Question of the Week

We recently received an NPDB report for one of our Medical Staff members.  The Adverse Action Code, used by the hospital in its NPDB report, was “Voluntary Surrender of Clinical Privilege(s), While Under, or to Avoid, Investigation Relating to Professional Competence or Conduct.”  However, the narrative section of the NPDB report reflected that the physician resigned during a “performance improvement plan” (PIP).  We don’t consider a PIP to be an investigation and ordinarily we would not report a physician who resigned during a PIP.

The problem is that the threshold criteria in our bylaws state that an individual is ineligible for appointment, reappointment or continued appointment if they “resign during an investigation or in exchange for not conducting an investigation.”  Our bylaws also provide that failing to satisfy threshold criteria at any time results in an automatic relinquishment of appointment and clinical privileges.

The physician is a longstanding member of our Medical Staff and we have never had any quality or behavior issues with him.  Based on the NPDB Report, he doesn’t seem to meet our threshold criteria and his appointment should be automatically relinquished, at least according to our bylaws.  What do we do?

Before you make any decisions, you are going to need additional information.  You can start with the physician and ask him to provide information regarding the underlying issues that led the other hospital to adopt the PIP.  You are also going to want a copy of the PIP itself.  Your bylaws should allow you to request this information from the physician.  You can also request the physician to sign an authorization so you can get information directly from the other hospital.  This will allow you to understand their side of the story.

Depending on what you learn, it may be appropriate to allow the physician to request a waiver for failing to satisfy one of the threshold criteria.  For instance, if you learn that the PIP was being carried out as part of initial collegial efforts and progressive steps activities, without any history of prior problems, and would not have risen to an investigation in your hospital, you may consider granting the physician a waiver.

The waiver process typically involves all the heavy hitters including input from the department chair and a recommendation from the Credentials Committee and Medical Executive Committee with final action by the Board.  Any grant of a waiver should expressly articulate the reasons supporting the decision.

Even if you decide to grant a waiver, that doesn’t mean you have to ignore the PIP.  If the PIP developed by the other hospital has useful conditions, you may want to adopt some or all of them to help you evaluate the physician’s performance and provide meaningful feedback to him.

The language in the Bylaws pertaining to automatic relinquishment if threshold criteria are not met should include a reference to the waiver process.  Therefore, the granting of a waiver should address and resolve the automatic relinquishment with no need for further action.

Both the threshold eligibility criteria and the automatic relinquishment language in the Bylaws are incredibly useful tools and are two of our “go to” favorites.  As we expand our list of robust threshold criteria and our list of events that trigger an automatic relinquishment, we should also strive to make sure that these are being applied in a way that is fair and reasonable.  Along these lines, it is important to make sure we have adequate information, especially from the involved physician, before making a final decision.  And if occasionally we bend to make sure the result is appropriate under the circumstances, that’s not a bad result either.

If you have a quick question about this, e-mail Susan Lapenta at