This document provides a summary of key legal and process considerations for medical staff when navigating investigations into a medical staff member's conduct or competence. It outlines when the medical staff process versus administrative process should be used, timelines around summary suspensions of privileges, requirements for fair investigative committees and hearings, and ensuring physician access to relevant documents. The overall goal is to follow medical staff bylaws and legal standards to maintain immunity while addressing quality or conduct issues in a fair manner.
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A presentation by Andreas Hverfner at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
This Hospital Skills Program (HSP) module has been developed to support the professional development of doctors working in a hospital generalist role in NSW hospitals.
Doctors participating in the HSP will have at least two years of clinical postgraduate experience and not be currently participating in a specialist vocational training program.
This HSP module has been developed by CETI on behalf of NSW Health as part of the Hospital Skills Program for generalist doctors. It aims to guide doctors, their employers and educators with regard to learning and professional development needs, workplace responsibilities and clinical tasks.
This module is one of several that have been developed by CETI to support the implementation of the HSP.
Medical Emergency Teams - do they even matter?scanFOAM
A presentation by Andreas Hverfner at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
This Hospital Skills Program (HSP) module has been developed to support the professional development of doctors working in a hospital generalist role in NSW hospitals.
Doctors participating in the HSP will have at least two years of clinical postgraduate experience and not be currently participating in a specialist vocational training program.
This HSP module has been developed by CETI on behalf of NSW Health as part of the Hospital Skills Program for generalist doctors. It aims to guide doctors, their employers and educators with regard to learning and professional development needs, workplace responsibilities and clinical tasks.
This module is one of several that have been developed by CETI to support the implementation of the HSP.
S12 Solutions is a mobile application and website created to make Mental Health Act (MHA) assessment setup and claim form processes quicker, simpler and more secure. To understand the impact of the S12 Solutions platform locally, Wessex AHSN have undertaken an independent evaluation on behalf of the Hampshire and the Isle of Wight Sustainability and Transformation Partnership (HIOW STP).
The practice of anesthesia and sedation continues to expand beyond the operating room and now includes the gastroenterology suite, magnetic resonance imaging suites, and the cardiac catheterization laboratory. Non-anesthesiologists frequently administer sedation, in part because of a lack of available anesthesiologists and economic aspect, which emphasizes the safety of sedation. The Joint Commission International (JCI) set a standard responding to this issue indicating that qualified individuals who have drug and monitoring knowledge as well as airway management skills can only administer sedating agents.
S12 Solutions is a mobile application and website created to make Mental Health Act (MHA) assessment setup and claim form processes quicker, simpler and more secure. To understand the impact of the S12 Solutions platform locally, Wessex AHSN have undertaken an independent evaluation on behalf of the Hampshire and the Isle of Wight Sustainability and Transformation Partnership (HIOW STP).
The practice of anesthesia and sedation continues to expand beyond the operating room and now includes the gastroenterology suite, magnetic resonance imaging suites, and the cardiac catheterization laboratory. Non-anesthesiologists frequently administer sedation, in part because of a lack of available anesthesiologists and economic aspect, which emphasizes the safety of sedation. The Joint Commission International (JCI) set a standard responding to this issue indicating that qualified individuals who have drug and monitoring knowledge as well as airway management skills can only administer sedating agents.
The community and patients tend to forget that the clinicians and other healthcare personnel are also human like them. Every human makes an error while performing his or her task, accurately reporting the performance and due to general forgetfulness. However, the consequences of errors in medical practice are potentially serious for both patients and doctors alike.
Clinical Science for Medical Devices: A Guide for Entrepreneurs | Jim Gustafs...UCICove
About UCI Applied Innovation:
UCI Applied Innovation is a dynamic, innovative central platform for the UCI campus, entrepreneurs, inventors, the business community and investors to collaborate and move UCI research from lab to market.
About the Cove @ UCI:
To accelerate collaboration by better connecting innovation partners in Orange County, UCI Applied Innovation created the Cove, a physical, state-of-the-art hub for entrepreneurs to gather and navigate the resources available both on and off campus. The Cove is headquarters for UCI Applied Innovation, as well as houses several ecosystem partners including incubators, accelerators, angel investors, venture capitalists, mentors and legal experts.
