medical staff

March 12, 2026

Posted on by Courtney Patterson

QUESTION:
This week’s question is taken from those submitted at the January 15-16, 2026 Complete Course for Medical Staff Leaders, held in Amelia Island.

Sometimes it’s very tempting to call a colleague you may know at another hospital to clarify the details of an applicant.  While I believe this is done routinely, is it legally permissible if the applicant has not declared this person a reference?

ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:
As a general rule, it is perfectly acceptable (and appropriate) to contact anyone who may have any information that is relevant to an applicant’s qualifications.

This is America – so of course this has been litigated.  Check out what the United States District Court for the District of New Jersey said in this 2014 case (where a physician alleged wrongdoing by a Credentials Committee chair, who contacted individuals not listed by the applicant on her application):

“As to [the Credentials Chair’s] request for information from non‑references…affirmative contact with these individuals, that is, without prior clearance for such action from Dr. Pal, reflects a diligent and comprehensive investigation in connection with her application for privileges…”

Pal v. Jersey City Medical Center (D.N.J. Oct. 24, 2014)

So, who can you contact?  Anyone who may have information about the applicant’s clinical skill, experience, training, professional conduct, health status, etc.  You likely have a statement in your Medical Staff Bylaws and on your Medical Staff application forms that states something to this effect (virtually all organizations do).

The “usual suspects” for affiliation verifications/references include other health care facilities where the applicant is employed or has been employed, or has held medical staff membership or clinical privileges.  Department chairs from current and previous organizations, as well as residency program directors (if recently out of training), and current and past employers are also often contacted.

But, what about a nurse supervisor at a facility that has reported interpersonal conduct issues by the practitioner?  What about the applicant’s arresting or probation officer?  An ex-wife who filed a restraining order?  Yes to all of these!  Anyone who may have information relevant to the qualifications of the practitioner to be a medical staff member (including maintaining orderly operations of the hospital) or to exercise privileges (including anyone who may have information about health status, reliability, clinical performance, education, training) can be contacted and asked for information.

To get back to your question – you specifically asked whether you can contact a colleague you know.  Of course (as noted above), the answer is yes (we really do mean anyone who may have information about the applicant, including anyone who may be able to share real life observations or other information).  But, here’s the kick – whenever you request and/or obtain information about an applicant, that should be documented in the credentialing file.  Therefore, before you call in a personal favor to a friend, realize that your contact with that individual needs to be documented in the file and anything they tell you will not be “off the record.”

So, if you plan to contact a personal friend, acquaintance, or colleague to request information, remember to treat the contact and request with the same formality that you would treat other requests.  If you are asking for important information, trying to clear up concerning rumors or verify whether the applicant has made a misrepresentation, etc., it may be best to make the request for information in writing (and to supply a copy of any authorization/release that your applicant has signed).

Never promise that information revealed to you will be kept secret (this is a promise you cannot keep!).

And, if your friend/colleague holds a leadership position at another facility (e.g., they are the chair of credentials or department chair at the facility where the applicant recently held privileges), remember that they have legal obligations of confidentiality with respect to their proceedings as medical staff leaders and when they act in those roles they are agents of the facility.  Accordingly, it may be best in those cases to direct your request to the facility itself, rather than the individual (so that the individual is not put in a difficult position).

If you have a quick question about this, e-mail Rachel Remaley at rremaley@hortyspringer.com.

February 5, 2026

Posted on by Courtney Patterson

QUESTION:
Our hospital recently received a request from a former Medical Staff member for a complete copy of her credentials and peer review files.  Are we required to provide the copies as requested?

ANSWER FROM HORTYSPRINGER ATTORNEY IAN DONALDSON:
While you always need to check your state law, in most states a hospital would not be required to provide a former Medical Staff member (or even a current member) with a copy of her credentials and peer review files.  (This is different than an HR file, as most states do require that employees be granted access to personnel files.)

