July 16, 2020

QUESTION:        Our newly elected Chief of Staff is currently a department chair at our hospital.  She really likes the department chair position and is good at it.  At the same time, she also wants to fulfill the will of the Active Staff members who elected her to serve as the Chief of Staff.  Can she serve both positions at the same time?

ANSWER:            Serving in two leadership roles in the same hospital is not technically a conflict of interest, so unless there is a provision in the medical staff bylaws stating that an individual cannot serve in both roles, there is likely no technical reason that she cannot serve in both positions.  That said, practically speaking, it may not be the best idea.  Department chairs often have significant duties in terms of performing mentoring efforts and collegial counseling sessions with members of their departments in addition to their obligations to reviewing applicants for appointment and reappointment as well as service on the MEC.  In large clinical departments, these responsibilities can be quite intensive.  The Chief of Staff will generally be intimately involved in the active management of the most significant medical staff issues.  Combine those two sets of responsibilities and it is a lot for one person to do, and to do well.  In our experience, when department chairs or division chiefs are elected to serve as either the Vice Chief of Staff or the Chief of Staff, they have typically resigned the department chair/division chief position that they previously held.

February 6, 2020

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QUESTION:      What do you recommend for the composition of the Credentials Committee and the terms for service for the members?
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ANSWER:         A Credentials Committee is best composed of experienced leaders, such as past chiefs of staff or other physicians who have had medical staff leadership experience.  Many Medical Staffs have representation from a variety of specialties to ensure that the committee has the expertise necessary to address difficult credentialing and privileging issues.  With the increasing number of advanced practice clinicians (e.g., nurse practitioners and physician assistants) providing services in hospitals, more and more Medical Staffs are appointing at least one advanced practice clinician to the Credentials Committee as a voting member and for that individual’s input and expertise on the topic of credentialing and privileging these providers.

Service on the Credentials Committee should be the primary medical staff obligation of the members and terms should be at least three years so that committee members have an opportunity to gain some experience and expertise in credentialing.  The terms should also be staggered so that there is always a repository of expertise on the committee.  This Credentials Committee’s primary responsibility is to review and make recommendations on applications for medical staff appointment and clinical privileges.  It can also oversee the development of threshold eligibility criteria for clinical privileges.

August 29, 2019

QUESTION:        Our Credentials Policy says that applicants for Medical Staff appointment and clinical privileges will be interviewed by the department chair, the Credentials Committee, the Medical Executive Committee, the Chief of Staff, the Chief Medical Officer or the Chief Executive Officer.  Is there really any benefit to performing an interview as a part of the credentialing process or should we just eliminate this language from our Policy?


ANSWER:            There certainly is some debate about the effectiveness of interviews in predicting future job performance.  However, much of the research indicates that unstructured job interviews are ineffective.  On the other hand, structured interviews are one of the most effective selection techniques.

In structured interviews, applicants are asked to respond to the same set of questions and their answers are rated on a standard scale.  Sounds complicated, right?  Not necessarily.  We understand that the development of a complex, standard scale for rating would involve the participation of experts; however, a common set of straightforward questions that are structured to elicit information about past behavior (as opposed to questions designed to elicit information about how an applicant would respond in a hypothetical situation) and that are relevant to Medical Staff appointment, measured against a simple rating scale, can be useful.  This task shouldn’t be outside of the Credentials Committee’s wheelhouse.

There is always the risk of variability among interviewers, but this could be minimized by having at least two individuals conducting the interview, using the same scale but rating separately, and then comparing notes after the interview to reduce variability in rating.

Like we mentioned earlier, questions about past behavior are key because there is less opportunity for an applicant to provide a response that is not capable of being verified.  Interview questions can also elicit information about whether the applicant’s views and practice style are consistent with the medical staff and hospital’s culture.

For example:

Q:        What attracts you to this hospital/why are you interested in working here?

Q:        Tell us about a time in which a case of yours was reviewed through the peer review process and how you participated/responded.

Q:        Describe a situation in which you were asked to do something beyond your established responsibilities (e.g., service on medical staff committee, fill in a call coverage gap) and tell us how you responded.

