medical staff bylaws

October 1, 2026

Posted on by Courtney Patterson

QUESTION:

What is a fair and reasonable time limit after which you can declare an application incomplete?  Does the time limit have to be stated in the Bylaws?  (Submitted at The Complete Course for Medical Staff Leaders in New Orleans, April 2026)

ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:

There is no legal or accreditation standard that governs when an application that is incomplete may or should be deemed withdrawn (and, in turn, not processed further).  So, each organization is free to determine its own time frame.

To avoid disputes, the time frame should be clearly outlined in the Medical Staff Bylaws or another Medical Staff governance document (such as a Medical Staff Credentials Policy), along with other provisions that define what makes an application “complete” and otherwise address how incomplete applications will be managed.  Most organizations that we work with consider an application withdrawn if the applicant has not completed it (by answering all questions, providing all requested information, and resolving all concerns) within 30 to 90 days of receiving notice of the information that is missing/required.

When deciding what sort of time frame you wish to utilize (and write into your Bylaws/Medical Staff governance documents), consider:

  • Will the time frame allow most practitioners – no matter the issue in their background – sufficient time to provide a complete reply? How often do you anticipate making an exception and giving an applicant more time to respond?  Note that organizations choosing a 30-day time frame are likely to grant exceptions far more often than those that choose a longer time frame, such as 60 or 90 days.  And while it’s no problem to grant an exception/extension (though the Bylaws/policy language should authorize it), doing so gives a future applicant a foothold to argue that they too should be given more time to respond.  The best tools in Medical Staff credentialing and peer review are those that can be applied methodically and consistently (except when truly exceptional circumstances are present).  So, as a general rule, it is best to try to pick a time frame that you will feel comfortable enforcing routinely.  And if you are going to grant an exception, allowing an applicant more time to complete an application (beyond the standard time frame), it is a good idea to articulate why.
  • For example, imagine that you have requested the practitioner obtain and submit the results of a fitness for practice examination by a specified health care provider. This may be anticipated to take longer than 30 days.  So, you could state in the letter to the practitioner that you understand it may take longer than the normally-allotted 30 days to obtain the examination and submit the results and, in turn, you will grant the practitioner an extension such that the response/information is due within 30 days after the examination, provided the practitioner shows that he/she has scheduled the examination within seven days of receiving the letter and the examination takes place within 60 days of receiving the letter.
  • Will the time frame impact the rest of the credentialing process in an unanticipated way? For example, if the organization chooses to give practitioners 90 days to respond once notified that an application is incomplete and more information is required, will that impact the organization’s ability to satisfy its delegated credentialing agreements with payors?  Many payor credentialing agreements and standards mandate that credentials verifications expire after a specified number of days (e.g., 120, 180).  Therefore, be aware that longer time frames for completing the application might result in those applications requiring re-verification prior to final Board action.  Is that something the organization is willing to live with?

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

August 27, 2026

Posted on by Courtney Patterson

QUESTION:
Like the rest of the country, we are struggling to recruit physicians to our community.  As we expand our efforts, we are seeing more candidates who trained outside the United States.  If they are certified by a foreign board, how should we approach their applications?

ANSWER FROM HORTYSPRINGER ATTORNEY IAN DONALDSON:
Outside of the occasional recognition of the Royal College of Physicians and Surgeons, most Medical Staff Bylaws we see require certification by an American board.  That means applicants with foreign board certification are ineligible for appointment unless a waiver is granted.

This can be a dicey proposition, since waivers generally require a showing of “exceptional” circumstances.  Whether an applicant can demonstrate such circumstances is in the eye of the beholder, so giving your Credentials Committee a set of guidelines for determining waivers related to foreign board certification can help it evaluate candidates in a consistent manner.  We recommend these guidelines walk the Committee through key factors like:  (1) are the foreign board’s certification requirements comparable to certification by an American board, (2) what constitutes “exceptional circumstances” under these circumstances (i.e., is certification by an American board not realistically available to the applicant due to the applicable board’s pathway rules for internationally trained physicians or does the applicant simply prefer not to pursue them), and (3) what information should an applicant who is requesting a waiver provide (e.g., a description of the foreign board’s certification requirements, documentation addressing pathway availability (e.g., relevant ABMS board policy excerpts and/or correspondence confirming eligibility/ineligibility), etc.).