To avoid any confusion when these types of requests are made, we recommend hospitals adopt a policy that governs access to credentialing and peer review files.  For existing members, the policy might describe the rules for accessing “routine” and “sensitive” documents, with sensitive documents receiving special protection (for example, names of those who raised a concern will be redacted).  For former members, the policy could state simply that copies will not be provided (assuming that is consistent with state law), but that the hospital will respond to credentialing requests from other hospitals so long as the former member has signed the appropriate authorization and release.

If you have a quick question about this, e-mail Ian Donaldson at idonaldson@hortyspringer.com.

January 29, 2026

Posted on by Courtney Patterson

QUESTION:
One of the new members of our Peer Review Committee is adamant that we should not be using the term “investigation” when referring to the review of a provider’s care. What is the big deal with using that term?

ANSWER FROM HORTYSPRINGER ATTORNEY HALA MOUZAFFAR:
The term “investigation” is a loaded term in the Medical Staff world. Because of that, it is very important that we are careful in how we throw that term around, and that we only use it when it is truly appropriate.

The term “investigation” should be reserved for only when the Medical Executive Committee has made the determination to employ the formal investigation process laid out in your Medical Staff Bylaws.  The formal investigation process is that very long section in your Bylaws that details appointing an investigating committee, explains how investigations are handled, outlines hearing rights, defines rights to an appeal, and so forth.  Additionally, we want to be specific as to when a formal investigation has begun because it carries legally required notice requirements and potentially reporting requirements.

For that reason, when other Medical Staff committees are engaging in routine review activities – such as taking a closer look at cases referred for peer review or interviewing individuals as part of the peer review process – we should avoid calling those activities an “investigation.”  Using that term outside its formal meaning risks confusing informal review with the official investigation process required by the Bylaws.

Instead, we recommend using other terms – such as review, assessment, evaluation, or fact‑finding – when referring to these non‑formal activities.  While this distinction may seem subtle, it can be crucial if the committee’s actions are ever subject to legal scrutiny.

If you have a quick question about this, e-mail Hala Mouzaffar at hmouzaffar@hortyspringer.com.

November 13, 2025

Posted on by Courtney Patterson

QUESTION:
We just found out that a member of our Medical Staff was arrested and charged with domestic battery, assault, terroristic threats, and unlawful possession of a firearm.  The charges were brought by the physician’s now ex-girlfriend.  Pictures of the girlfriend are floating around, and they were pretty bad.  The physician swears it was all in self-defense and that his girlfriend “lost her mind” when he tried to break up with her.  What do we do?

ANSWER FROM HORTYSPRINGER ATTORNEY SUSAN LAPENTA:
Ideally, your Bylaws, or Credentials Policy, include language which allows you to trigger an administrative relinquishment in a situation like this.  Specifically, we recommend the Bylaws provide:  “The occurrence of specific criminal actions, including an arrest, charge, indictment, conviction, plea of guilty or plea of no contest, pertaining to any felony or any misdemeanor involving…a violent act will result in an automatic relinquishment of appointment and clinical privileges.”

This languages allows you to effectively address the situation without imposing a suspension, triggering an investigation, or making a recommendation for an adverse professional review action.  If the charges are dropped, the physician can seek reinstatement from the relinquishment.

The automatic relinquishment language works so well that we recommend including it in the Bylaws, or Credentials Policy, to address other sticky situations including:  (1) failure to complete medical records; (2) failure to satisfy threshold eligibility criteria; (3) failure to provide requested information; (4) failure to attend a mandatory meeting; (5) failure to complete or comply with training or educational requirements; and (6) failure to comply with a request for fitness for practice evaluation.

If you don’t have language in your Bylaws Documents that would allow you to trigger an automatic relinquishment, you may try to get the physician to take a leave of absence, or to voluntarily agree to refrain from practicing while the criminal matter is playing out in the courts.  In situations like this, the physician is often focused on the criminal charges and may be willing to resolve the medical staff issue in a nonconfrontational way.

If this doesn’t work, you may have to consider disciplinary action, including a precautionary suspension, investigation, recommendation to revoke appointment and privileges, and a hearing and appeal.  This course of action may be needed not only to protect patients and staff, but also to protect the reputation of the hospital and the medical staff.

