February 16, 2023

Our bylaws say that new medical staff members are “provisional” for at least 12 months, sometimes for 24 months.  Is this the same thing as focused professional practice evaluation?

No – or at least it shouldn’t be!  Focused professional practice evaluation (“FPPE”) is the Joint Commission terminology for the period of focused review that is required for following the grant of any new clinical privileges as the way of confirming practitioner competence – this means a focused review of all privileges for new applicants and all new privileges for existing practitioners (i.e., increases in privileges).  FPPE can be accomplished in many different ways – chart review, proctoring/direct observation, external reviews, even discussions with others who are involved in the care of the individual’s patients.  The Joint Commission does not mandate the duration of FPPE for any practitioner and, in fact, have specifically noted in the past that using a traditional 12-month provisional period as the time frame for performing FPPE could be overly burdensome for practitioners who had high volumes.

To that end, there is no requirement that hospitals and medical staffs maintain a provisional appointment status, though we do still see many hospitals that continue to utilize that status, generally as a way to assess the “citizenship” aspects of medical staff appointment – like behavior, attendance at and participation in medical staff affairs, completion of medical records, fulfillment of call obligations, etc.  In addition, at the same time, but generally for a much shorter duration, all new members are subjected to FPPE, the requirements of which depend on the practitioner’s specialty and clinical privileges.  The key is to understand that if a medical staff is going to maintain a provisional status or process, it should be addressed separately from the FPPE to confirm competence process.

August 25, 2022

I just got back from what was probably the worst-run medical staff committee meeting ever. The problem is that I’m the chair and was running the meeting!  I thought it would be easy, but it was a lot harder than it looked. Any pointers?

Running a meeting is hard work – here are some tips that may help:

Tip #1.  Start on time.  This is one of the most important tips.  If a meeting isn’t started on time, chances are it won’t end on time, and that has consequences which we’ll discuss below.  If a meeting always starts on time, the attendees will more than likely be there on time, since no one likes to walk into a meeting late, and being late disrupts the meeting.

Tip #2.  Limit the conversation.  What “limit the conversation” means is that if a couple of attendees in the room are making the same point, over and over again, that’s unproductive, so the chair should step in and say “Ok, any other points of view that we haven’t discussed yet?”  Also, if a discussion “drifts,” the chair should step in and restate the purpose of the discussion.  This can be hard to do, but it is a skill that needs to be developed.  Otherwise, the participants start thinking the meeting is a waste of time, and the downward spiral begins.

Tip #3.  Take an issue off-line.  There are times when a meeting is getting bogged down because no one has the information needed to make a decision.  For example, is the bylaws revision being discussed a Joint Commission Standard?  A best practice?  If no one knows for sure, further discussion will not help the committee make a decision, so that issue should be taken off the agenda until the next meeting, to research the issue.

Another reason to take an issue off the agenda is when there are so many conflicting points of view that the issue won’t be able to be resolved at the meeting.  The chair knows that no matter how much more discussion there is, the issue won’t be resolved.  So, the chair should stop the discussion, and maybe appoint a small group to investigate or research the issue, then bring the results back to the committee.

Tip #4.  End on time.  This is the most important tip.  If a meeting is to end at 8:30 a.m., end the meeting.  Although some attendees don’t mind going over, others will start thinking about work that needs to be done, or another meeting to go to, or an appointment to make – focus is lost.  A meeting that runs on and on and on isn’t efficient and becomes much less effective as time goes on.  Also, not ending on time affects meeting attendance.  If an attendee knows that the meeting always goes over, he or she is less likely to attend the meeting.

Sometimes agendas are just too full, or there may have been too much discussion on one issue, etc. – that happens.  But, instead of plowing on through with more and more disinterested attendees as each minute ticks by, just end the meeting, and hold those agenda items over for the next meeting.  The exception is if the issue is of critical importance, but that will be few and far between.

March 3, 2022

Has The Joint Commission (“TJC”) issued new Elements of Performance (“EPs”) regarding obstetrical/maternity care?

Yes, TJC issued these new EPs in the early days of the pandemic, so it’s not surprising that these may have received little attention.

The new EPs are under the Provision of Care (“PC”) chapter, at PC.06.01.01 and PC.06.01.03, and were effective July 1, 2020.  TJC’s press release stated that the EPs were implemented because maternal morbidity and mortality was becoming worse, especially in the areas of maternal hemorrhage and severe hypertension/preeclampsia.