Follow us on social media:
Facebook: @UCICove
Twitter: @UCICove
Instagram: @UCICove
LinkedIn: @UCIAppliedInnovation
For more information:
cove@uci.edu
http://innovation.uci.edu/
Chapter 3Risk Management in EmploymentEmployment Re.docxketurahhazelhurst
Chapter 3:
Risk Management in Employment
Employment Relationship carries Risk
• Risk to an organization is not limited to
provider-patient relationships
• As in any business, the healthcare organization
has responsibilities to its employees. Many of
which, if not properly implemented/enforced,
can lead to negative and litigious results
Employment-at-Will
• An employer may dismiss an employee
hired for an indefinite period of time for
any reason or no reason at all without
incurring liability to the employee
• Caveat: cannot discharge for an unlawful
reason, such as racial discrimination
Implicit Employment Contracts
• Though most states follow the employment-at-
will doctrine, many organizations may
unknowingly negate their ability to apply this
principle through
– Employer policies (i.e. progressive disciplinary policy)
– Oral assurances (i.e. looks like you have a bright
future ahead of you here)
– Industry customs (i.e. after so many years in one
position, employees are promoted to the next level)
– Employer conduct (i.e. allowing some employees
more chances to correct errors than others)
Burden of Proof
• In civil litigation of discrimination, the burden of
proof is usually on the plaintiff -they must show:
• Membership in a protected group
• Satisfactory job performance or appropriate
qualifications for the job being sought
• Receipt of discipline, termination or rejection
despite having the qualifications
• Employees of another protected class were
disciplined less severely or the employer continued
to accept application of people who were no better
qualified
Sexual Harassment
• Unwelcome sexual advances, request for
sexual favors or other verbal or physical
conduct of a sexual nature when it is one of
the following:
• is a condition of employment
• is the basis of employment decisions
• interferes with work performance
• creates a hostile work environment
Minimizing Risk of Sexual Harassment
• Organization must exercise reasonable care to
prevent and correct any sexually harassing
behavior
– Written policies/procedures
– Documented staff training on policies/procedures
– Consistently adhere to and enforce policies
– Immediately investigate allegations of sexual
harassment
Responsibility of the Employee
• Employee must report occurrences of sexual
harassment to employer
– Employer must be given the opportunity to investigate
and take corrective action
• Though it is important that an employer investigate
all reports of sexual harassment, proactively
addressing situations or behavior that may be
perceived as sexual harassment is imperative.
– If management is aware of a potential situation and does
nothing, the risk of litigation and penalty is increased
People with HIV or AIDS
are protected by the ADA
Persons with HIV disease, both
symptomatic and asymptomatic, have
physical impairments that substantially
limit one or more major li ...
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Key Bankruptcy Considerations Heading into a RecessionQuarles & Brady
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We will discuss:
-What coronavirus testing must be covered by health plans
Important changes to "over the counter" drugs and medicine
-Addressing layoffs and furloughs, and how to survive the benefit costs
-Best practices for distribution and loan options for those who have been affected
-Delaying, repaying and fixing 2020 required minimum distributions
-How to treat paid leave under your retirement plans
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Introducing New Government Regulation on Toll Road.pdfAHRP Law Firm
For nearly two decades, Government Regulation Number 15 of 2005 on Toll Roads ("GR No. 15/2005") has served as the cornerstone of toll road legislation. However, with the emergence of various new developments and legal requirements, the Government has enacted Government Regulation Number 23 of 2024 on Toll Roads to replace GR No. 15/2005. This new regulation introduces several provisions impacting toll business entities and toll road users. Find out more out insights about this topic in our Legal Brief publication.
ALL EYES ON RAFAH BUT WHY Explain more.pdf46adnanshahzad
All eyes on Rafah: But why?. The Rafah border crossing, a crucial point between Egypt and the Gaza Strip, often finds itself at the center of global attention. As we explore the significance of Rafah, we’ll uncover why all eyes are on Rafah and the complexities surrounding this pivotal region.
