Once a hospital is on notice about something that may affect the care of its patients, it has an obligation to obtain enough information to review the matter thoroughly. It must then take the steps necessary to protect its patients.

This question is most often raised when a physician has been the subject of professional review action at another hospital, or when a physician is involved in malpractice litigation that calls into question his or her qualifications. In such situations, the hospital should not simply adopt the action taken by the other hospital or accept the allegations or jury verdict in the malpractice litigation. Rather, the hospital should obtain sufficient information to permit a thorough review of the matter and then to make an independent assessment of the concerns raised. As part of this review, the medical staff leaders can and should factor in firsthand information about the physician's practice at their hospital.

It is important to remember that the burden is on the physician to provide the information necessary to resolve any doubts about his or her qualifications for continued appointment and clinical privileges. This also applies to conduct that occurs outside the hospital. The physician's refusal to provide the necessary information, or to assist in obtaining it from a third party, may be grounds for automatic relinquishment of clinical privileges until that information is provided and the doubts are resolved. Of course, the Medical Staff Bylaws should contain provisions authorizing the "automatic" relinquishment of privileges in such situations.

We suggest taking the following steps:

1. Talk to the physician.

The first step is to meet with the physician, share the information that has come to the medical staff leadership's attention (but not necessarily how it came to light, if the individual who reported it wishes to remain anonymous), and inquire of the physician if a problem exists and, if so, the nature of the problem. The physician may or may not be forthcoming, but speaking directly to him or her should always be the first step.

2. Get the facts.

Ask the physician to provide all relevant information needed to determine whether there is a legitimate issue of concern. Depending on the situation, that information may include minutes of meetings from the hospital where the physician is under review, correspondence to the physician outlining the problem by hospital or medical staff representatives where the review is under way or contemplated, transcripts of proceedings, results of chart reviews, patient medical records, etc.

3. Make inquiries.

If there is any doubt about whether the physician has provided all necessary information to make an informed decision, ask the physician to authorize the other hospital to directly provide all relevant information.

4. Make an independent assessment.

The investigation has been sufficiently thorough when the questions have been resolved to satisfy the Executive or Credentials Committee that the physician is qualified to exercise the clinical privileges held or appropriate action is taken to modify those clinical privileges. The primary duty of physician leaders is to look out for the best interests of patients.