part of their health care, that they were back to full strength, able to do the work they want to be able to do to take care of patients. Mental health care is not different than the physical health care. And so as you have something that you want to receive care for, we want you to be as encouraged as possible to get care. And as you get care, we want to be able to support you so that you can safely take care of others.

And this is our way of entering you in the system so that we can keep support as you take care of yourself so you can take care of everyone else. Actually, the reason that this is in the place it is in our disclosure questions is kind of way predating the lack of stigmatization around this because Michigan Medicine has a really long history of supporting clinicians with mental health or substance issues. And I can think of physicians at the institution who, going back 20 plus years, have been able to be supported through new diagnoses and through treatment and are still providing amazing care today. Some of them are even mentors of mine. So I think it's really important for us to say that the history of this at Michigan has always been one of supporting doctors, not just finding diagnoses.

Dr. Liz Harry:

And so, what is the future of this? Where are we going? It feels like this is a field that has evolved, it feels like at Michigan, there was a lot of conversation about this early on, and very understandably and tragically, the COVID pandemic really brought this conversation to a forefront. You guys live in this space. Where are we headed and what are you excited about in the space of credentialing and licensure? Maybe Steph, I'll start with you.

Dr. Stefanie Simmons:

Yeah, thank you. Well, first I'm excited for every state licensing board to have questions about past diagnosis and history removed from the licensing applications. We're just around the corner from that. I mentioned earlier that Michigan has always been consistent. There's actually a house bill right now in Michigan active to codify those already excellent questions so that people can not only be sure that their mental health care is private, but that it will remain private in the future from their licensing perspective. I love the perspective of care and making sure that we're wrapping our arms around clinicians who are experiencing human events in their lives. More organizations, more employers need to adopt that perspective because it is not universal. And so as we are increasingly recognizing that health care is human, on both sides of the equation, the patient side and the clinician side, I'm looking forward to seeing increasing resources for health care workers as they go through their lives, and their very human lives, and also, frankly, storytelling because even where the processes are supportive, there's not always an open conversation about what that looks and feels like to individuals.

So for instance, when we ask health care workers whether they think they will be negatively judged for receiving mental health care, 60 to 70% of health care workers say, "Yeah, my colleagues would negatively judge me." But if you ask people, "Would you negatively judge someone?" Fewer than one in 10 say yes. So what that means is there's a perception gap between what I think you think and what you think, right? And we are going to assume the worst because that is a rational, like an economically rational assumption, but it's not necessarily reality, right? So the more that we can surface the real support and trust that our colleagues feel for us, the better. So storytelling is another area that I'm interested in seeing grow.

Dr. Liz Harry:

I love that health care is human line. I'll just tell a really, really short anecdote. I had to cancel clinic because I got a GI bug, and then I ended up seeing the patient that I had to reschedule a couple weeks later, and I said, "I'm sorry, I had to reschedule. I was sick." And she, with a complete straight face, said, "I've never had a physician be sick before. That was so strange." And I said, "Well, we're human too." And I sort of felt odd having to explain that we get GI bugs too and all the things happen to us just like everybody else.

Dr. Stefanie Simmons:

And we're parents and children and siblings and we develop mental health conditions and physical health conditions and substance use disorders. And we are also spending our lives dedicated to caring for others.

Dr. Liz Harry:

Yeah.

Dr. Stefanie Simmons:

Yeah. Human in so many ways.

Dr. Liz Harry:

Yeah.

Dr. Nik Theyyunni:

I kind of want to come back to that perception gap that you talked about earlier. One, this is one area where I think the children will save us, which is that I have some residents who are like, I think, a younger generation that I am now, and I'm coming to terms with that along with my gray hair slowly. But I do feel like they're a lot more open and a lot... I would say that they're open with how much they don't stigmatize mental health care, and that is an attitude I've been trying to steal. But I also think that perception gap exists for trainees and for young doctors and for doctors in general in lots of things. Actually, one of my favorite anecdotes from training with Steph Simmons many years ago is that we had a very sick patient where I did a procedure and I stuck myself with a needle, which is like not a thing to be proud of, but a thing that if you do this long enough, will happen to you. It just happened to me like almost my first day.

And my first impulse was, "I should hide this because it's definitely not a thing that will make me well-liked or thought of as positive." And Steph definitely saw and made it very normal, and talked me through it, and said I was going to be okay, and gave me a hug. And I hope that we can bring that attitude from our interpersonal interaction, but also to what we think of when we think of how we manage administration in our health care system. And so that's the hope for what we want to do when I think about what I'm excited about for the future, with our credentialing and privileging. I know it seems silly to think of disclosure questions as a warm hug, but maybe someday.

Dr. Liz Harry:

But what I love about that is it is one of the first entree points into our system. And so it is, in some ways, how we welcome people into our system. And so thinking of it like a warm hug and a welcome, it was your first day, or close to your first day, and here's Steph to the rescue. I love the idea of, how do we create that sort of welcoming environment through the credentialing questions? That's wonderful. Amy, what are you excited about?

Amy Brant, RN:

What I'm excited about in credentialing and privileging is to see things evolve, to learn, to make changes. So for our credentialing, when we switched to a three-year credentialing cycle, that was really big to reduce some of the administrative burden, making it easier on our clinicians and our medical staff. Another thing that excites me is continuing to learn from the stories, hearing and seeing the examples of how we support our clinicians, I think that is really important, how we handle a yes question and how resources are provided. For a yes question, let's say, and a disclosure, we have the ability to trigger an assessment to make sure that people have resources in the state of Michigan, to make sure that they have the care that they need.

The other thing that I am excited about is continuing to look at processes. In credentialing, there are various documents and forms and things that have to be completed. I think it's exciting to see how we can streamline things, make things more efficient, make things easier.

Dr. Nik Theyyunni:

I think one of the hardest things to do in health care is to say, in five years, I would like to be less paperwork, and also more safety, right? And how do we do both of those things? That's one I'm excited about.

Dr. Stefanie Simmons:

I think that's honestly one of the biggest challenges across the board in health care today, is how do we reduce administrative burden while improving quality and maintaining humans at the center of the process? Not just in credentialing and in licensing, but across the board in all of our processes. So when you guys figure it out, because I know you will, share your tips and tricks with the rest of health care because it's needed everywhere.

Dr. Liz Harry:

Well, and I love the through line here of health care is human in all of the ways, and that the goal here is that everybody gets excellent care, whether it's our patients or our care team providing that care, that they get excellent care for our patients and for themselves and for their families. And so I just want to say a huge thank you to Steph and Nik and Amy for sharing your expertise, your stories, your advocacy on this very important topic.

Credentialing may seem like it's just a technical process, but as we've learned today, it profoundly affects the wellbeing and the privacy, the comfort, the psychological safety of those who care for us and those who are receiving care. And so talking about this, changing perceptions about seeking care, about how we think about health care, and that mental health care is health care, looking at these policies, looking at the way that we can support all of us is really important, so excited to keep the conversation going.

For resources on clinician mental health, credentialing information at Michigan Medicine or the Dr. Lorna Breen Heroes Foundation, check out the show notes. If you found this helpful, please share, subscribe, and let us know what topics matter to you. And until next time, stay well and remember, we're stronger together. Thank you.