It is extremely unlikely that the physician’s criminal defense counsel would allow the physician to participate in these processes.  However, it is important that you adhere to your Bylaws Documents and offer all the process the Bylaws promise.

If you have a quick question about this, e-mail Susan Lapenta at SLapenta@hortyspringer.com.

November 6, 2025

Posted on by Courtney Patterson

QUESTION:
When a concern is raised about the behavior of a Medical Staff member, we’ve typically referred it to our department chairs to handle.  Some chairs do a really good job addressing these issues while others, well, let’s just say they struggle.  We were wondering if there’s a better way?

ANSWER FROM HORTYSPRINGER ATTORNEY LEEANNE MITCHELL:
Yes!  There are multiple drawbacks to asking a single individual – regardless of who that person is – to deal with difficult behavioral matters.

First, the department chair is often either a competitor or partner of the physician under review.  This can make it difficult for the department chair regardless of whether an actual “conflict of interest” exists.  Also, depending on the size of a department, the department chair may not deal with many behavioral concerns.  As a result, the chair never obtains enough experience to become truly comfortable addressing behavioral issues.  Finally, as your question might be hinting at, not all department chairs are created equal – some may have great leadership qualities, and some may be serving only because it’s a role that they are forced to rotate through in a particular department.

The bottom line when it comes to behavioral issues – especially ongoing patterns of conduct – is that it requires leadership expertise to address, not clinical expertise.  For that reason, we recommend appointing a small core group of experienced leaders – often referred to as a Leadership Council – to handle behavioral concerns.  The Leadership Council might be comprised of the Chief of Staff, Vice Chief of Staff, Chair of the Peer Review Committee, and the Chief Medical Officer.  Regardless of what it’s called, the advantages of using a Leadership Council approach to handle behavioral concerns include:

  • consistency across departments (no more variability based on the personality and leadership skill set of individual department chairs);
  • easier to avoid conflicts of interest;
  • permits department chairs to preserve their working relationships with physicians under review;
  • expertise through experience;
  • emphasizes the importance of the issue and enhances the credibility of the physician leadership because a group of seasoned leaders – not a single person – is speaking with the physician under review; and
  • problems are discussed by a small and nimble group, which promotes the exchange and development of ideas on a real-time basis.

If you have a quick question about this, e-mail LeeAnne at lmitchell@hortyspringer.com.

October 16, 2025

Posted on by Courtney Patterson

QUESTION:
I serve on the peer review/MEC in one hospital system and as department chair at another regional system.  A physician is under FPPE for very serious patient safety concerns at the first system, and he has now applied for privileges at the second system (where I am department chair).  I don’t think I can divulge any protected information I have knowledge of.  What can I do?  (Registrant Q&A, submitted electronically at The Complete Course for Medical Staff Leaders, held in Nashville (Spring 2025).)

ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:
You are in quite the pickle!  To avoid this scenario, we have historically advocated for Medical Staff leaders to avoid, if possible, serving in leadership roles at multiple nearby hospitals.  But, we understand that leadership pools are shallow and leadership functions are being performed by a very small minority of do-gooders within medical communities.  Further, we observe that it is quite common for medical directors of hospital-based services to serve as department chairs at multiple facilities.

Luckily, you can likely find a solution to your conundrum that will allow you to satisfy your obligation to protect patients at system #2 (where you are department chair), while also fulfilling your duty of loyalty and confidentiality to the first system (where you serve on the peer review committee and MEC).

Specifically, in a situation such as this, the best way forward may be to take action to cause system #2 to make a request to system #1 for information concerning the practitioner in question.  In other words, as department chair at system #2, you could – as part of your evaluation of the application in question – contact system #1 to request an updated affiliation verification or an updated reference (for example, from the department chair and/or CMO at system #1).

