QUESTION:
I serve on the peer review/MEC in one hospital system and as department chair at another regional system. A physician is under FPPE for very serious patient safety concerns at the first system, and he has now applied for privileges at the second system (where I am department chair). I don’t think I can divulge any protected information I have knowledge of. What can I do? (Registrant Q&A, submitted electronically at The Complete Course for Medical Staff Leaders, held in Nashville (Spring 2025).)
ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:
You are in quite the pickle! To avoid this scenario, we have historically advocated for Medical Staff leaders to avoid, if possible, serving in leadership roles at multiple nearby hospitals. But, we understand that leadership pools are shallow and leadership functions are being performed by a very small minority of do-gooders within medical communities. Further, we observe that it is quite common for medical directors of hospital-based services to serve as department chairs at multiple facilities.
Luckily, you can likely find a solution to your conundrum that will allow you to satisfy your obligation to protect patients at system #2 (where you are department chair), while also fulfilling your duty of loyalty and confidentiality to the first system (where you serve on the peer review committee and MEC).
Specifically, in a situation such as this, the best way forward may be to take action to cause system #2 to make a request to system #1 for information concerning the practitioner in question. In other words, as department chair at system #2, you could – as part of your evaluation of the application in question – contact system #1 to request an updated affiliation verification or an updated reference (for example, from the department chair and/or CMO at system #1).
You would not need to specify the exact reason for asking for the information. It should suffice for you to state that, as department chair, you believe it is appropriate and necessary to request further information about the practitioner’s tenure at system #1 (if pressed, you should not have to say anything more than “confidentiality requirements prohibit me from providing any additional explanation”). Of course, to avoid any appearance of impropriety or any allegation that you inappropriately divulged protected or privileged information, it is probably best to have the request for information from system #1 occur in writing (rather than via a telephone call or in-person conversation). From a practical perspective, that might mean contacting the Medical Staff Services Department at system #2, to let them know that you recommend system #1 be contacted for more information regarding the physician’s affiliation.
Note that any request for information that is sent should be worded broadly enough to ask not only about any adverse professional review actions (e.g., revocations, suspensions, restrictions), but also any other recent or pending focused reviews of the practitioner and/or performance improvement plans involving the practitioner. With this step taken, there would be no need for you to violate any confidentiality requirements that apply at system #1 by revealing additional details. You could simply sit back and wait for the reply from system #1.
If you have a quick question about this, e-mail Rachel Remaley at rremaley@hortyspringer.com.