reappointment

May 28, 2020

Posted on by hortyspringer

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.

March 19, 2020

Posted on by hortyspringer

QUESTION:          As we ramp up our response to COVID-19, we are concerned that we may not be able to process routine applications for reappointment in a timely fashion.  Do we have any leeway?

ANSWER:            The Joint Commission recently published an FAQ on this issue.   According to the FAQ, if an established member’s clinical privileges are going to expire during the national emergency, The Joint Commission will allow an automatic extension so long as the following conditions are met.

First, a national emergency must have officially been declared.  As we know, this happened by proclamation dated March 13, 2020.  Second, your organization must have activated its emergency management plan.  This activation should be documented.

Finally, state law must not prohibit extending the duration of privileges during an emergency.  Most states are issuing broad emergency orders allowing for flexibility in the health care arena to respond to COVID-19.  We do not expect this last factor to serve as a prohibition.

According to The Joint Commission, the duration of the extension cannot exceed 60 days after the state of emergency has ended and the organization should “determine[] how the extension will be documented.”  We have included a sample resolution below that addresses both extending the term of reappointment and the grant of disaster privileges.

BOARD RESOLUTION

PRACTITIONER CREDENTIALING DURING THE COURSE

OF THE COVID-19 NATIONAL EMERGENCY

WHEREAS, the COVID-19 national emergency has caused widespread closure and/or personnel strain at health care facilities, universities, and government agencies, and has resulted in the cancellation of many activities underlying practitioner credentialing (e.g. board certification examinations, basic life support, and other certifications) and disruption of the Hospital’s ability to obtain primary source verification of certain practitioner credentials during the course of processing applications for initial appointment to the Medical Staff and Advanced Practice Clinician Staff (“appointment”), for the grant of clinical privileges, and for the processing of applications for reappointment to the Medical Staff and Advanced Practice Clinician Staff (“reappointment”);

WHEREAS, the COVID-19 national emergency may create a need for the Hospital to grant clinical privileges to practitioners whose credentials are not in accordance with those required in non-emergency periods, as outlined in the Medical Staff Bylaws, Medical Staff Credentials Policy, and related policies, procedures, and privilege delineation forms;

NOW, THEREFORE, BE IT RESOLVED THAT the Board has determined that immediate, temporary credentialing methods are necessary to ensure that the Hospital can continue to meet the needs of the community during the course of the COVID-19 national emergency.  As such, the credentialing methods set forth in this resolution are hereby authorized for individuals seeking appointment, reappointment, and clinical privileges, for the duration of the COVID-19 national emergency and for the immediate time period thereafter up to 60-days following the conclusion of the COVID-19 national and/or local emergency declarations)

BE IT FURTHER RESOLVED THAT during the course of the COVID-19 national emergency, the procedures for disaster privileging may be followed to grant clinical privileges to those specifically responding to the COVID-19 national emergency, as well as to applicants for initial appointment or initial clinical privileges, or applications for additional privileges from practitioners already practicing at the Hospital, insomuch as the credentialing of such individuals is disrupted by the COVID-19 national emergency.

BE IT FURTHER RESOLVED THAT during the course of the COVID-19 national emergency, the Chief of Staff is authorized to extend the reappointment and clinical privileges of any practitioner who is currently appointed with privileges at the Hospital as of March 13, 2020 (the date the COVID-19 national emergency was declared).  Unless otherwise determined by the Chief Executive Officer, the extension of reappointment and clinical privileges will last until 60-days following the conclusion of the COVID-19 national emergency or until such time as the individual’s application for reappointment and renewal of clinical privileges can be processed, whichever occurs sooner.

ADOPTED by the Board, March _____ 2020.

                                                                              

Chairman, on behalf of the Board of Trustees

For more information on privileging during a national emergency or disaster, click here or here.

April 20, 2017

Posted on by hortyspringer

QUESTION OF THE WEEK

QUESTION:        Our current Medical Staff Bylaws state that in order to be eligible for reappointment and renewal of clinical privileges, an individual must have “completed all medical records” during the previous appointment term.  However, even if an individual was compliant 100% of the time, on the date the application was filed, not all of the individual’s medical records would be complete, as some would be outstanding.  How do you resolve that issue?

ANSWER:            We have had several hospitals that we have worked with on Medical Staff Bylaws projects raise the issue that no one is, in fact, compliant with medical records all of the time.  Therefore, no one would truly be eligible for reappointment if eligibility required that an individual have completed all medical records during the previous appointment term.  As referenced in the question, even if an individual was compliant with medical records requirements 100% of the time, on the date the application was filed, not all of the individual’s medical records would be complete (some would be outstanding, but not delinquent).