You would not need to specify the exact reason for asking for the information.  It should suffice for you to state that, as department chair, you believe it is appropriate and necessary to request further information about the practitioner’s tenure at system #1 (if pressed, you should not have to say anything more than “confidentiality requirements prohibit me from providing any additional explanation”).  Of course, to avoid any appearance of impropriety or any allegation that you inappropriately divulged protected or privileged information, it is probably best to have the request for information from system #1 occur in writing (rather than via a telephone call or in-person conversation).  From a practical perspective, that might mean contacting the Medical Staff Services Department at system #2, to let them know that you recommend system #1 be contacted for more information regarding the physician’s affiliation.

Note that any request for information that is sent should be worded broadly enough to ask not only about any adverse professional review actions (e.g., revocations, suspensions, restrictions), but also any other recent or pending focused reviews of the practitioner and/or performance improvement plans involving the practitioner.  With this step taken, there would be no need for you to violate any confidentiality requirements that apply at system #1 by revealing additional details.  You could simply sit back and wait for the reply from system #1.

If you have a quick question about this, e-mail Rachel Remaley at rremaley@hortyspringer.com.

September 11, 2025

Posted on by Courtney Patterson


QUESTION:
We recently asked a physician for input about a complaint that had been filed about his interactions with other members of the healthcare team.  He immediately asked, “who filed the report?” Should we disclose that information?

ANSWER FROM HORTYSPRINGER ATTORNEY IAN DONALDSON:
Assuming this request for input occurred under your “routine” peer review process, the answer is a resounding “no,” as we want to protect the identity of those who are willing to come forward and raise a concern.

We always write our Professionalism Policy to say that the specific identity of any individual reporting a concern (or those who otherwise provide information about a matter) will not be disclosed to the practitioner.  The only exception would be if the individual who filed the report consents to the disclosure of their identity or where the information is later used to support an adverse professional review action that results in a Medical Staff hearing.

Of course, even if the identity of the reporter isn’t disclosed, the individual under review may guess or know who filed the report.  As such, it can be a good idea to remind the practitioner who was the subject of the report to avoid any actions that could be perceived as retaliatory, even if retaliation isn’t the intent.

If you have a quick question about this, e-mail Ian at IDonaldson@hortyspringer.com.

August 21, 2025

Posted on by Courtney Patterson


QUESTION:
A member of our Medical Staff disclosed they have a prescription to use medical marijuana. Is this something we should follow up on?

ANSWER FROM HORTYSPRINGER ATTORNEY HALA MOUZAFFAR:
There are some general principles to know before addressing a situation involving medical marijuana in the workplace:

  1. Marijuana is still illegal under federal law. This means people who use medical marijuana are not entitled to federal protections like those in the Americans with Disabilities Act.  Instead, the rules and protections are set by each state and enforced by state agencies, medical boards, or other state-run committees.
  1. Not all states are created equal. States treat medical marijuana in the workplace in different ways.  Some states have laws that protect users – for example, stopping employers from discriminating against them or requiring reasonable accommodations be made.  Other states have taken the stance that practitioners should refrain from using medical marijuana, and some states have not addressed the issue at all.
  1. A prescription doesn’t mean unrestricted use in the workplace. No state requires employers to permit the use of medical marijuana during work or on work property.

With that in mind, we recommend hospitals treat a situation like this like any other where they receive notice that a practitioner may be experiencing a health problem.  The matter should be reviewed under the Practitioner Health Policy or another applicable policy to determine if the underlying cause for the use of medical marijuana affects the practitioner’s ability to safely treat patients.  After that, be sure to check with counsel to see how your state addresses marijuana use in the workplace.

If you have a quick question about this, e-mail Hala Mouzaffar at hmouzaffar@hortyspringer.com.

July 10, 2025

Posted on by Courtney Patterson

QUESTION:
We are having a hard time getting medical staff members who are willing to serve on committees and currently have a significant number of medical staff spots that we need to fill on our infection prevention committee, performance improvement committee, tissue committee, and the pharmacy and therapeutics committee.  One idea was to try and consolidate some of these functions so there are fewer committees.  Is this doable? Advisable?

