July 14, 2016

Posted on July 14, 2016July 14, 2016 by hortyspringer

QUESTION: We have several ambulatory surgery centers (“ASCs”) in our System. We recently looked at the bylaws of the ASCs and they are quite antiquated. Even more of a concern, we learned that the credentialing process in the bylaws is not being followed at the ASCs. We need to work with the ASCs to change their bylaws, but where do we start? The medical staff bylaws (and credentials policy) for the hospitals in our System are now all very similar. Can we incorporate the ASCs into the medical staff bylaws?

ANSWER: You asked if the ASCs could be incorporated into the medical staff bylaws of the hospitals in your System. This approach has the appeal of simplicity. However, given the vast differences in the size, structure, and organization of the medical staffs at the ASCs and the medical staffs at the hospitals, this option seems awkward at best. There might also be some regulatory issues with this approach. Specifically, the ASCs are required to have their own medical staffs in some states. Thus, in order for the medical staffs of the ASCs to function as a part of the medical staffs of the System hospitals, it could be necessary to seek an exception from the Department of Health.

Another option would be to take the medical staff documents that were prepared for the System hospitals’ medical staffs and use them as a starting point for the creation of governance documents for the ASCs. We recommend this approach for several reasons. First, this approach would provide an opportunity to update the ASC bylaws to reflect current practices. Second, this approach would help ensure that the ASC bylaws are well-drafted and in compliance with controlling law. Third, while the hospital medical staff documents would have to be substantially pared down and streamlined for use by the ASCs, these documents would include key provisions, such as a System Credentials Committee, a Professional Affairs Committee to resolve disputes among the Medical Executive Committees, and language to ensure that decisions at one System facility are applicable at all System facilities, which would facilitate uniformity within the System.

May 26, 2016

Posted on May 26, 2016 by hortyspringer

QUESTION: Do hospital-employed physicians have a conflict of interest with respect to private practice physicians in matters involving credentialing? Privileging? Peer review?

ANSWER: Some independent physicians may feel that employed physicians should not be involved in leadership positions or that there should be quotas pertaining to the number of employed physicians in these positions for fear that their employment relationships could influence their actions. Legally, there is no support for viewing an employment relationship as a disqualifying factor. And we have rarely seen the type of political pressure from management that independent physicians worry about being brought down on employed physicians.

Of course, if a specific concern is raised about an individual’s participation in any given process, it always makes sense to consider whether an individual’s employment would result in a conflict of interest under the guidelines that have been adopted by the medical staff. But practically, it seems difficult to imagine a medical staff adopting bylaws documents that exclude employed physicians from serving in leadership positions – or from otherwise participating in credentialing and peer review activities – given the large number of physicians who are now employed by hospitals.

February 18, 2016

Posted on February 18, 2016February 22, 2016 by hortyspringer

QUESTION: A registrant at our recent Complete Course for Medical Staff Leaders in Naples asked: Can you change the bylaws AFTER someone’s already credentialed, even if it might make that physician ineligible at recredentialing (e.g., thresholds)? If ineligible, is that reportable to the NPDB?

ANSWER: Yes and No. An organization can decide to revise its eligibility criteria; it may choose to “grandfather” current staff members (upheld by several courts in cases involving board certification, when potential applicants alleged disparate treatment). However, grandfathering is not required. An organization can decide to apply the new criteria uniformly. It is fair to provide advance notice and an opportunity for those affected to be heard (and to become eligible, if possible).

Leaders should carefully assess the need to apply the standard to current members and to articulate the quality rationale. A determination of ineligibility is not an adverse professional review action and is not reportable to the National Practitioner Data Bank.