Submitted at HortySpringer’s Complete Course for Medical Staff Leaders held in New Orleans, April 2026:

QUESTION:
Does a practitioner who has been notified he/she is being investigated have the right to know the names and specialties of the members of the Investigating Committee prior to meeting with them?

ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:
There is nothing in the Medicare Conditions of Participation for Hospitals that requires a hospital or its medical staff to inform a practitioner of the composition of an investigating committee.  Nor is immunity under the safe harbor provided by the Health Care Quality Improvement Act dependent on providing that information.  The Joint Commission accreditation standards also are silent on this matter.  So, whether you must inform a practitioner of the identity of the members of an investigating committee is dependent on whether your state law requires it (off the top of my head, I cannot think of a single state that does…but it’s worth checking the detailed provisions governing peer review in your state hospital licensing regulations just to make sure because some states have extensive requirements) and whether your hospital’s Medical Staff Bylaws and other governance documents require it.

We generally recommend Medical Staff Bylaw and policy language that requires a practitioner to be informed promptly that an investigation has been commenced (unless specified leaders document good reason for not doing so).  Further, we recommend policy language stating that the practitioner will always be invited to a meeting/interview with the investigating committee prior to it reaching its findings and issuing a report.  This opportunity to be heard is fundamental to fairness of the investigation process.

Most organizations inform the practitioner of the identity of the investigating committee’s members at the time they notify the practitioner of the commencement of the investigation or, alternatively, as part of the notice/request to meet (with that notice also providing information about the nature of the concerns identified during the investigation).  But, that level of sharing is not always required in the Bylaws or policy documents.  Regardless of whether it is required, there is inherent value in providing this level of transparency in the investigation process and we generally recommend it.  Doing so sends the message to all Medical Staff members and other practitioners that the professional review activities of the Medical Staff are fair and impartial and “on the up and up.”  No one wants to be subject to scrutiny by their workplace peers, but doing so when the rules and participants are clear is far more palatable.  Further, if practitioners know the participants in an investigation, they are better able to raise any conflicts of interest or other concerns early in the process.  And if any of those concerns are valid, it could help hospital and medical staff leaders avoid a future dispute (and possible avoid having to repeat the review process at a later date).

If you have a quick question about this, e-mail us at info@hortyspringer.com.