8 Tips for Interim Medical Staff Services Directors: Keeping Credentialing and Privileging Processes on Point When You're Covering the Role

Healthcare systems lose ground fast when the Medical Staff Services Director seat is empty. Here's what interim coverage actually requires — from someone brought in to fix it.

There's a pattern I've seen repeat itself across healthcare systems more times than I can count.

A Medical Staff Services Director leaves. The position sits open for weeks — sometimes months. An executive from another department steps in to provide interim coverage. They're well-meaning, capable in their own domain, and doing their best. But Medical Staff Services is one of the most specialized, compliance-intensive functions in a hospital. The gap shows.

By the time I'm brought in — whether as an interim director while a permanent placement is sourced, or explicitly to clean things up — the department is rarely in the same shape it was when the vacancy began. Not because anyone failed. Because this field doesn't forgive inattention. The regulatory clock doesn't pause. Reappointment deadlines don't move. The Joint Commission (TJC) doesn't care about your staffing challenges.

What follows is a field guide for anyone stepping into interim Medical Staff Services oversight without deep Credentialing and Privileging (C&P) experience — and a candid look at where things fall apart most often.

1. Licensure and Certification Verification: Simple, Critical, and Dangerously Easy to Neglect

Let's be honest about something: tracking licensure and certification renewals is one of the most monotonous tasks in the department. It is repetitive, routine, and unglamorous. And that is exactly why it fails.

Staff members who thrive on variety and stimulation don't naturally gravitate toward this kind of work. The right person for this role genuinely doesn't mind routine — they find satisfaction in a clean, current spreadsheet and a process that hums. But not everyone is built that way, and when oversight is absent, even well-intentioned staff start to let things slip.

The failure mode is almost always the same: a senior manager assumes lower-level staff are running the process correctly. They're not auditing it. They're not spot-checking it. They're trusting. And as we used to say in healthcare systems — and plenty of other industries have figured out too — assuming makes an "ass" out of "u" and "me."

Don't assume. Verify. Audit. Ask questions you already know the answer to, just to confirm.

Every provider's license, board certification, DEA registration, and required certifications must be actively tracked and verified on an ongoing basis. The process must include advance notification of upcoming expirations — and critically, immediate suspension of privileges when a credential lapses. Not the day after. Not when someone gets around to it. On the date of expiration, or preferably the day prior.

When a provider practices with an expired license, the liability exposure — regulatory, legal, and reputational — lands on the department. A tight tracking process with real oversight isn't optional. It's the floor.

2. Privilege Expiration and Reappointment: Not a Day Over — and Start Earlier Than You Think

If your medical staff bylaws and corresponding TJC standards require privileges to be renewed every two years, they must be renewed before the two-year mark. Not a day over.

Less seasoned C&P staff routinely underestimate this. It can look like paperwork. It is not paperwork. A practitioner practicing with expired privileges is a Joint Commission finding waiting to happen — and if something goes wrong clinically during that window, the credentialing department owns it.

What makes this especially dangerous is that reappointment isn't a single task — it's a pipeline. It cannot be initiated three weeks before expiration. It requires advance initiation, completion of a multi-step verification and review process, presentation to the Medical Executive Committee (MEC), and governing body approval — all before the expiration date. Every one of those steps has dependencies. Any one of them can stall.

When I step into an interim role, identifying where the reappointment pipeline is backed up is one of my first priorities. Bottlenecks here are predictable: incomplete applications sitting with providers, committee meeting schedules that don't align with expiration timelines, governing body approval cycles that weren't factored in. Surfacing these early and escalating appropriately is exactly where an experienced interim MSD earns their value — and exactly where a gap in leadership quietly creates a crisis.

3. Scope of Practice and Privilege Visibility: Does the Floor Actually Know What a Doctor Can Do?

What process is in place to ensure medical staff are practicing within their approved scope? How do you know it's being followed?

Here's a question that TJC surveyors ask clinical floor staff directly — and one that exposes gaps fast: How does a nurse on the floor know what a physician is and isn't allowed to do at this facility?

The answer should be a centralized, accessible privilege library — typically a virtual system where every medical staff member's approved privileges are documented and available to clinical staff who need to verify them. But having the system isn't enough. The interim MSD needs to understand: How is it updated? Who is responsible for updating it? What is the turnaround time when privileges change, are restricted, or expire? Is there a documented process — and is it actually being followed?

