March 26, 2020

QUESTION:        We are a six-hospital system and are doing our best to address and anticipate the health care needs of patients with COVID-19.  Two of our hospitals are Critical Access Hospitals, which is why our medical staffs are not unified.  Nonetheless, we have a system CVO and our bylaws, credentials policy and privileging criteria are consistent.  If we want to be flexible about deploying needed practitioners to our various hospitals by using temporary privileges for those practitioners who do not hold privileges at each hospital, must we get new peer references from their primary system hospital? What are our other options for granting privileges for these practitioners at hospitals in our system where they are needed?


ANSWER:        Technically, each hospital with a separate CCN and license is supposed to get a peer reference to confirm current competence, under both Joint Commission and DNV GL NIAHO standards, without reference to whether a hospital is part of a system.  However, under these difficult circumstances, of course it makes sense to take advantage of the system’s knowledge of privileging at other system hospitals to speed up the availability of practitioners to go where they are needed most.  Here are some options:

  • For those who are somewhat risk averse and have the time and resources, the system CVO (or centralized Medical Staff Office) could pre-populate a short “application” form so there would be little the “applicant” would need to do other than sign electronically. That form could refer to a standard department chief/chair peer reference communication to be used within the system, which confirms current competence based on OPPE (or FPPE if applicable for recently appointed practitioners) or the last reappointment recommendation/report.  However, those under a performance improvement plan or investigation would not be eligible except on a case-by-case basis.
  • Pursuant to a system information sharing policy, Board resolution, or agreement, the standard department chief/chair peer references could be accessed electronically throughout the system or the actual recent OPPE or reappointment reports could simply be made available directly without the need for the separate peer reference form.
  • A system could simply let the practitioners go where they are needed, via a Board and MEC resolution, and justify it later if surveyors question it. Will surveyors really cite hospitals for having moved quickly to get known practitioners to respond to the community?  We doubt it.
  • A few systems have created a category on each medical staff in the bylaws for all physicians who are appointed to other hospitals’ staffs. The CVO has all the information.  The physicians in that category are permitted to exercise privileges at all system hospitals where the services they provide are offered, even though they designate a primary hospital.  (One reason that systems do this is to create a panel of peer reviewers to review cases at other system hospitals when there is a potential conflict, or to use those physicians as locum tenens in system hospitals to avoid contracting with locum tenens firms and thereby getting unknown physicians.)
  • Another option is for each hospital to grant disaster privileges quickly and as needed, in reliance on the CVO’s files containing licensure, and verify identity when they report for duty.

Join Charlie Chulack and Barbara Blackmond for the next installment in our Grand Rounds audio conference series on April 7 on Making the Most of your Relationship with Credentials Verification Organizations (CVOs).

December 19, 2019

QUESTION:        We have nine hospitals in our system.  We are not ready to have a unified medical staff (and maybe never will be) but we need to find a way to have more uniformity in our documents and decision-making.  Do you have any suggestions?


ANSWER:            There is no single right answer to the question of whether medical staffs within a system should form a unified staff.  Although CMS changed the rules in 2014 and allowed hospitals with separate CMS Certification Numbers (CCN) to have a unified medical staff, unification may not be the best choice for your system.  It is important, however, for medical staffs within a system to strive for uniformity and consistency in their documents and decision-making.  Take it from us, it is a problem when one hospital in a system decides to deny reappointment or imposes a precautionary suspension and the physician shifts his practice to a sister hospital.  Fortunately, there are ways to avoid that disaster short of unification of the medical staff.

Most systems we work with have started with a uniform application form and uniform peer reference forms.  This helps ensure that each hospital in the system is asking the same questions and getting the same responses both from the applicant and from the peer references.

Many systems have gone to the next step and created a credentialing verification organization to gather and verify information that is then forwarded to the physicians and other practitioners involved in the credentialing process.  This helps to ensure that each medical staff has the same primary source information to use in making credentialing recommendations.

As a next step, many systems have developed a system credentials policy.  This helps to standardize the standards and the key credentialing processes.  Each medical staff will then have the same threshold eligibility criteria for appointment, the same way of dealing with misrepresentations and omissions, and the same investigation and hearing processes.  This approach can also be taken for other key documents such as the professionalism policy, health policy and peer review policy.

Once your standards are aligned, you might next want to consider the development of key medical staff committees that would function at a system level.  Many systems have done this with the credentials committee.  Representatives from each medical staff typically serve on the system credentials committee.  This helps ensure that the same people are applying the same standards.  This should drastically reduce variation in recommendations at least at appointment and reappointment.

Good language in your credentials policy can also address those situations where one medical staff in your system has developed a performance improvement plan, commenced an investigation, or recommended revocation of appointment and privileges.  The key is to have language which allows these actions to be effective at all hospitals in the system without having to redo all the hard work that has already been done but, at the same time, to allow some discretion when a different outcome would be warranted by the facts.

June 22, 2017

QUESTION:        I am a new physician CEO at a physician group affiliated with a hospital system.  I get calls and e-mails from physicians directly when they have concerns about the communication/behavior/responsiveness of other physicians, before any medical staff involvement.  There is an agreement to share information between medical staff committees and the employer group.  How should I respond?

ANSWER:            It would be a good idea to develop a policy for the group as to how issues are triaged and addressed. If the issues primarily involve conduct in the hospital setting, as opposed to employment, you could still choose to handle them initially within the group process (and consider subsequent reporting if the issue is not resolved) or you could report the concerns to the appropriate individual in the hospital. That may be the CMO, a medical staff officer, or Leadership Council as described in a Medical Staff Professionalism Policy.

While it may be suitable for you to handle some issues in an informal way by your personal immediate involvement, too much of that style of intervention may not be a good use of your time.  Many issues are best directed through appropriate channels within either the group or the hospital/medical staff.  (That doesn’t necessarily mean too much bureaucracy!)  There may be more to a story than what is reported by one person; often, more fact-gathering is needed.

For issues that implicate medical staff performance, in some systems, a group’s CMO may be appointed to a hospital medical staff peer review committee or may be invited to the Leadership Council or similar group. A Leadership Council is commonly composed of the officers, hospital CMO and key support staff, and can convene regularly or when an issue involving the hospital practice or behavior of an employed physician is to be triaged.