February 15, 2018

QUESTION:        Our hospital is employing a lot more physicians than in the past.  When we receive a complaint about the behavior of one of these employed Medical Staff members, we’re not sure if we should review it through the Medical Staff process or through the employment process (i.e., HR policies or the employment agreement).  Or should we use both?

ANSWER:            We recommend that the Medical Staff Professionalism Policy (or Code of Conduct Policy) have a “triage” process.  If a behavioral concern is raised about a Hospital-employed physician, a Medical Staff leader (such as the Chief of Staff) will discuss the concern with a representative of the employer.  The Medical Staff leader and the employer representative then decide which process will be used to review the complaint.

If a decision is made to use the employment process, the Medical Staff process would be held in abeyance.  Critically, though, the employer would keep Medical Staff leaders continually informed of the status and outcome of the review.  If the Medical Staff leaders are unhappy with how the review is being conducted, they can commence their own review under the Professionalism Policy at any time.  On the other hand, if the Medical Staff leaders are satisfied with what the employer is doing, the Medical Staff leaders would essentially adopt that action as their own.  Thus, the Medical Staff is not “punting” or abdicating its responsibilities.  It’s evaluating the actions of the employer, then deciding to either adopt that action as its own or conduct a separate review.

There are several goals to this process.  The first is to avoid a duplication of effort by both the physician under review and those conducting the review.  The second is to use the most effective process to address the concern.  In some cases, the employer will have better tools for dealing with the issue, while in other cases the Medical Staff process will be more effective.  Finally, a triage process can help to avoid inconsistent results that send mixed messages to physicians and create legal risk.

For a more detailed discussion of peer review of hospital-employed physicians, join us in sunny Austin, Texas for The Peer Review Clinic on March 1-3, 2018.