If a provider's privileges change on Monday and the floor doesn't reflect that until the following week, the system has failed. Clinical staff making decisions based on outdated privilege information creates patient safety exposure and a TJC finding.

This is one of those areas that looks purely administrative from the outside and is entirely clinical in its consequences.

4. Quality Oversight: Are OPPE and FPPE Processes Actually Running?

Scope of practice is about what a provider is approved to do. Quality oversight is about whether they're doing it competently — and whether anyone is watching.

When I step into an interim role, I want to see evidence that the quality evaluation infrastructure is functioning, not just existing on paper:

• Ongoing Professional Practice Evaluation (OPPE) results being reviewed routinely by the MEC and clinical service line leaders
• Initial Focused Professional Practice Evaluation (FPPE) results being closed out appropriately and on schedule
• Outliers in OPPE being identified, evaluated, and acted on — not just documented
• For-cause FPPEs being initiated when warranted and appearing in the MEC minutes as they should

If any of those boxes can't be checked with confidence, that's where the interim MSD needs to focus immediately. A department where OPPE data is being collected but never reviewed, or where for-cause FPPEs aren't making it into the minutes, is a department that looks compliant on the surface and isn't.

5. The MEC Minutes Tell the Story

If it isn't in the minutes, it didn't happen — at least not in the eyes of a surveyor.

Privilege renewals, OPPE reviews, quality concerns, adverse actions, FPPE outcomes: all of it needs to be reflected accurately and consistently in MEC documentation. This is one of the first things I review when stepping into a new role, and it is one of the most reliable indicators of how the department has been functioning.

Gaps in the minutes are gaps in the record. Clean them up.

6. Bylaws as a Staffing Tool

Most interim directors without a C&P background don't know that the bylaws themselves contain mechanisms to address urgent staffing needs — temporary privileges, emergency privileges, expedited review pathways.

When a healthcare system is in a critical staffing situation, a knowledgeable Medical Staff Services Director can work within the existing bylaw framework to enable faster turnaround without cutting corners on compliance. That's not creative interpretation. That's knowing the rules well enough to use them.

7. Quality Issues and Adverse Actions: Don't Wait for Legal to Lead

This is the area that makes interim directors most uncomfortable. It's also where delay causes the most damage.

When I assumed one director role, there were seven suspensions and adverse privileging actions in the first one to two months. Not because things suddenly went wrong — but because the MEC hadn't known what to do for months prior. Instead of suspending privileges, providers were being given administrative assignments to keep them out of patient care. The MEC didn't know they could approve reappointment for one year instead of two when quality concerns warranted closer monitoring. They didn't know the options available to them in emergency situations.

The in-house legal support assigned to the situation was experienced in employment law — not in the intersection of TJC standards and credentialing requirements. That gap cost significant time and created unnecessary exposure.

Know your bylaws. Know the regulatory framework. Know what options exist. When quality issues surface, acting decisively within that framework protects the MEC, the C-suite, and ultimately the patients.

8. TJC Survey Readiness: Know Where You Stand from Day One

When was the last survey? When is the next one? What regulatory audits are on the horizon?

These are among the first questions I ask. The Medical Staff chapter is the third largest of the 25 areas hospitals must address to maintain Joint Commission certification. It is dense, specific, and unforgiving in survey. Every interim MSD should have a working familiarity with the MS chapter — I recommend printing it, annotating it, and keeping it accessible as a live reference throughout the engagement.

You cannot manage survey readiness you haven't assessed.

Bringing In Coverage That Actually Covers

Medical Staff Services is not a department that runs on autopilot. When the director seat is empty — even temporarily — the risk to the system accumulates quietly, in missed deadlines, incomplete documentation, and processes no one is actively managing.

I provide interim Medical Staff Services Director coverage for healthcare systems in transition: while a permanent placement is being sourced, during periods of restructuring, or when a department needs stabilization before the next survey cycle. Engagements are available on a project basis, short-term contract, or retainer — including remote coverage models for systems that need senior-level oversight without a full-time on-site presence.

If your system is navigating a gap in C&P leadership, I'd welcome a conversation.

Schedule a discovery call → or submit an inquiry → and I'll be in touch within one business day.

Work With Claudia

Claudia M. Rausch

15 years of federal and institutional healthcare policy experience — available to hospitals, medical executive committees, medical staff services offices, and legal counsel navigating credentialing, privileging, and NPDB matters. Engagements are strictly confidential.

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