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In 2020, the Ministry of Home Affairs established a committee led by Prof. (Dr.) Ranbir Singh, former Vice Chancellor of National Law University (NLU), Delhi. This committee was tasked with reviewing the three codes of criminal law. The primary objective of the committee was to propose comprehensive reforms to the country’s criminal laws in a manner that is both principled and effective.
The committee’s focus was on ensuring the safety and security of individuals, communities, and the nation as a whole. Throughout its deliberations, the committee aimed to uphold constitutional values such as justice, dignity, and the intrinsic value of each individual. Their goal was to recommend amendments to the criminal laws that align with these values and priorities.
Subsequently, in February, the committee successfully submitted its recommendations regarding amendments to the criminal law. These recommendations are intended to serve as a foundation for enhancing the current legal framework, promoting safety and security, and upholding the constitutional principles of justice, dignity, and the inherent worth of every individual.
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How to Obtain Permanent Residency in the NetherlandsBridgeWest.eu
You can rely on our assistance if you are ready to apply for permanent residency. Find out more at: https://immigration-netherlands.com/obtain-a-permanent-residence-permit-in-the-netherlands/.
How to Obtain Permanent Residency in the Netherlands
A Practical Roadmap For Navigating Medical Staff Legal Nightmares In Current Times
1. A Practical Roadmap For Navigating
Medical Staff Legal Nightmares In
Current Times
SSM Health Care Of Wisconsin
Medical Staff Meeting
January 21, 2020
Presented by Sarah Coyne
2. Medical Staff Process – The Tricky Parts
• DISCLAIMER: WE LAWYERS REALIZE THAT MOST MEDICAL STAFF MEMBERS
PROVIDE EXCELLENT CARE AND CONDUCT THEMSELVES PROFESSIONALLY –
THIS IS A ROADMAP FOR THE RARE OCCURRENCES - WHEN THINGS ARE
GOING BADLY WITH A GIVEN MEDICAL STAFF MEMBER. (Well, I am a
lawyer....you knew there had to be a disclaimer).
• Nuances of managing the fork in the road between medical staff process and
administrative process for employed physicians.
• Challenges of navigating the process set forth in the medical staff bylaws in a
manner that maintains immunity for all participants in the process.
• The interface of medical staff leaves of absence with investigations.
• The various reporting obligations for hospital medical staff members.
3. When The Problem Is Identified Through HR
• Human Resources is often the first to learn of a problem, especially when:
• The catalyst is a complaint from a co-worker.
• The physician is employed by the hospital.
• There is a critical crossroads right at the beginning with regard to a complaint
about an employed physician: Will the investigation be handled as a function of
employment or medical staff membership – i.e., through corrective action.
• Practical tips:
• Ensure that HR understands that medical staff has its own review and corrective action
process.
• Ensure that HR will communicate immediately with medical staff leadership so that a
reasoned decision can be made.
• There should be communication the other way as well, if the medical staff is undertaking an
investigation or corrective action process – let HR know so that you don't get at cross-
purposes.
4. Why Choose Medical Staff Process - Ever?
• Collegial intervention didn't work.
• Kinder gentler processes didn't work (FPPE, evaluation for potential impairment,
etc.)
• Not employed.
• Defined process as opposed to the employment process.
• Immunity.
• Fiduciary duty to patients (avoiding negligent credentialing).
• Raising the red flag for future employers/ credentialing facilities.
4
5. Health Care Quality Improvement Act (HCQIA)
• The medical staff bylaws corrective action section of the bylaws and fair hearing
plan must reflect HCQIA – this provides federal immunity for those involved in
professional review actions. (Parallel state law immunity Wis. Stat. s. 146.37)
• If proceeding down this path, follow the process to the letter – sometimes it is
tricky to figure out where exactly you are in the process.
• The idea is to encourage frank peer review by limiting civil liability.
• If health care providers as a professional review body meet the standards set
forth in HCQIA, then immunity attaches to the medical staff participating in the
process, the board to the extent it is involved, the administrators involved, etc.
• But like many things – immunity is a defense you assert if you are sued – it
doesn't mean that you can't be sued.
