1) Health facilities have obligations under state and federal law to report certain disciplinary actions taken against licensees to the state licensing agency and the National Practitioner Data Bank. 2) Michigan law requires reporting of licensee criminal convictions, other state licensing actions, and actions taken for suspected impairment. It also governs requests for information from the state agency. 3) Federal law requires reporting adverse actions that affect clinical privileges for more than 30 days to the NPDB. Whether an action is reportable depends on factors like if it was due to the professional review process or for employment purposes. 4) Health facilities must create files documenting actions taken against licensees in case the state requests information on a reported action. Deter

1. Health Facility Obligations For Reporting Licensees To
The State And/Or National Practitioner Data Bank
The In-House Perspective

2. Generally Applicable Law In The In-House Setting
Michigan Public Health
Code:
1. MCL 333.16222
2. MCL 333.16223
3. MCL 333.16243
4. MCL 333.20175
National Practitioner Data
Bank
1. Title IV of the Health Care
Quality Improvement Act
of 1986 (HCQIA), Public
Law 99-660
2. Section 1921 of the Social
Security Act
3. Section 1128E of the
Social Security Act

3. MCL 333.16222 Identifies Obligation To Report For MPHC, Criminal, Other
State Action
1. Licensee or registrant has knowledge of a violation of the MPHC by another
licensee or registrant
i. Except discovered during ethics or peer review committee function
2. Licensee shall notify of criminal conviction within 30 days after the date of
conviction.
3. Licensee notification of other state licensing action within 30 days after the
date of conviction.

4. MCL 333.16223 Obligation To Report For Suspected Impairment
1. Licensee has reasonable cause to believe that a licensee is impaired.
i. Except a bona fide health professional-patient relationship

5. MCL 333.16243 Requests for and reporting To LARA/BPL
1. Health Facility for action under MCL 333.20175
2. Insurer for settlements
3. Court for felony or misdemeanor or negligence in medical malpractice
4. Report by licensee for 16222 and/or 16223 violations
5. NPDB and Michigan health care arbitration program.

6. MCL 333.20175 Health Facility Or Agency Notice of Disciplinary Action
1. Professional competence
2. Results in change of employment
3. Based on conduct that adversely affects the licensee’s clinical privileges for
more than 15 days. Including reduction, restriction, suspension, revocation,
denial, or failure to renew.
4. Restriction or acceptance of surrender:
i. While under investigation
ii. In lieu of investigation
5. Resignation or termination/non-renewal of contract in lieu of disciplinary action.

8. Anatomy of a health professional disciplinary action in the in-house setting:
1. Information received by health facility regarding licensee
2. Determine whether the information related to human resources,
quality/compliance, and/or medical staff matter
3. Health facility management/leadership or medical staff leadership/executive
committee determine whether an investigation is warranted
4. Follow internal policy/procedure or bylaws regarding investigation
5. Meet with licensee regarding investigation per policy/bylaws
6. Determine appropriate corrective action
7. Notify licensee of corrective action
8. Report corrective action to LARA and/or the NPDB where indicated

9. Employment Action
1. Allied Health
Professionals
2. Employed Physicians
with clean-sweep
provisions.
Medical Staff Bylaws
Action
1. Medical Staff Members
2. Independent Physicians
3. Employed Physicians
without clean-sweep
provisions.
4. APRNs
Others
1. Independently
contracted licensees
(acupuncture, massage,
some MSWs)

10. Reporting Malpractice Payments
Should a payment exclusively for the benefit of a clinic, hospital, or other
health care entity be reported?
No. Medical malpractice payments made solely for the benefit of a clinic,
hospital, or other health care entity should not be reported to the NPDB.
However, a payment made for the benefit of a professional corporation or
business entity consisting only of a sole practitioner is reportable to the NPDB.
Insurer report to LARA for “final disposition not resulting in payment on behalf
of insured.” MCL 333.16243(b).

11. Employment Action versus Peer/Professional Review Action
A hospital filed a report announcing the revocation of a practitioner's clinical
privileges. The hospital used the employment termination procedure, not the
professional review process to revoke the practitioner’s clinical privileges
because there was no longer a need for their specialty at the hospital. No
action was taken through the professional review process. The practitioner
was not given a choice of which process (system of professional review or
employment termination procedure) the hospital would use. Should the
hospital have filed the report?
No. The termination was not a result of a professional review action and, therefore,
was not reportable. Also not reportable to LARA so long as not due to or in lieu of
disciplinary action.

12. Clean-Sweep Provisions In Physician/APRN Contracts
1. In the event of a termination of agreement, [Physician/APRN’s] medical staff
membership and clinical privileges are automatically relinquished.
2. Less messy: automatic action with no hearing, appeal, or review rights.
3. Automatic action not based on professional review function so not reportable to
NPDB depending on reason for non-renewal/termination.
4. Automatic action not necessarily reportable to LARA depending on reason for
non-renewal/termination.

13. Suspensions
1. Automatic suspension of clinical privileges as provided by the medical
staff bylaws for failure to complete medical records.
NPDB: Not part of professional review function
LARA: Yes if the suspension exceeds 15 days.
2. Summary suspension of physician’s clinical privileges for 14 days to put
an FPPE in place after peer review determines that physician technique is
controversial.
NPDB: No, so long as suspension does not exceed 30 days.
LARA: No, so long as suspension does not exceed 15 days.

14. Focused Professional Practice Evaluation
Generally not reportable, however, can create a reportable event.
1. Restricts privileges (i.e. proctoring, monitoring, or approval required before
physician can perform certain procedures that lasts longer than 15/30 days.)
2. Physician resigns under FPPE.

15. Adverse Recommendations by Medical Executive Committee
Hospital’s medical executive committee recommends that a physician should
have their privileges revoked for a specific medical procedure after peer
review committee recommendation. The decision triggers fair hearing
requirements under Bylaws and the physician requests a hearing. The
hospital reports the decision to the NPDB and LARA within 30 days of the
MEC recommendation. Should they have reported?
No. There is nothing to report until the privileges are actually restricted. However,
once the hospital takes action (summary suspension) that restricts the physicians
privileges for greater than 15/30 days it may require a report. If the physician
prevails at fair hearing then the report should be amended.

16. Reporting Change In Staff Privileges
Create a file of all materials relied upon for notifying
the state of change in staff privileges.
1. Identify appropriate custodian (HR, Legal,
Department, Credentialing, Medical Staff Office)
2. Retain patient records
3. Retain Pyxis/Pandora reports
4. Retain communications
5. Retain relevant Corrective Action Report(s)
6. Relevant Physician Contracts/Job Description
7. Relevant policy/procedure
8. Identification of relevant witnesses
9. Keep a copy on file if requested from the state
10.Review the file with counsel to ensure
responsive.

18. Presented by
Robert A. Welch, Jr.
Ascension
Robert.Welch2@Ascension.Org