Month: June 2019

June 27, 2019

Posted on by hortyspringer

QUESTION:        We heard that some hospitals have recruited physicians, had them sign employment contracts, then “red flags” are raised during credentialing, or the physician is denied appointment and clinical privileges.  Is there any language in an employment contract to help in those cases?

ANSWER:            We recommend that all employment contracts contain a provision that states:

If the Physician fails for any reason to commence performing services on the Commencement Date, the Employer may, at its option, cancel this Agreement by serving written notice of cancellation to the Physician.  In the event notice of cancellation is sent, the parties shall have no further obligation to one another.

The provision does not require an employer to cancel the contract, but does give the employer the option.  So, if the physician does not commence performing services because the application has not been acted on because the employer or the hospital is gathering further information, the employer may decide that it does not want to exercise the option at that time.  Conversely, if the “red flags” are significant, the employer most likely would cancel the contract.

While this language is useful to include, it is not a guarantee that a physician who has been recruited will go away quietly.   In fact, we have seen a number of cases where the physician still sues, so the best practice is to better align your recruitment and credentialing decisions so that you do not find yourself in the situation where a new recruit has any significant “red flags.”  For additional information, join us for our audio conference

“Aligning Your Employment and Credentialing Decisions”
July 2, 2019 – 1:00 pm to 2:00 pm (ET)

or contact us for information on how to obtain a CD or MP3.

June 20, 2019

Posted on by hortyspringer

QUESTION:              I noted that one of the cases that was in this week’s HLE arose as a result of a hospital granting temporary privileges to an applicant for medical staff appointment.  While we do not routinely grant temporary privileges, they are useful from time to time.  How much risk is there in granting temporary privileges?

 

ANSWER:                 While temporary privileges should not be routinely granted, it is not unusual for a hospital’s medical staff bylaws to state that temporary privileges may be granted to applicants for initial appointment whose complete application is pending review by the Medical Executive Committee and the Board. In order to be “complete” there must be verification of licensure, training or experience, current competence, and an ability to perform the privileges requested. In addition, the bylaws should state that in order to be eligible for temporary privileges, an applicant must (i) have had no current or previously successful challenges to licensure or registration, (ii) have not been subject to involuntary termination of medical staff membership at another organization; and (iii) have not been subject to involuntary limitation, reduction, denial, or loss of clinical privileges.   The bylaws may include other criteria that must be met before temporary privileges are granted.

Additionally, the hospital must query and evaluate information from the National Practitioner Data Bank and check the Office of Inspector General’s List of Excluded Individuals/Entities before temporary (or any privileges) can be granted.  Finally, the grant of temporary privileges should be time limited consistent with the standards of the applicable accreditation organization.  According to The Joint Commission standard “Temporary privileges for applicants for new privileges are granted for no more than 120 days.” 

It is not clear, but it appears from the facts of the case described above, that the hospital’s hospitalist group had such a need for the nocturnist that it wanted to use temporary privileges to rush a candidate through the hospital’s credentialing process.  The temporary privileges were granted and rescinded in 2012, but the litigation did not end until 2019.  In this case, not only did granting temporary privileges fail to fill the nocturnist position, but also caused the hospital years of litigation.

The best way to avoid these kinds of situations and the endless litigation that sometimes ensues is only to grant temporary privileges to applicants after a thorough vetting, after confirmation that there are no red flags and only under the above-described circumstances.

June 13, 2019

Posted on by hortyspringer

QUESTION:         A registrant at our April Complete Course for Medical Staff Leaders in New Orleans submitted a question about waiver of threshold eligibility criteria for an applicant  (a general practitioner who did an internship in 1985 but not a residency and so cannot even sit for the boards, who has been doing only outpatient primary care since).  The criteria specify that grandfathering is possible for those who finished training before 1985; after 1985, a physician must achieve board certification within three years of appointment.  All references are excellent. What can we do?

ANSWER:            The question does not reveal why this physician wants to be on the medical staff or whether privileges would be sought in addition to appointment.  In order to be eligible for any privileges, regardless of medical staff category, any applicant must be able to demonstrate current competence, according to CMS. Often, the eligibility criteria require that a candidate has practiced in at least two of the preceding four years in a hospital setting. Many organizations have a category for office-based practitioners, without any privileges. Some physicians wish to have a connection with the hospital for purposes of continuity of care when they refer patients for inpatient care to hospitalists.  Possibly this physician wants appointment to be on health plan panels.  (The latter is not a reason, in itself, to grant appointment.) When a physician is appointed to any category of the medical staff, even a category that does not carry with it any privileges, the public (and health plans) may rely on the hospital’s imprimatur.

The courts have upheld grandfathering in certain circumstances, but usually that is limited to individuals who have been on a medical staff for a number of years who have a track record that can be evaluated, when new policies require board certification for all applicants after a certain date. The hospital is not required to process an application for initial appointment from those who are not eligible.  In the questioner’s situation, the only option other than declining to process the application based on ineligibility may be to consider appointing this individual to a membership-only category with no privileges. To consider even that type of appointment, many organizations would obtain evaluations from physicians to whom the outpatient practitioner has referred patients, to be sure that this outpatient practitioner is referring patients for the right reasons and doing the right pre-referral assessment.

As a final point on waivers generally, an occasional waiver in exceptional circumstances is usually preferable to modifying standards to fit a particular unusual situation and risking opening the door to others. Anytime a waiver is to be considered, it’s best to follow a process, specified in the Credentials Policy, and include a statement that the waiver is not intended to set a precedent for anyone else.  And, any waiver should be based on exceptional qualifications of the applicant and the best interest of the hospital and community.

June 6, 2019

Posted on by hortyspringer

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QUESTION:        Our Medical Staff year ends this month, so we have new officers and department chairs coming on board.  Every year we struggle with getting these individuals up to speed, since they typically have little to no leadership experience. What are our options to offer training to the uninitiated?

ANSWER:            We hear this time and time again wherever we go.  Physicians are elected or appointed to key roles that impact credentialing, peer review, and, most importantly, patient safety, yet they are given no guidance or training on how to perform these important functions. Fortunately, you have a number of options available.

Many organizations have taken it upon themselves to develop internal leadership training opportunities.  This could range from holding quarterly “retreats” supplemented by external experts in the field (an option we have been very honored to partner with a number of hospitals and systems on) to developing “in house” training modules that are provided to new leaders as a part of their onboarding process. One of our favorites was an outgoing Chief of Staff who wanted to pass on her experiences and lessons learned by developing a “Cup of Coffee” training course for tips on how to hold a productive collegial intervention.

Others have simply created a Medical Staff leader handbook that passes along important information about responsibilities, the importance of confidentiality, the legal protections that are available to Medical Staff leaders, etc.

Of course, we feel that one of the best ways to provide education to your new leaders is to send them to one of our national seminars.  Horty Springer has been offering seminars for physician leaders for more than 40 years, covering a range of topics related to credentialing and peer review. We just released our seminar schedule for 2019/2020, so consider joining us in Las Vegas, Naples, Savannah, or Chicago.  We’d love to see you and your new leaders there!