6. Administrative vs. Privileges Suspension
• If the medical staff member is posing an immediate threat to patient care or
hospital operations and is employed:
• Administrative suspension (with or without pay) provided that this will result in the provider
not being able to exercise privileges; OR
• Summary suspension of privileges under the medical staff bylaws.
6
7. Counting Days – Summary Suspension Of Privileges
• If a practitioner’s medical staff privileges are suspended for more than
FOURTEEN DAYS, the practitioner will have a right to request a hearing.
• Investigation should begin (and if possible, conclude) during the fourteen days.
• Nightmare: Bylaws that shorten the fourteen days (or lengthen it)!
• Hearing must be AT LEAST THIRTY DAYS after the practitioner requests it – not a maximum,
a minimum.
• Suspension or limitation of privileges (including voluntary agreements) for
MORE THAN THIRTY DAYS means a report to the NPDB.
8. Summary Suspension "Don'ts"
• Don't summarily suspend a physician for behavior that happened a long time
ago/ has been known for a while – it is supposed to be an aversion of imminent
problems.
• Don't assume that events that happened offsite are irrelevant – if there was
some sort of violent crime, it is relevant to whether patients are in danger... BUT
• Don't assume that everything that happens offsite IS relevant, e.g. maybe a
misdemeanor/ traffic incident that occurred offsite is legitimately unlikely to
carry over.
9. How Corrective Action Meshes With Summary Suspension
• When a request for corrective action is brought to the MEC, the MEC can:
• Decide it has enough information.
• Convene an ad hoc committee to investigate.
• Once the MEC does have enough information, they make a recommendation to
the board. If this recommendation falls into the list of those deemed ADVERSE
(i.e. restriction or reduction of privileges/ appointment), then the physician is
entitled to request a hearing.
• If the physician is also summarily suspended (because there is a perception that
he or she should not exercise privileges during the pendency of the corrective
action process), that will also entitle him or her to request a hearing after
fourteen days.
• It is ONE hearing that will address BOTH pathways to the hearing.
9
10. Knowing The Facts
• Before taking action on privileges, the acting committee should do a very
thorough analysis of the facts – this is always an area of attack.
• Review medical records.
• Talk to key witnesses.
• Talk to the physician.
• Err on the side of fairness to the physician and document that (his or her side of
the story, his or her access to documents, etc.).
• Nightmare: Committee decides to revoke privileges without having reviewed
documents, without having heard in any depth from the doctor, and without
having a significant period of discussion.
• Recommendation: If the problem is with a person who works in collaboration
with the physician or under the physician's supervision, focus on the actual
practitioner with the issue unless there was a really egregious failure to
supervise/ collaborate.
11. Selecting And Preparing The Investigative Committee
• Pick someone (counsel, medical staff coordinator) to organize the meetings of
the investigative committee – first one should be in person, after that they
might have to be by phone.
• At first meeting, have them sign a confidentiality statement and impress the
importance of confidentiality. Have them decide who they want to interview,
including the physician. Help them to reach out to those individuals and
schedule them – interviews should be in person with all members of the
committee if possible.
• Be aware of timelines in the bylaws – in general the whole process should not
take more than one month (if possible).
• Make sure the physicians on the committee are armed with the bylaws and the
request for correction action so they know what their mission is.
• They should ultimately come to a consensus or at least majority and
recommend possible courses of action.
12. The Physician Under Review's Side Of The Story
• The physician under review should have unfettered input to the investigative
committee is crucial and should be actively considered by the MEC.
• The input can be a meeting, in writing, or (ideally) both.
• Nightmare: The physician is given ten minutes to present his case.
• Fairytale: The physician is given an opportunity to meet with the IC and an
opportunity to submit documentation including a narrative.
13. Ultimate Adverse Recommendation By MEC
• The MEC technically does not have to defer to the investigative committee's
recommendation, but usually does.
• An adverse recommendation by the MEC will entitle physician to request a
hearing.
• Bylaws will spell out which actions are “adverse actions” which will essentially
be recommendations for curtailing/ limiting privileges or appointment.
• Bylaws will spell out timing and process for requesting a hearing.
