Introduction

HortySpringer Pathways Webinar Session 4: Formal Investigation & The MEC Action that Follows

While the vast majority of concerns about a practitioner’s clinical performance, professional conduct, or health status are resolved with education and other informal and/or collegial measures, virtually every health care organization will periodically come face-to-face with a concern that is far too serious for collegial intervention or a practitioner who is resistant to the leaders’ collegial efforts.  That’s when a formal “investigation” becomes necessary.  And since the stakes are high (appointment and/or privileges can be at stake!), it’s important to be meticulous.

But, how can organizations master investigations when they are only a small, infrequent part of the review process?  A good first step is to ensure that all hospital and physician leaders are trained about the role of investigations in the grander PPE process.  This can help to eliminate one of the biggest hiccups in the investigation process (when no one is sure whether or not the current process is actually an “investigation” or not).  Then, outlining detailed investigation procedures in the Medical Staff Bylaws and/or Credentials Policy can help to guide the leadership (along with their counsel) once a formal investigation is actually underway.  During this final installment of the 2024 Pathways leadership training program, we will discuss essential provisions for your Bylaws and policies, as well as tried and true methods for conducting investigations and considering/taking adverse professional review action.

Topics to be Covered:

• When does an investigation begin? (Is an applicant for reappointment under “investigation”?  Is failure to renew the same thing as a resignation while under investigation? Do all precautionary suspensions begin an investigation?  Should investigations begin only with written and signed requests for corrective action?)

• Why is an investigation necessary after one or more rounds of PPE have already been conducted?

• Who should serve on an investigating committee (should it be a subcommittee of the MEC?)

• Providing the practitioner with notice of an investigation and an opportunity for input

• What to tell the MEC and/or Board about ongoing investigations

• The role of attorneys in investigations

• Comprehensive fact gathering (interviewing witnesses and exhaustively gathering information that may be relevant)

• Documenting witness interviews

• Investigating committee report/findings & recommendations

• When does the investigation end? (and what are the NPDB reporting implications?)

• Steps to take before making an adverse professional review recommendation

• How to record minutes of an MEC meeting at which adverse recommendation is made

• Giving a reference for someone under investigation or with an adverse recommendation pending

• Special considerations at reappointment when the practitioner is under investigation or has an adverse recommendation pending

Supplemental Materials:

• Investigation checklist

• Sample letter appointing investigating committee member(s)

• Sample letter documenting voluntary refrain

• Sample reappointment letter (applicant under investigation)

Learning Objectives:

Upon completion of this audio conference, participants should be able to:

1. Identify the method(s) for commencing a formal Medical Staff investigation;

2. Appoint an investigating committee that complies with the requirements of the Health Care Quality Improvement Act (HCQIA) and minimizes the risk of conflicts of interest;

3. Prepare an investigation report that documents with clarity the good work of the investigating committee, including the information gathered, the issues considered, and the recommendation for next steps; and

4. Usher the investigating committee’s report through the MEC, for consideration and action, in a manner that is thoughtful and fair to the practitioner under review.