October 10, 2019

QUESTION:        The five medical staffs in our system are thinking about unifying.  Are there any particular steps we need to follow and any changes we need to make to our bylaws?

 

ANSWER:          In May 2014, CMS revised the Medicare Conditions of Participation to allow a multi-hospital system to have a unified and integrated Medical Staff.  There are several steps that must be taken in the integration process.  First, the system must ensure that there is nothing in the state hospital licensing statutes or regulations that would prohibit the medical staffs of separately licensed hospitals from integrating into a single staff.

Second, the Board (and there must be a single Board) must document in writing its decision to use  a unified medical staff model.  This decision would be conditioned on acceptance by the hospitals’ medical staffs to opt-in to an integrated medical staff model.

Third, the medical staff of each of the hospitals must take a separate vote to opt in or opt out of the unified medical staff.  The vote at each hospital must be governed by the respective medical staff bylaws in effect at the time.  Only voting members of the medical staff who hold privileges to practice on site at the hospital may participate in the vote.

Fourth, the unified medical staff will also want to adopt new medical staff bylaws and related policies.  The new bylaws should take into account the unique circumstances of each hospital, including any significant differences in the patient populations and the clinical services that are offered at each hospital.

Importantly, the new bylaws must also include a process by which the voting members of the medical staff who exercise clinical privileges at the hospital may vote to opt out of the unified medical staff in the future.

September 5, 2019

QUESTION:        How do we handle a situation when there is a physician on the Credentials Committee who is married to another physician, and the spouse’s application is up for consideration?

ANSWER:           Every so often we run across physician couples.  In those instances, there may be a situation in which the conflict of interest rules for credentialing or peer review activities are implicated.  For example, imagine that Dr. Wright is appointed to the Medical Staff, is recognized as having good leadership qualities, and is appointed to the Credentials Committee.  Then, his spouse applies for Medical Staff appointment.  The application comes before the Credentials Committee and Dr. Wright is told “You can’t vote on the application” but Dr. Wright insists on voting, because  “I know this applicant better than any other applicant that has been before this committee!”

Well, that may be so, but Dr. Wright can’t vote!  Going back to compliance training and basic conflict of interest rules, Dr. Wright has a conflict of interest regarding his spouse’s application.  He is emotionally involved in the outcome, and probably financially involved too.  Of course, Dr. Wright can provide any relevant information he may have regarding his spouse and can answer any questions the Credentials Committee may have about her.  But, after doing so, it’s prudent for him to leave the Credentials Committee meeting, and not participate in the discussion of his spouse’s credentials or the vote on the application.  Also, the minutes should reflect that he left the meeting, the vote occurring after he left, and his return to the meeting.

December 20, 2018

QUESTION:        What we’d like to get as a present this year is a way to find strong, interested and effective department chairs and other Medical Staff leaders.  Any ideas?  Thanks – Virginia.

ANSWER:            Yes Virginia, there is a Santa Claus – in other words, yes, we have a few ideas.  Let’s start unwrapping the present.

In many hospitals, it has been traditional to rotate the department chair among those in the department so that everyone gets his or her turn, which does not always make for strong, interested, and effective leaders.  However, not every physician has an aptitude for, or interest in, a medical staff leadership position.  In order to solve this dilemma, a hospital should consider developing stronger qualifications for serving in medical staff leadership roles, including officers as well as department chairs, and to provide for compensation for these individuals.  Another solution could be to determine whether there are too many departments and, if so, consider consolidating departments.  By having fewer positions to fill, the hospital will then have a larger pool of qualified individuals who want to serve.

All of this said, one of the biggest changes that we have seen in medical staff leadership in the recent past is to eliminate the use of “ad hoc” nomination committees for identifying medical staff leaders – whether the leaders be officers, department chairs, or committee chairs — and moving toward a standing committee dedicated to leadership development and succession planning that meets throughout the year.  Having a standing committee in place allows the leadership to take a more comprehensive look at the medical staff, identify new members who might make good leaders in the future, and give them time for training, education, and development.

For more on this, and other topics, please join Linda Haddad and Nick Calabrese for the first Grand Rounds Audio Conference of 2019Six New Year’s Resolutions Every Medical Staff Needs to Make.

September 20, 2018

QUESTION:        What are the responsibilities of our hospital’s Board of Directors (“Board”) with regard to oversight responsibilities of the Medical Staff?

ANSWER:            Although it is important to check your state laws and standards set forth by your accrediting organization, a good starting point would be to refer to the Medicare Conditions of Participation (“Medicare CoPs”) pertaining to the Board’s responsibilities, including its oversight responsibilities of the medical staff.  For instance, the Medicare CoPs place the ultimate responsibility for quality of care provided at a hospital and monitoring the care provided to patients on the Board.  Among others, the Medicare CoPs require the Board to define criteria for and appointing members to the medical staff, grant clinical privileges, ensure the existence and approval of medical staff bylaws, and approve various services in the hospital.  Ultimately, the Board holds the responsibility for the quality of patient care in the hospital.  The Board and medical staff engage to provide effective credentialing, privileging, and peer review and quality management processes.

Although responsibilities provided by the Medicare CoPs are extensive, do not forget to consult your applicable state laws as well as the standards of your accrediting organization, which may dictate further oversight responsibilities of the Board.