• Nightmare: Bylaws that give a really short timeline for hearing.
• Fairytale: Bylaws that allow for reasonable scheduling.
• The governing body and hospital administration are apprised at this point
(usually administration is involved and governing board is aware well before
this).
14. Medical Staff Hearings – Providing Adequate Notice
• Two separate notices required under HCQIA:
• Notice of Adverse Action Recommendation (and Right to Request a Hearing).
• Notice of Hearing (after practitioner has requested it).
• Nightmare: Trying to give notice to a physician who will not answer the door or
sign a "return receipt requested").
• Recommended: The bylaws bless multiple methods of delivery, e.g. including
electronic mail that confirms receipt at a certain time.
15. Potential Landmine: Limiting Physician Access
• The physician under review should have full access to the medical records of any
patient where that patient's care is the basis (or one of the bases) for the adverse
recommendation.
• The physician under review should also have the bylaws and any policies/
procedures requested.
• HOWEVER:
• The physician should not be able to access the files of other physicians.
• There should be no right to discovery in the bylaws (there isn't in HCQIA).
• The hospital does not have to facilitate interviews/ depositions with hospital staff (although
can't do much about the physician contacting such staff).
16. Nightmare: Denying Physician Access To Documents
• Recent court case: Blaine v. North Brevard County Hospital District required the
hospital to give the plaintiff physicians a hearing for failing to provide physicians
with data they had requested during the course of reappointment.
• The court held that under the medical staff bylaws, the hospital was required to
give the physicians a hearing before their request for reappointment and renewal
of clinical privileges could be denied for failing to provide “patient data.” The
“patient data” appeared to be related to the hospital’s cancer program and
necessary for accreditation purposes.
17. HCQIA Requirements For A Fair Hearing
• Physician may be represented by an attorney (or someone else).
• Some sort of tribunal.
• Mutually acceptable arbitrator.
• Hearing committee of physicians not in direct competition.
• Hearing Officer.
• Nightmare: Bylaws that allow the physician indefinite veto power.
• Fairytale: Bylaws that allow the physician input, but allocate ultimate authority to the hospital to
appoint the hearing committee.
• Physician may call and examine witnesses, present evidence, submit a written
statement, and upon conclusion, receive a written decision.
• “Appeal” rights to board are common but not essential for HCQIA immunity.
18. HCQIA And Confidentiality
• HCQIA states that information that identifies the entity, practitioner or patient that
is reported to peer review committees is confidential and shall not be disclosed
(other than to reviewed practitioner) except:
• In the course of the PRA.
• As necessary to query the NPDB.
• In accordance with federal regulations or state law.
• The committee taking action on privileges MUST understand that confidentiality is
LEGALLY REQUIRED (by HCQIA and in Wisconsin by Wis. Stat. s. 146.38). No leaking!
It creates a separate battlefield.
• Recommendation: Have the committee members sign agreements to maintain the
confidentiality of the matter at the beginning.
• Recommendation: Collect all paper materials at the end of each meeting.
19. Physician Health/ Impairment
• Impairment issues may be handled through a separate impaired provider policy,
which may be "kinder and gentler" than either HR or medical staff process.
• However, be aware of who owns the implementation of that policy.
• If there are independent medical examinations, be aware that the evaluator may
have a duty to report to the Department of Safety and Professional Services under
Wis. Stat. s. 448.115.
• A good policy will have a pathway from the impaired provider route to the medical
staff corrective action route.
• Nightmare: Taking corrective action that results in loss of privileges/ NPDB report
without having considered that the behavior/ conduct stemmed from a health or
impairment issue.
20. "What Is Going On With Dr. X?"
• Patients, co-workers and community members may start to wonder why a physician
under review has stopped practicing or stopped exercising certain privileges.
• Because confidentiality is key, the strategy for responding to such inquiries should be
thought out in advance and scripted, e.g.:
• To patients/ community members: He has taken a leave of absence.
• To co-workers: He is not currently scheduled, for personal reasons (for confidential reasons).
• The right message will vary greatly with each case.