ANSWER FROM HORTYSPRINGER ATTORNEY LEEANNE MITCHELL:
In terms of the fast answers – (1) likely yes, and if so, (2) absolutely yes!  One of the biggest concerns that we hear being raised these days is that the medical staff leadership pool – whether that means individuals willing to serve as medical staff officers, department chairs, committee chairs, and even committee members – is shrinking dramatically.  Sometimes it’s difficult to populate even the committees that fulfill the primary “medical staff functions” like credentialing, privileging and peer review, often leaving very slim pickings for the ancillary hospital committees.

In terms of whether it’s “doable,” one thing to verify first is what your state hospital licensing regulations may require in terms of medical staff or hospital-specific committees.  While most state regulations just speak in terms of specific functions that have to be fulfilled – often by a committee – some (here’s looking at you Pennsylvania!) do specify a number of separately named committees that hospitals are expected to maintain.

However, in the absence of any regulatory constraints, the manner in which you decide to assign the various functions that have to be met within the hospital to different committees is purely discretionary.  It has become common to see a single overarching “quality committee” that fulfills the functions that used to be performed by separate infection control, P&T, tissue/transfusion, performance improvement, and quality committees.  The key is that you want to ensure that the necessary functions are being fulfilled and that your committees – whether one, two or ten – are organized in such a way as to ensure that occurs.

If you have a quick question about this, e-mail LeeAnne at LMitchell@hortyspringer.com.

March 27, 2025

Posted on by Courtney Patterson

QUESTION:
A member of our Medical Staff recently had a significant skiing accident which included a concussion.   When he returned to the hospital, staff noticed a change in his behavior and in his clinical performance.  Last week, he had two significant surgical complications and there are concerns that he might not be safe to practice.  The President of the Medical Staff and the Chief Medical Officer want to summarily suspend his privileges and then mandate a health evaluation – not as a punitive measure but to keep patients safe.  Does that sound like a good plan?

ANSWER FROM HORTYSPRINGER ATTORNEY SUSAN LAPENTA:
Health concerns can be particularly challenging.  There are several reasons why we don’t recommend the imposition of a summary suspension in a situation like this, except as a last resort.  First, the standard for imposing a summary suspension is pretty high and typically requires a finding that “failure to take such an action may result in an imminent danger to the health of any individual.”  (This is the standard built into the federal Health Care Quality Improvement Act.)

Second, most bylaws require that there be significant process after the imposition of a summary suspension.  This process typically includes a meeting with the Medical Executive Committee and, if the Medical Executive Committee continues the suspension, the commencement of an investigation, which might lead to a recommendation for disciplinary action.

Third, just calling the action a suspension changes how it is perceived.  A suspension sounds punitive even if you say it’s for patient safety concerns.  Furthermore, the imposition of a suspension creates reporting obligations.  A summary suspension that is in effect for more than 30 days must be reported to the National Practitioner Data Bank and the State Board.  In fact, some state reporting statutes require any suspension to be reported regardless of the duration.

In our experience, in situations where there might be an injury leading to an impairment, the preferred approach, and the approach that is consistent with accreditation standards, is a more collegial one.  For example, as a first step, the President of the Medical Staff and the Chief Medical Officer could meet with the physician, share their concerns, and discuss next steps and options.  This discussion could include a request that the physician voluntarily refrain from exercising surgical privileges until the fitness for practice evaluation can be completed and reviewed by the Practitioner Health Committee.

A physician in this situation will almost always agree to get the evaluation even if they don’t necessarily think it’s needed.  You can use this approach even if it is not expressly spelled out in your bylaws.

Better yet, build this approach into your Medical Staff bylaws documents.  That way, Medical Staff leaders have the authority to require a fitness for practice evaluation by a physician approved by them and can get the necessary authorizations to share information with, and receive information from, the physician who performs the evaluation.  It also helps to have bylaws language which states that if a physician refuses to get the fitness for practice evaluation that the result would be an automatic relinquishment of clinical privileges, not a suspension.

If you have a quick question about this, e-mail Susan Lapenta at slapenta@hortyspringer.com.