QUESTION: We have a physician who is up for reappointment and when we started to pull the credentialing, peer review, and quality information together we realized there were very serious concerns that might warrant an adverse recommendation. We were wondering, do we have to start a formal investigation or, if warranted, can we just make an adverse recommendation at reappointment? Are there any steps we should follow to make sure we are being fair to the physician and protecting ourselves at the same time?
ANSWER: Reappointment should be an opportunity to make an evidence-based decision that reflects data that has been gathered during the most recent appointment period. (You can certainly look back further if you need to gain perspective or discern if there are patterns of care or conduct that have been developing.) Ideally, you will address issues as they come up through the peer review process. But sometimes, even with a robust peer review process, you don’t see the whole picture until reappointment.
Certainly, if, in looking at relevant information at reappointment, you are concerned enough to consider an adverse recommendation because a lesser action will not be sufficient to protect patients, you have the authority to make that recommendation. To answer your specific question, there is generally no reason why you would have to commence a formal investigation, separate and apart from the reappointment process. While many bylaws require that the Medical Executive Committee commence an investigation before making an adverse recommendation, that step would not be required if you are already in the midst of the reappointment evaluation.
In most organizations, the Credentials Committee would do the heavy lifting at reappointment. That means the Credentials Committee would evaluate the information including documents from the peer review process, incident reports, letters, minutes, and reports. The Credentials Committee can also rely on the clinical expertise of the department chairperson at reappointment.
As a matter of fairness and good practice, even if your bylaws (or credentials policy) don’t require it, we strongly recommend that the Credentials Committee meet with the physician before it makes an adverse recommendation. The physician should be given advance notice of the concerns and at the meeting (or in advance of it) the physician should have an opportunity to respond to the concerns. It will be very helpful to keep a detailed summary of this meeting, including the physician’s response. The minutes should also reflect, in some detail, the reasons for the adverse recommendation – you’ll need that when you get to the hearing.
One issue that sometimes comes up in difficult reappointment matters is timing. If the physician’s current appointment is set to expire, you may need to grant a short-term conditional reappointment to give you time to conduct the evaluation and assessment, meet with the physician, and prepare a report of concerns to support an adverse recommendation. The report and recommendation of the Credentials Committee will need to be forwarded to, and acted on, by the Medical Executive Committee. If the Medical Executive Committee upholds the adverse recommendation that will trigger the physician’s right to a hearing.
Remember, the hearing and appeal processes are going to take months to complete. The Credentials Committee and Medical Executive Committee should consider whether there are any conditions that need to be put in place while the processes are being carried out to keep patients safe in the interim.