21. Promising Absolute Confidentiality To Witnesses
• Outside of the corrective action process, a co-worker's commentary or
complaints about another practitioner may be kept confidential.
• Nightmare: Having promised confidentiality to a witness who is the only one with first-hand
knowledge of the basis for a fair hearing.
• Nightmare: Hospital is obligated to turn over all relevant documents to physician who has
requested a hearing and the physician insists on confronting those who reported problems.
22. What Happens After The Hearing?
• Hearing panel or officer issues a report within the timelines in the Fair Hearing
Plan.
• Physician and MEC both receive a copy of the report.
• If adverse, usually goes straight to governing board for consideration (approval,
rejection, or modification).
• If governing board decision is adverse, most Fair Hearing Plans allow for appeal to
the board – this is NOT necessary for HCQIA immunity.
• If upheld on appeal, the life cycle comes to an end – the next step would be for the
physician to bring a lawsuit alleging some sort of wrongful limitation of privileges –
HCQIA immunity would be a strong defense but does not prevent the lawsuit from
being filed.
23. Leaves Of Absence
• If a leave of absence while under investigation restricts privileges, it is a mandatory
report.
• NPDB's regulation states that, "[a]cceptance of the surrender of clinical privileges or
any restriction of such privileges" is reportable.
• To the extent a leave of absence restricts a practitioner's ability to exercise privileges,
it is considered a surrender that is reportable.
• If a practitioner can take a leave of absence without affecting his or her privileges,
and his or her privileges remain intact during the leave of absence, the leave of
absence is not reportable to the NPDB.
• Nightmare: Unclear language in the bylaws about the procedural implications if the
physician is declined return from leave.
• Fairytale: A nice clear conduit between denial of return from leave and the
procedural rights mandated under HCQIA.
24. Licensing Board Actions
• A limitation on the license may trigger a restriction of privileges under the bylaws –
which if automatic, will not give rise to hearing rights.
• A limitation on the license may result in the physician's breach of his or her
employment agreement – would be a factor in favor of going the employment
route rather than the medical staff route.
• Nightmare: Physician's license is limited but he/ she does not disclose this to the
hospital.
• If there was an outright omission on an application (for employment, for appointment, for
reappointment) that is in itself a basis for corrective action regardless of the underlying reason
for the license limitation.
• The bylaws should require disclosure of any such limitations (license, DEA, etc.).
25. Where Do Lawyers (On Both Sides) Fit In?
• Usually, hospital medical staffs do not want to involve the physician's lawyer until
there is a right to request a hearing – and this is consistent with HCQIA.
• HOWEVER, in that case, the hospital/ medical staff lawyer should not be present
at meetings where the physician is not being allowed to bring his/ her attorney.
• Hospital/ medical staff attorney is not required from counseling behind the
scenes.
• If hospital administrative position and goals are not aligned with MEC goals,
there may be a need for separate counsel – watch for diverging interests.
• At the hearing, each side is represented by counsel.
26. Should Reporting Drive The Medical Staff Bus?
• Ideally no – realistically, it often does.
• While an NPDB report or licensing board report is not necessarily (and usually is
not) career ending, it is of course offensive to the subject of the report and it does
complicate future hospital and payor credentialing.
• Sometimes, in an effort to avoid reporting, the MEC will manage timelines
accordingly – e.g. lift summary suspension within thirty days/ find settlement
options where there is not a restriction on privileges/ handle through employment
and let privileges hang out there.
27. What Must Be Reported To The NPDB?
• Hospitals and other health care entities must report adverse clinical privileges
actions to the NPDB.
• Any professional review action that adversely affects the clinical privileges of a
physician or dentist for a period of more than thirty days; OR
• The acceptance of the surrender of clinical privileges, or any restriction of such
privileges by a physician or dentist:
• While the physician or dentist is under investigation by a health care entity relating to possible
incompetence or improper professional conduct; or
• In return for NOT conducting such an investigation or proceeding.
28. Agreements Not To Exercise Privileges
• Is an agreement not to exercise privileges during an investigation, without
actually surrendering the privileges, a resignation while under investigation that
is reportable?