Developing guidelines to address this issue will provide your Credentials Committee with a structured process to review these types of requests, which are likely to become more and more common in the future.

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

July 9, 2026

Posted on by Courtney Patterson

QUESTION:
One of our physicians has been asked to attend a peer review meeting to discuss several cases that raised concerns. The physician has informed us that she intends to bring her attorney to the meeting. Are we required to allow legal counsel to attend?

ANSWER FROM HORTYSPRINGER ATTORNEY FISHER FILIPPAZZO:

This is a great question and one that comes up frequently during the peer review process. As a general rule, physicians do not have a right to bring legal counsel to routine peer review meetings unless that right is specifically provided by the Medical Staff Bylaws, peer review policy, or applicable state law. Also, if a physician will not be permitted to be accompanied by counsel, the hospital attorney should not attend either.

It is important to remember that a routine peer review meeting is not the same thing as a formal hearing. Peer review meetings are intended to be collegial discussions among physicians regarding clinical care, opportunities for improvement, and any concerns that have been identified. Allowing attorneys to participate can quickly change the nature of the discussion and make it more difficult for the committee to conduct an effective review.

Sometimes physicians express concern that the outcome of the review could ultimately affect their privileges. While that concern is understandable, hearing rights, including any rights related to legal representation, are typically triggered only if a professional review action reaches a stage where formal procedural rights apply. In most organizations, a routine peer review meeting is simply a step in the information-gathering process.

That does not mean the physician is unable to present information. The physician can be invited to submit a written response, provide supporting documentation, or otherwise address the concerns raised by the committee. In fact, committees often receive the most helpful information when discussions remain focused on the clinical issues rather than legal arguments.

For these reasons, hospitals should review their Medical Staff Bylaws and peer review policies to ensure they clearly address whether attorneys may attend peer review meetings and apply those provisions consistently.

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

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.

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.

January 22, 2026

Posted on by Courtney Patterson

QUESTION:

We are currently reviewing the application of a physician and have encountered several red flags during credentialing.  Our main concern is that the physician failed to disclose on his application a prior hospital where he practiced and where his privileges were restricted – information we uncovered through a National Practitioner Data Bank query.  Throughout the process, the physician has been largely unresponsive and difficult to work with, and he has explained the omission as an oversight by his office staff. Given the nature of the restriction, however, it seems unlikely this affiliation would be easily forgotten.  How should we proceed if we believe the explanation may not be truthful?

ANSWER FROM HORTYSPRINGER ATTORNEY MARY PATERNI:
While some misstatements and omissions on application forms may be benign, others can be serious, and your concerns are well founded.  Because this is the applicant’s first interaction with the Medical Staff, it is important that they make a strong impression.  Beginning that relationship with potentially intentional omissions may signal future issues if the applicant is appointed and granted clinical privileges.

If you do not already have one, consider incorporating into your Medical Staff Bylaws an administrative process that addresses an applicant’s failure to disclose pertinent information on their application.  Specifically, the Bylaws should state that the hospital will stop processing the application upon discovery of a misstatement or omission.  The applicant should then be notified of the issue and given an opportunity to respond, after which the hospital may determine whether to resume processing the application.  We also recommend including corresponding language in the attestation the applicant signs upon completion of the application.

Because this is an administrative issue – not an adverse recommendation – the Bylaws should make clear that a decision to stop processing an application due to a misstatement or omission is not a “denial” and does not give rise to hearing or appeal rights.  In other words, the hospital isn’t rejecting the application based on the physician’s competencies, training, or experience.  The application simply won’t move forward because the applicant failed to fully or accurately disclose information needed to fully vet his application.

If you have a quick question about this, e-mail Mary Paterni at mpaterni@hortyspringer.com.