The new EPs require assessments regarding hemorrhage and hypertension/preeclampsia risk on admission to labor and delivery and on admission to postpartum.  These EPs also require that the quality improvement committee establish criteria that trigger reviews for such cases, and that the reviews evaluate the effectiveness of the hemorrhage response team.  There are also requirements that education be provided to patients and families regarding signs and symptoms of postpartum hemorrhage and severe hypertension/preeclampsia.

The Medical Executive Committee is also involved, since it is required to assign a multidisciplinary committee the task of developing procedures to manage pregnant and postpartum patients who experience maternal hemorrhage, and for measuring and managing blood pressure to lessen the likelihood of harm relating to maternal severe hypertension and/or preeclampsia.

So, this may be a good time to update your rules and regulations to make sure that these new EPs are covered.

October 14, 2021

What should be done if an applicant for reappointment is under investigation but his current term of appointment is set to expire before the investigation is completed?

As most know, the Joint Commission has made it clear that privileges are granted for a period not to exceed two years and that continuations or extensions are not appropriate.  While this rule likely came about to avoid routine extensions due to administrative failures to process reappointments in a timely manner, it makes situations like the one above difficult to manage.

Keeping in mind this two-year limitation, we’ve found the best way to address applicants for reappointment who are currently under investigation is through a short-term conditional reappointment pending the outcome of the process.  This keeps the hospital on the right side of the Joint Commission, while providing time for the investigation to work its way out.

Having language in your Medical Staff Bylaws documents to support this approach is a key to good credentialing.

July 15


“A physician recently smelled of alcohol and was behaving oddly while conducting rounds.  The physician refused a screening test, so the Medical Staff leadership imposed a precautionary suspension.  Is there a better way?”

Yes!  First, all hospitals should have a Practitioner Health Policy to govern health issues affecting privileged practitioners.  Such a policy is required if your hospital is accredited by the Joint Commission, and it’s a best practice in any event.  A Practitioner Health Policy allows Medical Staff leaders to identify practices and procedures that work in your setting, and can then be applied in a consistent manner (which helps to avoid allegations of discrimination).

Your Practitioner Health Policy should have a section dealing with responses to immediate threats, such as the one you describe above.  The first step is for the Policy to identify who may respond to handle such situations.  We recommend that a broad group of Medical Staff leaders be authorized to take the steps described in the Policy, to ensure that someone is always available.

The Policy should then identify who, and how many, individuals may request a practitioner to undergo a screening test to identify a possible impairment.  Ideally, two Medical Staff leaders will make such a decision (or a Medical Staff leader and an administrator such as the CMO).  Having two individuals involved in the decision protects them from allegations of bias, and should enhance the credibility of the process in the eyes of the practitioner under review.

To answer your specific question, if the practitioner refuses to cooperate with a screening test, the Practitioner Health Policy should say that the individual automatically relinquishes clinical privileges pending further review by the Leadership Council (or whatever committee handles health issues).  This is not a permanent fix – potentially impaired practitioners would not be permitted to simply move out of town and subsequently harm themselves or others.  Instead, it’s a method of buying time to persuade the practitioner to cooperate with the review process without imposing a suspension.  A suspension causes the situation to feel more confrontational, which sends the wrong message when the goal is to help a colleague.  A suspension also starts the clock ticking for hearings and NPDB reports, which can detract from efforts to constructively deal with the health issue.

For more information about how to deal with practitioner health issues, please join us in Orlando, FL from September 19 – 21, 2021 for the Peer Review Clinic. For more information, click here.

April 29, 2021

QUESTION:    “What is the history of the peer review process in the United States?”

ANSWER:       In the United States, the evolution of the peer review process was pioneered by the American College of Surgeons (“ACOS”).  In 1913, the year of its founding, the ACOS appointed a man named Ernest A. Codman to chair a committee on hospital standardization.  Codman was an outspoken critic of contemporary hospital recordkeeping practices and made public appearances speaking on the importance of adequate medical records, which he believed were essential for studying patient outcomes.

By 1919, the ACOS had created and adopted a document on hospital standardization.  The 1924 version of the ACOS “Minimum Standard” for hospitals is archived and easily accessible online.  In the 1924 Minimum Standard, the ACOS set forth the following mandates:

  1. That membership upon the staff be restricted to physicians and surgeons who are (a) full graduates of medicine in good standing and legally licensed to practice in their respective states or provinces; (b) competent in their respective fields and (c) worthy in character and in matters of professional ethics…
  1. That the staff initiate and, with the approval of the governing board of the hospital, adopt rules, regulations, and policies governing the professional work of the hospital; that these rules, regulations, and policies specifically provide…[t]hat the staff review and analyze at regular intervals their clinical experience in the various departments of the hospital, such as medicine, surgery, obstetrics, and the other specialties; the clinical records of patients, free and pay, to be the basis for such review and analysis.