• Yes, the agreement not to exercise privileges is reportable if other reportability conditions are
met. NPDB regulations state that "acceptance of the surrender of clinical privileges or any
restriction of such privileges . . .while under investigation" is reportable. An agreement not to
exercise privileges is a restriction of privileges. Any restriction of privileges while under
investigation, temporary or otherwise, is considered a resignation and must be reported.
• Nightmare: An email from medical staff leadership to the physician stating essentially, "In
return for your agreement not to exercise your privileges, we will stop the investigation into
the concerns against you and no report will be made to the NPDB."
• Nightmare: "Your summary suspension is ending because you agreed that you will not see
patients at our hospital in the future – this will not be reported to any agencies."
29. What Is A Restriction?
• Denials or restrictions of clinical privileges for more than thirty days that result
from professional review actions relating to the practitioner's professional
competence or conduct that adversely affects (or could adversely affect) the
health or welfare of a patient - MUST be reported to the NPDB.
• This includes denials of applications for initial privileges.
• A restriction is the result of a professional review action based on clinical
competence or professional conduct that leads to the inability of a practitioner to
exercise his or her own independent judgment in a professional setting.
30. Surrender Of Privileges Or Appointment
• Surrender of privileges while under investigation or in order to avoid
investigation (or the result of the investigation) is reportable.
• Nightmare: The hospital bends over backwards to facilitate handling something
through HR rather than medical staff process and then the physician sends an ill-
advised resignation letter "I resign my privileges."
31. Threshold Eligibility Criteria
• A denial of clinical privileges at appointment or reappointment that occurs solely
because a practitioner does not meet a threshold criterion for that privilege should
NOT be reported to the NPDB.
• Such denials are NOT deemed the result of a professional review action relating to
the practitioner's professional competence or conduct and should not be reported
to the NPDB.
• Rather, these are decisions based on eligibility.
32. Withdrawal Of Application For Appointment
• Voluntary withdrawal of an initial application for medical staff appointment or
clinical privileges prior to a final professional review action generally should not be
reported to the NPDB.
• However, if a practitioner applies for renewal of appointment or privileges and
voluntarily withdraws that application while under investigation for possible
incompetence or professional misconduct, then the withdrawal of the application
must be reported.
• Applies regardless of whether practitioner KNEW he or she was under investigation
– TELL THE PROVIDER WHAT IS GOING ON.
33. Nonrenewals
• Generally not reported to NPDB.
• However, if practitioner decides not to apply for renewal of medical staff
appointment or privileges while under investigation for professional
competence or conduct – that is considered a surrender while under
investigation and must be reported to the NPDB.
• Regardless of whether the practitioner was aware.
34. No Need To Report Investigations
• The fact of an investigation need not be reported to the NPDB.
• However, when the investigation has started, the chances of reporting go up
because surrender while under or to avoid an investigation is reportable, and
"investigations" run from "the start of an inquiry until a final decision on a clinical
privileges action is reached."
• Not limited to how investigation is defined in the bylaws.
• NPDB distinguishes a ROUTINE formal peer review process in which a "health care
entity evaluates, against clearly defined measures, the privilege-specific competence
of all practitioners." That is NOT an investigation for the purpose of reporting.
• But an investigation of a specific practitioner is different.
35. Reporting Revocation Of Temporary Privileges
• No distinction is made for corrective action regarding temporary privileges.
• If temporary privileges are for a specific amount of time and everyone
agrees on that, and they expire while under investigation – no report.
36. Reporting Summary Suspensions
• A summary suspension must be reported if it is:
• In effect or imposed for more than thirty days;
• Based on the professional competence or professional conduct of the physician; and
• The result of a professional review action taken by a hospital.
• Summary suspensions that have NOT lasted more than thirty days but are
EXPECTED to last more than thirty days and are otherwise reportable MAY be
reported to the NPDB. If the summary suspension lasts thirty days or fewer, a
void report should be submitted.
• The procedural rights of the practitioner are provided AFTER a summary
suspension, not before.
37. Reporting The Fact Of Proctoring
• It is a tough question whether proctoring must be reported to the NPDB if the
proctoring requirement is imposed for more than thirty days.