Q:        Tell me about a time when you had a conflict with another physician and how you dealt with that conflict.

Q:        What role do you see the nursing staff playing in patient care in the hospital?

If interviewing every applicant simply isn’t an option because of time constraints, interviews should, at the very least, be conducted when there are questions or concerns about the applicant’s qualifications, experience, education, training, or other aspects of his or her practice that have been raised at any time during the review of the application.  Thus, rather than having a strict requirement that all applicants will be interviewed, you can adjust your Policy language to instruct that applicants may be interviewed.

August 15, 2019

QUESTION:        After nearly six long years of service to my Medical Staff, my term as Chief of Staff is nearly over.  Elections will be held in September and I will hand over this role at the end of December.  Are there any steps I should be taking in these final few months to “pass the torch”?

ANSWER:            First off, thank you for your many years of service and kudos to you for anticipating the changing of the guards that is coming up this fall.  While December may feel far away when people are still returning from their summer vacations, the end of the year will arrive sooner than you think.

Based on your statement that you’ve spent six years in leadership, I’m guessing that you automatically became Chief of Staff after serving a term as the Vice Chief and that prior to that, you served a term as the Secretary-Treasurer.  If automatic succession of officers is indeed the practice within your Medical Staff, the good news is that the soon-to-be-Chief has already had some experience in leadership, has likely already been attending MEC meetings and is probably generally “in tune” with the day-to-day functions of the Medical Staff leadership already.  Accordingly, he or she should be better prepared to take over (when compared with, say, a Chief of Staff elected at random and not through succession).

A few tips on how to increase the chances of a successful and seamless transition:

    • Consider the value of leadership education for new leaders. In our experience, many Medical Staff leaders have questions not only about tough credentialing and peer review issues, but also about fundamentals.  Amongst other things, this includes questions about running meetings (e.g., agendas, minutes, recusals, quorums), intervening with a colleague in a way that is collegial and/or friendly but still gets the point across, and legal protections for leaders (e.g., “If I get sued by a doctor, is my malpractice insurer going to cover that?”).

Some hospitals and medical staffs choose to send all new leaders to leadership education within the first year of any term of office (and require it as one of the duties of the office).  Others simply provide education for all leaders on a periodic basis and ask that anyone who is interested attend.  Providing education to both new and seasoned leaders can be helpful and can provide opportunities for leaders of all experience levels to discuss new strategies and develop new policies and procedures at home.

If you don’t already have a leadership education tradition, now may be the time to suggest it – to help the incoming Chief get off on the right foot.

    • Consider one or more meetings with the incoming Chief of Staff, as well as the chairs of the Medical Staff committees that handle most credentialing and peer review matters. These meetings should be focused on preparing the new leaders to take over.  They can provide an opportunity to review issues that are “in process” and likely to require additional follow-up after the transition to new leadership.  Further, leaders can share insights about challenges and successes during the previous leadership term.  If certain Medical Staff members have been difficult to work with, it might be helpful to inform the incoming Chief of that fact – and any hot button issues that are still sizzling.  If certain Medical Staff members have been helpful to you as a leader (for example, by showing a willingness to sit on an ad hoc committee or hearing panel), it can be helpful to relay information about that as well.  Further, if you have come to know about helpful resources or techniques during your term as Chief, now is the time to teach the incoming Chief about those things, so that he or she does not have to recreate the wheel.
    • If you conducted any collegial conversations with a colleague that you did not document, remember to sit down with the incoming Chief of Staff over the next few months to give him or her a “heads up.” That way, if similar concerns arise during their term, they will know that they are not the first to encounter such issues and may need to take a more progressive approach to managing the issue.
    • Consider working intimately with the incoming Chief of Staff over the next few months so that he or she will be fully prepared to step into your shoes in December. Discuss proposed agendas for upcoming meetings, show the Vice Chief how you work with the Medical Staff Office or other support professionals to gather and distribute materials in advance of the meeting (and provide notice of meetings), copy the Vice Chief of important communications and memos related to the job, and invite the Vice Chief to attend meetings, particularly if those meetings will discuss issues that are unlikely to be finalized by the end of the year.  Now is your opportunity to “train” the incoming Chief for the job.  And if he or she can find the time to engage, it will likely make the job of Chief that much easier to tackle when December rolls around.
    • Finally, if the leadership structure at your Hospital does not already formalize the role of the immediate past Chief of Staff, consider whether that would be helpful. Many Medical Staffs utilize the past-Chief on a Leadership Council (a small group of the most involved leaders, which triages complicated clinical peer review issues and directly manages many professionalism and practitioner health concerns).  Others utilize the past-Chief(s) as chairs or members of important committees, such as the Credentials Committee or the multi-specialty peer review committee, thus allowing those committees to benefit not only from the experience, but also the institutional memory, of the past-Chief.  Even if you are not ready to take on another term of leadership after six long years of service, consider making yourself available as an advisor to other leadership bodies on an as-needed basis going forward.  We generally recommend that the Medical Staff Bylaws and related documents acknowledge that the past-Chief will serve as an advisor to other leaders (if for no other reason than to make clear that the past-Chief is entitled to the same immunities as other leaders and his or her actions are covered by the same peer review confidentiality and privilege protections).

