April 4, 2013

Question: Our Professional Practice Evaluation Committee (PPEC) chair is also a member of our Credentials Committee. Does this arrangement create inherent conflicts, or should we be concerned that this individual may be biased by what she learns in one meeting or the other?

Answer: It is always wise to be mindful of potential biases/conflicts (or appearances) that might arise when a Medical Staff member wears multiple hats. And while the Medical Staff leadership always has the discretion to determine whether a conflict or bias exists, in this case, we do not believe that having the PPEC Chair on the Credentials Committee is inherently problematic.

Primarily this is because the two committees are involved in very different processes (i.e., focusing on a specific problem vs. credentialing and privileging issues).  In addition, because of the multiple levels of review in each of these processes, there are sufficient checks and balances in place to prevent one individual from influencing any recommendations that are ultimately passed up the chain of command.  It is also helpful to note that neither the PPEC nor the Credentials Committee has authority to recommend adverse actions.   This resides with the Medical Executive Committee.

Of course, if some unique situation ever did arise, the committee members always have the discretion to recuse this individual if it is believed that his or her presence would be unfair to a certain physician or if his or her presence would inhibit discussion or otherwise skew the recommendation of the committee. Sometimes, recusal is best just to manage appearances, to keep the focus on the merits.