• If the proctor cannot perform certain procedures without proctor approval, it is a
reportable restriction.
• If the proctor is just reviewing records after a procedure, it is not reportable.
• Routine proctoring for new privileges would not be based on professional
competence or conduct and is not reportable, even if the proctor must be present.
• Recent Texas court case: If the proctoring COULD HAVE been accomplished in thirty
days, do not report even if for various reasons it actually was in place more than
thirty days (e.g. five proctored cases of a low volume condition).
38. Reporting Residents And Interns
• Residents and interns generally do not have clinical privileges and therefore, a
restriction of their practice is not an "adverse action" reportable to the NPDB.
• EXCEPTION: If they are functioning outside the scope of their graduate education,
e.g. moonlighting.
39. NPDB Sanctions For Failing To Report
• If NPDB suspects a hospital has not reported when required to do so, the
Secretary of DHHS will open an investigation and provide written notice to the
hospital.
• NPDB may impose penalties for failure to report.
• The hospital can request a hearing.
• If the hearing is denied for untimeliness or lacking a sufficient statement of facts,
or if the hospital does not prevail at hearing, the sanctions include:
• Publication of the hospital's name in the Federal Register; and
• Loss of the hospital's HCQIA immunity for three years (starting thirty days after publication).
40. Things That Are Not Reportable
• Employment actions.
• Hospital administrative actions (such as discipline for failure to maintain
insurance or board certification).
• Automatic revocation of privileges (for the above reasons and others, e.g. failure
to complete medical records).
• A physician's surrender of privileges for personal reasons, unrelated to
professional competence or conduct.
41. Examples
• A physician applies for medical staff membership and is approved by the
credentials committee but withdraws his application before the governing board
weighs in. The physician is not under specific investigation, just general
credentialing.
• NOT REPORTABLE.
• An employed physician is terminated through the HR process and pursuant to his
employment contract, his medical staff privileges automatically terminate although
the medical staff did not act on his privileges.
• NOT REPORTABLE.
• A physician applies for expanded privileges and is denied by the credentials
committee and the board on the basis that he lacks the skills.
• REPORTABLE.
42. State Law Reporting
• If a physician is reported to the NPDB, the physician will simultaneously be reported
to the State Medical Examining Board which will initiate a screening inquiry.
• MEB may shut things down at the screening stage or proceed to investigation.
• If not resolved and action is proposed on the license, this can proceed to a hearing before an
Administrative Law Judge.
• The physician is responsible for all of the State's costs.
• The limited license is reported to the NPDB by the State.
• Even if a physician is NOT reported to the NPDB, the physicians involved in the review
process should be aware of reporting requirements under Wis. Stat. s. 448.115
• Requires physicians to report other physicians.
• Can be handled by hospital on behalf of all physicians with knowledge.
• If the situation involves rudeness/ behavioral concerns with a patient, consider
SEVEN CALENDAR DAY timeline for investigating and reporting caregiver misconduct
to the State (Office for Caregiver Quality).
42
Current Cases: Medical Staff Nightmares And Fairy Tales
This session will cover the challenging and thorny medical staff issues that your speakers have handled (from a legal perspective) in recent times. This will include the algorithm for deciding whether to proceed down an employment road versus a medical staff road with employed physicians, the tricks of managing corrective action and confidentiality issues and how to handle questions from coworkers, patients and community members, leaves of absence, the reporting parameters for suspension versus relinquishment of privileges, and other interesting but challenging experiences.
Program Objectives:
Learn from recent experiences about the current issues posing the most difficult problems in medical staff discipline/ corrective action.
Understand the options with employed physicians (or other medical staff members).
Understand leave of absence implications from a medical staff standpoint.
Understand reporting parameters in various scenarios.
Understand the nuances of managing privileging and corrective action processes with physicians who are employed by the system versus independent physicians with privileges.
Understand the roadmap for navigating the process set forth in the medical staff bylaws in a manner that maintains immunity for participants in the process and reduces liability risk.
Understand the interface of medical staff leaves of absence with investigations.
Understand the various reporting obligations for individual physicians, medical staff leaders and hospitals.