December 5, 2025

Posted on by Courtney Patterson

QUESTION:
At the Complete Course for Medical Staff Leaders, you mentioned the importance of transparency and meaningful notice to applicants, members of the medical staff, and other practitioners who have been granted privileges.  What is the obligation to send written notice to an applicant that a waiver process is available, a waiver request has been granted, and/or a waiver request has been denied?

ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:
Transparency in medical staff affairs is not only about ensuring medical staff members and other practitioners with privileges have access to Medical Staff Bylaws and other medical staff policies and rules and regulations, and are notified to any major changes to those documents.  It also includes providing meaningful and timely notice to applicants and practitioners about matters involving their credentialing and peer review.  This includes providing notice that an application is not going to be processed, as well as the reason why (whether it’s because the applicant has requested clinical privileges that are not available at the hospital, because the applicant does not satisfy the threshold eligibility criteria set forth in the Medical Staff Bylaws or Medical Staff Credentials Policy, or because the application is incomplete – to name just a few reasons).

Many hospitals and medical staffs choose to include in the Medical Staff Bylaws (or Credentials Policy) a process for requesting a waiver of one or more of the threshold eligibility criteria, in the event an applicant fails to satisfy the criteria and nevertheless wishes to receive additional consideration and have an application subjectively considered.  Generally, waivers are considered only if the applicant provides substantial evidence showing that there are exceptional circumstances and that the applicant’s qualifications (clinical performance, professionalism, etc.) are just as exceptional, if not more, than other individuals who satisfy the criteria for which the applicant is requesting waiver.

While most hospitals and physician leaders agree that it is important to notify the applicant if a waiver request is denied, we are occasionally asked whether it is necessary to provide the reason for the denial.  Provided you have good waiver language written into your Bylaws/policies, the burden is on an individual requesting waiver to demonstrate that waiver is appropriate and an exception to the general rule of non-eligibility/ non-consideration should be made.  Therefore, if the MEC and Board have determined that the applicant has not met the burden of demonstrating they are an appropriate candidate for a waiver, it should suffice to simply state that after considering all of the information submitted by the applicant, the Board determined that a waiver is not appropriate and, in turn, the application cannot be processed further.

Should you also notify an applicant in writing if a waiver is granted?  This question is rarely asked since, in most scenarios, the applicant is happy to receive a waiver and, in turn, there are rarely disputes about waivers that have been granted (rather than denied).  Nevertheless, there are a couple of reasons that you may wish to consider providing notice to the applicant when you grant a waiver:

  • First, whenever a waiver is granted (or denied), it is a good idea to articulate and document the reason, in order to create institutional history of all waivers that have been considered and the outcome. This is important for tracking whether the hospital is methodically upholding the threshold eligibility criteria and for ensuring consistency with respect to any waivers granted/denied (e.g., are similarly situated requestors being treated similarly?).  Ultimately, an eligibility process is administrative – rather than subjective – only if the threshold eligibility criteria are objective and those criteria are applied consistently to individuals.  So, having a record of consistent application helps the hospital in the long run.  Of course, you could create the documentation through meeting minutes or other records of the action taken.  But, in our experience, the articulation/documentation of waivers often falls through the cracks.  Adopting a process of notifying the applicant whenever a waiver is granted might help to close that gap.
  • Perhaps more importantly, however, notifying an applicant of the grant of a waiver also provides an opportunity to document (and inform the individual) of any time limits or other conditions associated with the waiver.

For example, if an individual is granted a waiver of an MOC (maintenance of board certification) requirement due to an exceptional circumstance that prevented them from completing the MOC requirements during their previous appointment term (e.g., extreme illness or family emergency), the hospital might grant a short-term waiver (e.g., one appointment term), to be revisited at the time of the next reappointment cycle.  If the waiver will be temporary, rather than permanent, it is important to notify the applicant/practitioner so that they will have realistic expectations and not be caught off guard when the criterion is applied in the future.