These efforts by the ACOS continued for several decades until they eventually evolved into the Joint Commission on Accreditation of Hospitals in 1951.  Since its inception, The Joint Commission has promoted and surveyed the use of peer review (sometimes called “medical audits”) on hospital medical staffs.

You can find more information on the website of the American College of Surgeons, available here.

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).

February 21, 2019

QUESTION:        A physician on our medical staff has made numerous inappropriate entries into the EMR.  These include critiques of other physicians, the hospital, and its staff.  We have approached the physician several times to inform him that a patient’s medical record is not an appropriate forum for these comments, but he claims he has the First Amendment right to put whatever he wants to in the records, and continues to do so.  What can we do?


ANSWER:            The regulatory and accreditation requirements set forth by the Joint Commission and both federal and state law make it clear that they require the medical record to document objective clinical information relative to an individual patient’s medical condition that will enable a patient’s caregivers to provide the appropriate patient care.  Entering comments in a patient’s medical record that are critical of the hospital or of other individuals are inappropriate editorial statements, which do not advance the care of a patient.  In addition, they clearly create and increase legal risks to the hospital and to all individuals involved in the care of the patient.

A physician who has a complaint or concern regarding an administrative policy, the hospital’s utilization practices, or the care provided by any other individual should be advised that the medical record is not the proper forum for that issue and should be directed to register those concerns through appropriate medical staff or administrative channels.  Most times, providing this education and counseling to the physician is sufficient to resolve the concerns.  If not, however, the physician should be advised that continuing disregard of the policy concerning the proper content of medical records will be referred for review under the Medical Staff Professionalism Policy.

April 19, 2018

QUESTION:        Our hospital is accredited by the Joint Commission.  When we perform FPPE to confirm competence for new Medical Staff members, we typically evaluate the physician’s first five cases.  We’ve recently heard rumblings that this may no longer be acceptable.  What’s up?


ANSWER:            Based on recent reports from hospitals, it appears that Joint Commission surveyors are requiring hospitals to be more rigorous in how they perform FPPE to confirm competence.

The point of FPPE for new physicians is to confirm that a physician who looks good on paper (via the credentialing process) looks just as good in actual practice.  FPPE can have the added benefit of helping new physicians become familiar with the hospital (e.g., through conversations with proctors about standard operating procedures, etc.).

Evaluating a physician’s first five cases may not give the hospital a realistic view of the physician’s practice.  For example, if the physician is a general surgeon and those first five cases are all appendectomies, the hospital would have no confirmation of how well the physician performs other, unrelated procedures.

Fortunately, groups of privileges may require similar skills and judgment.  Thus, the evaluation of a practitioner’s ability to exercise one privilege may be used to confirm a practitioner’s ability to perform one or more other privileges.  These are sometimes referred to as “Index Privileges.”

Thus, while FPPE to confirm competence should generally include more than a physician’s first five cases, there’s no need to individually evaluate every privilege a physician has been granted.  Instead, hospitals can identify groups of privileges that require similar skills, and use those groupings to help them confirm that a physician is competent to perform all the privileges that have been granted.


January 12, 2017

QUESTION:        Can text messages be used by our physicians and other health care professionals to communicate about patients and issue orders?

ANSWER:            The Joint Commission recently issued guidance regarding the use of text messaging in patient care.  The guidance was developed in collaboration with the Centers for Medicare & Medicaid Services (“CMS”).  Thus, even if your hospital is not accredited by the Joint Commission, it should pay attention to the guidance because of CMS’s involvement in developing it.

The guidance includes the following:

(1)     All health care organizations should have policies prohibiting the use of unsecured text messaging – that is, short message service (“SMS”) text messaging from a personal mobile device – for communicating protected health information.

(2)     The Joint Commission and CMS agree that computerized provider order entry (“CPOE”) should be the preferred method for submitting orders as it allows providers to directly enter orders into the electronic health record (“EHR”).

(3)     In the event that a CPOE or written order cannot be submitted, a verbal order is acceptable.

(4)     The use of secure text orders is not permitted at this time.

For more information, please click here.