QUESTION: Our Medical Staff policies call for a multi-specialty peer review committee to address concerns about a physician’s clinical skills, and a small Leadership Council to address behavioral concerns. What happens if there are concerns about a physician that involve both clinical and behavioral issues. Which process should we use?
ANSWER: One option is to have the multi-specialty peer review committee address the clinical matter while the Leadership Council separately addresses the behavioral concern. However, if the clinical and behavioral concerns are related, it may be best to have the same committee review both. Using two committees may result in a less effective review.
Another option is to have a single committee address both the clinical and behavioral concerns. However, if this approach is used, it should be explicitly described in your policies. Otherwise, no matter what review path is chosen, the physician in question might claim that the review is invalid because it was conducted by the wrong committee.
We recommend that language similar to the following be in the Professional Practice Evaluation Policy (for clinical concerns):
If a matter involves both clinical and behavioral concerns, the Chairs of the Leadership Council and the Professional Practice Evaluation Committee (“PPEC”) shall coordinate the reviews. The behavioral concerns may either be:
(i) addressed by the Leadership Council pursuant to the Professionalism Policy, with a report to the PPEC, or
(ii) addressed by the PPEC pursuant to this Policy, with the provisions in the Professionalism Policy being used for guidance.
Similar language should be included in the Professionalism Policy.