The same is true for any conditions that may attach to the waiver.  For example, if you have decided to grant a waiver of a threshold eligibility criterion requiring recent clinical experience exercising the requested privileges in a facility of comparable acuity, that waiver might be conditioned on the individual complying with a re-entry plan that includes continuing medical education and/or observation/shadowing to be completed prior to commencing clinical activities at the hospital, requirements for proctoring, consultation, or serving as an assist when initially commencing clinical activities at the hospital, and/or other FPPE activities.  If the waiver is conditional on the applicant agreeing to – and complying with – those conditions, it is important to notify the applicant and make it clear that the waiver may be forfeited (with the individual then failing to be eligible for continued medical staff appointment/privileges) if they do not comply.

If you have a quick question about this, e-mail this week’s editor, Rachel Remaley, at rremaley@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.

August 28, 2025

Posted on by Courtney Patterson


QUESTION:
How can our medical staff leaders best verify that a physician actually received a written request for information? Classically, I hear doctors say they “didn’t get the notice” – even when it is sent multiple ways – including certified mail.  (Registrant Q&A, submitted electronically at the Complete Course for Medical Staff Leaders, held in Las Vegas (Fall 2022))

ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:
It’s amazing (and somewhat comical) how much time hospitals and medical staff leaders have spent trying to ensure, and document conclusively, that a practitioner has received notifications about medical staff membership, clinical privileges, peer review matters, Bylaws amendments, and so on.  In an era where snail mail, fax machines, and hand delivery were more common, the devotion to tracking down physicians at great effort was (perhaps) understandable.  But, as you mentioned, many times physicians claimed they did not receive hospital correspondence – even when it was sent via certified mail, return receipt requested (a very inconvenient type of mail to send).

Luckily, we have moved past that era and there are now better tools available to hospitals and their medical staff leaders – ones that virtually eliminate the administrative burden of providing appropriate notice or special notice to a member of the medical staff (or other practitioner with clinical privileges).  Specifically – considering using email and/or online messaging apps/programs to correspond regarding all communications related to the practitioner’s medical staff membership and/or privileges.  This can include all routine communications (e.g., “it’s time to submit your application for reappointment”), as well as non-routine communications (e.g., letters of guidance or education sent through the peer review process).  In fact, many organizations these days are even using email for “Special Notice” – that is, the type of notice generally given for matters of importance, such as notice of adverse professional review action and/or the right to request a medical staff hearing.

Of course, the method(s) of notice utilized by the hospital and its medical staff leaders must comply with the Medical Staff Bylaws and other medical staff governance documents (such as the Rules and Regulations, or other medical staff policies).  So, it’s important to consult those documents – and see whether/how they define “notice” – before switching up your default method.  If necessary, you may need to pass an amendment that clarifies the default method for communicating with Medical Staff members and privileged practitioners (as well as applicants for medical staff membership or privileges) will be email.

To help with administration/implementation, also consider:

  • Stating in the Medical Staff Bylaws/Credentials Policy that every applicant/practitioner must provide a current email address to Medical Staff Services and keep that address up-to-date throughout the credentialing period and any term of medical staff membership and/or privileges;
  • Requiring the practitioner to certify that the email address he or she will use for hospital and medical staff correspondence is appropriately secured, sufficient to meet the requirements of the Health Insurance Portability and Accountability Act’s privacy and security regulations. As an alternative, the Bylaws might be drafted to state that every applicant and/or practitioner will be issued an email address by the health system and will be required to utilize that email address to send and receive emails related to the practitioner’s medical staff membership and/or privileges.  A final alternative is for the Bylaws to state that all correspondence will occur via a secured intranet or app (for which the practitioner will have a user ID and password);
  • Placing the burden on the applicant/practitioner to regularly check the email address that has been provided to Medical Staff Services and/or the app that is being utilized for correspondence;
  • Specifically stating the methods of communication that are considered acceptable for notice (e.g., email, regular U.S. mail, telephone) and special notice (e.g., email, federal express or other delivery service offering verification of delivery, hand delivery with documentation of delivery);
  • Outlining any other specific details that may apply to the provision of notice. For example, when calculating “days” for the purposes of giving notice, does the date that the notice was sent count?  Do weekends and holidays count?

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