August 17, 2017

QUESTION:        The Chief of Staff recently implemented a precautionary suspension after a Medical Staff member engaged in some seriously unprofessional behavior that was thought to compromise patient safety.  The MEC met to review the matter and lifted the precautionary suspension after four days.  A formal investigation was commenced and that process is now complete and the MEC is considering suspending the practitioner for 30 days.  For purposes of reporting to the National Practitioner Data Bank (NPDB), will that suspension be added to the four-day suspension he already served — meaning that it will constitute a 34-day suspension and will, in turn, become reportable to the NPDB as a suspension lasting more than 30 days?

ANSWER:            Even though the precautionary suspension and the “regular” suspension are related to the same factual matter, they are separate professional review actions and, in turn, they do not “add up” for the sake of reporting.  Therefore, the four-day precautionary suspension was not reportable to the NPDB.  The same will be true of a 30-day suspension, if that action is finalized by the Board.  Be sure to check the applicable requirements of state law, however, as some states require hospitals to report all suspensions of clinical privileges, no matter how long they last.

December 22, 2016

QUESTION:        As we are preparing for a medical staff hearing, a member of our Medical Executive Committee asked why our Medical Staff Bylaws state that the Chief Executive Officer appoints the hearing panel and not the Chief of Staff since it’s the Chief of Staff who knows most of the members of the medical staff.  We are trying to figure out whether this was a typo or not.  Should the Chief of Staff appoint the panel?

ANSWER:           No – that’s not a typo!  While we do still sometimes see bylaws which assign the Chief of Staff the responsibility to appoint the hearing panel (and worse yet, occasionally it’s the whole Medical Executive Committee that does so), it’s long been our recommendation that the CEO or the CMO fulfill that responsibility – in consultation with the Chief of Staff.

This is because, generally speaking, the Chief of Staff, both in his/her role as a Medical Staff officer as well as a member of the MEC (the body that will most often be making the adverse recommendation that triggers a hearing) tends to be someone who is very intimately involved in the underlying matter that led to the hearing.  The Chief of Staff will frequently be the individual who engaged in collegial intervention and other progressive steps with the affected physician, who was involved in the development of any conditions or restrictions and, ultimately, is involved in the adverse recommendation made by the MEC as the chair of that committee.  When an involved Chief of Staff is then responsible for appointing the hearing panel and presiding officer, we have seen the argument made that the selections were biased in favor of the MEC and are not neutral  – which can lead to objections and legal challenges (both before and after the hearing) to the appointment of the panel.

While we know that these claims are largely groundless, it is very important to manage the appearance of fairness at all steps of the hearing process.  The goal is to isolate the volunteer physician leaders – like the Chief of Staff – from these types of claims and allegations as much as possible, which is why the CEO or CMO should appoint the panel after consulting with the Chief of Staff.