So, we recommend expanding on the “completed medical records” language by having the Medical Staff Bylaws state that in order to eligible for reappointment, an individual must have:

completed all medical records such that he or she is not delinquent, as per the Medical Staff Rules and Regulations and Hospital policy, at the time he or she submits the application for reappointment or renewal of clinical privileges and, further, was not deemed delinquent (sufficient to result in the relinquishment of privileges) more than _____ time(s) during the prior appointment term.

January 26, 2017

Posted on by hortyspringer

QUESTION:        An applicant for reappointment has requested privileges that he has not performed for many years (and he doesn’t perform them anywhere).  Can we deny the request?

ANSWER:           The D word is not the best answer; why not approach it by developing eligibility criteria for core and special privileges?  A determination of ineligibility is not an adverse professional review action, and so is not reportable.  CMS requires that hospitals consider evidence of current competence in granting and renewing privileges.  What is “current”?  For many procedures and practice areas, there is a recognized correlation between proficiency and performance.  A two-year reappointment cycle is a logical period, except perhaps for procedures that are very rarely done (but it may be vital to maintain privileges for those unusual occasions where a patient can’t be transferred in time to help).

Join us for our Grand Rounds audio conference on Feb. 7 when we address how you can design policies to help handle a number of privileging dilemmas.

October 27, 2016

Posted on by hortyspringer

QUESTION:        We have an applicant who had significant issues at the last hospital where she practiced, significant enough that she left while under investigation.  The NPDB report provided us with very little information, really only enough to know that the matter appeared to involve behavior and not clinical care, but it certainly was not enough to feel like we know what happened.  The hospital won’t respond to our requests for information, and when we formally asked the applicant for additional information, her lawyer sent us a letter telling us she is bound by a “legally binding” settlement agreement not to disclose what happened except that she had decided not to pursue the investigative process.  What can we do?

ANSWER:            This is a classic example of an incomplete application.  Settlement agreement or no, you should advise the applicant that she has the burden of producing information sufficient to evaluate her qualifications.  You can agree to keep any information provided to you by the applicant, and by the other hospital, confidential for use in your credentialing process only.  However, you cannot process this application without some information to determine the basis for the physician’s resignation while under investigation.  If she does not provide the information within a reasonable time, you can advise her that her application will be deemed to have been withdrawn.  It is helpful to have very clear and direct language in the Medical Staff Bylaws to emphasize that the burden is on the applicant to provide information necessary to assess qualifications, as well as a statement that incomplete applications will not be processed.  Don’t be dissuaded by the existence of a settlement agreement – the courts have supported the need to obtain information relevant to the credentialing process.

In Scott v. Sisters of St. Francis Health Services, 645 F. Supp. 1465 (N.D. Ill. 1986), St. James Hospital refused to forward Dr. Mac Scott’s application to the Credentials Committee because it had been unable to obtain information regarding his suspension and subsequent resignation from the medical staff of Ingalls Hospital.  Dr. Scott had sued Ingalls Hospital and, as part of a settlement agreement, the hospital could only respond to inquiries about Dr. Scott with a form letter prepared by Dr. Scott’s attorney, which provided no meaningful information upon which to make a recommendation regarding appointment.

Dr. Scott sued, alleging:  (1) that the refusal to forward his application to the Credentials Committee was a violation of his civil rights and racially motivated; and (2) that the hospital president had exceeded her authority by refusing to forward the application.  The federal district court rejected those arguments and entered judgment in favor of the Sisters of St. Francis Health Services, stating:

Scott’s assertion, however, does not take into account the fact that the bylaws provide that Sister is to forward only completed applications to the Credentials Committee for consideration.  Sister discussed with Scott the problems he experienced at Ingalls and the need for additional information from Ingalls about his suspension.  Sufficient evidence was presented at trial to show Scott’s application was incomplete, and Scott’s efforts prevented St. James from obtaining needed information from Ingalls.  As such, Sister’s decisions to not forward Scott’s applications were not outside the bounds of her authority as President of St. James nor indicative of any intent to discriminate against Scott on the basis of his race.  [Emphasis added.]

Additional cases that have held that a hospital has no duty to process an incomplete application include Evers v. Edward Hospital Association, 617 N.E.2d 1211 (Ill. Ct. App. 1993), and Eyring v. East Tennessee Baptist Hospital, 950 S.W.2d 354 (Tenn. Ct. App. 1997).  (While Scott and Evers involved the initial credentialing process, Eyring was a reappointment case.)