February 2, 2023

We have a physician who has been working his way through our peer review process with very little sustained success.  Recently, there were several significant clinical events that caused Medical Staff Leaders to escalate the matter to the Medical Executive Committee which decided to commence an investigation.

Our question is “do we have to re-do all the great work done by our Peer Review Committee, or can we use that as part of our investigation?”

This is an excellent question and one that we hear quite frequently.  We know from experience Medical Staff Leaders will be able to address and resolve most issues that come to their attention, whether they are of a clinical or behavioral nature, using collegial and progressive steps.  However, every once in a while, a practitioner can’t or won’t change and Medical Staff Leaders will need to escalate concerns to the Medical Executive Committee for a formal, capital “I” investigation.

The procedure for conducting an investigation is laid out in your credentials policy, bylaws or investigation manual.  Once you get to an investigation, the stakes are high for everyone, so it is very important to follow the procedures outlined in your documents.

It is also important that the investigation is thorough, fair, and objective.  However, that does not mean that you have to re-do all the work done by the Peer Review Committee.  That would simply make no sense.  The Medical Executive Committee, or more likely an investigating committee appointed by the Medical Executive Committee, should have access to any documents that it deems relevant, including documents from the practitioner’s credentials file and quality file.  The investigating committee can and should review and rely on informational and educational letters along with letters of awareness, and letters of counsel or guidance.  It can and should review and rely on prior performance improvement plans (aka voluntary enhancement plans).  The investigating committee can and should rely on case reviews and reports from external experts.

If you have worked your professional practice evaluation process, once you get to the investigation phase, you may have already done most of the heavy lifting.  The role of the investigating committee may be primarily to pull together all prior progressive actions that had been taken and consider potential patterns and trends.  Additionally, the investigating committee may want to conduct interviews of individuals with relevant information including staff, the department chair and members of the Peer Review Committee.  Critically, even if your governing documents don’t expressly require it, the investigating committee will want to provide the subject physician with notice of the concerns that have been identified and an opportunity to discuss, explain or refute those concerns.

So, the bottom line is you can and should consider information reviewed by and generated for the Peer Review Committee at part of an investigation.  But you should also use the investigation to answer any outstanding questions and to meet with the subject physician.

January 4, 2018

QUESTION:        In the past, our reappointment process has been rather perfunctory.  The names of physicians and other practitioners who are up for reappointment get put on a list which is approved by the Credentials Committee, passed on to the Medical Executive Committee, and then forwarded to the Board in a consent agenda.  What steps can we take to make our reappointment process more meaningful?

ANSWER:            This is a great question.  Many hospitals are like yours and muddle through the reappointment process without getting a lot of bang for their effort.

The reappointment process, which includes the renewal of appointment and clinical privileges, is an important opportunity to review and confirm that a practitioner satisfies all of the core competencies.  To make the reappointment process more meaningful, you must have data.  The ongoing professional practice evaluation reports that you generate for all practitioners will provide a good starting point since they evaluate competence in a variety of areas throughout the appointment term.

You should also review and consider any licensure or disciplinary action, as well as any malpractice claims, settlements, or judgments that occurred during the previous reappointment term.  Of course, you should be receiving notice of and reviewing all of these events as they occur, but the reappointment is a good time to verify that the review has taken place.

It is also important that you review the clinical privileges that a practitioner is requesting at reappointment.  If a practitioner has not satisfied volume requirements for a privilege or has not exercised a privilege that is volume?sensitive, the practitioner may be ineligible to seek the privilege or may be required to provide additional evidence of current clinical competence before having the privilege renewed.

And it is important to consider your other quality data at reappointment.  Make sure the Credentials Committee, Medical Executive Committee and Board are aware of any peer review actions, including informational and educational letters, collegial interventions and performance improvement plans.  While these activities may not affect the final reappointment decision, they may warrant that the practitioner receive a different letter at reappointment which reflects clinical or behavioral matters that are being reviewed and addressed through the peer review process.