May 24, 2018

QUESTION:        A physician new to our staff has taken it upon himself to personally “investigate” potential patient safety issues; he says that the medical staff committees are “useless.”  He is not a member of any peer review committee.  What can we do?

ANSWER:            He should be counseled and advised (in writing) of proper channels for expressing his concerns.  He should be asked to provide specifics so the matters can be reviewed.  It is reasonable for hospital and medical staff leaders to develop a statement of expectations, which can be placed into the bylaws, credentials or peer review policy, or adopted separately, requiring that all medical staff members and privileged practitioners cooperate constructively in the peer review, patient safety and performance improvement processes. Careful procedures must be followed, to track any state peer review protection statutory requirements.  It is also a fundamental principle of professionalism and respect that any practitioner who has concerns about hospital policies or other practitioners’ performance should take those concerns through appropriate channels. Otherwise, the practitioner raising these concerns could open himself or herself up to defamation claims by other practitioners whose care or practice he or she has criticized.

The peer review process depends on the willingness of all privileged practitioners to cooperate constructively. Having this responsibility set forth clearly in writing can be very helpful in the event a practitioner continues to act out inappropriately, and thus place the organization and medical staff leaders at risk. In the event an adverse action is necessary, it is best to have a solid written record that leadership reached out to the physician and provided specific directives as to avenues for presenting quality and safety concerns.  If the practitioner persists after the counseling and written follow-up, he or she could be placed on a performance improvement plan or conditional continued appointment. That way, if this practitioner decides to sue, it will be easier to defend the claim because he or she will have brought about the action by his or her own conduct.  You should, however, look into all the issues the practitioner has raised, through appropriate mechanisms.

January 11, 2018

QUESTION:        Our Medical Staff Services Department is reviewing an application for a physician who has been recruited by the Medical Center as an employee. The physician does not meet all of the eligibility criteria in the Medical Staff Credentials Policy, but we understand the contract has already been signed.  What should we do?

ANSWER:            Unfortunately, this is an all-too-common problem. “Credentialing 101” says that an application from a candidate who does not satisfy the Medical Staff’s threshold eligibility criteria should never be processed – even in an employment situation.  So, hopefully, the contract contains a provision that states the contract is conditional upon the physician being appointed to the Medical Staff and obtaining clinical privileges in the relevant specialty.

To avoid this situation in the future, organizations should strive for coordination between their Medical Staff Services Department and their recruiters.  This means educating recruiters about the minimum qualifications set forth in the Medical Staff Credentials Policy, as well as giving your recruiters a list of “red flags” that will slow an application up during the credentialing process (e.g., gaps in experience, negative references, etc.)

To make sure your Medical Staff leaders have the knowledge and tools that they need to manage difficult issues like this, please join Barbara Blackmond and Ian Donaldson at The Complete Course for Medical Staff Leaders.

October 5, 2017

QUESTION:        Can credentials and peer review information about a practitioner be shared with a sister hospital if the sister hospital has the same Board, but each has its own separate Medical Staff?  Should they?

ANSWER:            Hospitals that are affiliated under the same Board, in a system, can exchange information, although we recommend several steps to maximize legal protection. We generally recommend including a provision in each hospital’s Medical Staff bylaws or credentials policy, as well as a statement on the application form, that the applicant understands that information will be shared among entities in the system and that the sharing of this information is not intended to be a waiver of the state peer review protection statute.  It is also a good idea to have a formal information?sharing agreement among the hospitals which clearly defines what information will be shared, when it will be shared, and to whom it will be forwarded.

As for whether the hospitals should share information, the answer is yes. Two hospitals under one Board would be considered one corporate entity.  Each individual hospital (or clinic, health plan, ambulatory surgery center and any other related facility) is part of that one entity.  Important to the Medical Staff leaders responsible for helping to maintain high standards of care through careful and thorough credentialing of physicians is the fact that because it is one entity, credentialers may be “deemed” to be making recommendations as to whether a specific practitioner is qualified and competent based on the collective knowledge of the entity as a whole, rather than the knowledge contained within an individual hospital.  The standard in the law — when it comes to doling out liability — is that the credentialers “knew or should have known” the relevant information that came from the sister facility.

May 5, 2016

QUESTION:        Can credentials and peer review information about a practitioner be shared with a sister hospital if the sister hospital has the same Board, but each has its own separate medical staff?  Should they?

ANSWER:            Hospitals that are affiliated under the same Board, in a system, can exchange information, although we recommend several steps to maximize legal protection, standardize the process, and quell any paranoia that may exist with regard to such sharing. We generally recommend including a provision in each hospital’s medical staff bylaws or credentials policy, as well as a statement on the application form, that the applicant understands that information will be shared among entities in the system and that the sharing of this information is not intended to be a waiver of the state peer review protection statute.  It is also a good idea to have a formal information-sharing agreement among the hospitals which clearly defines what information will be shared, when it will be shared, and to whom it will be forwarded – all of which is drafted in compliance with and with appropriate references to the state peer review statute.

As for whether the hospitals should share information, the answer is yes. Two hospitals under one Board would be considered one corporate entity.  Each individual hospital (or clinic, health plan, ambulatory surgery center and any other related facility) is part of that one entity.  Important to the medical staff leaders responsible for helping to maintain high standards of care through careful and thorough credentialing of physicians is the fact that because it is one entity, credentialers may be “deemed” to be making recommendations as to whether a specific practitioner is qualified and competent based on the collective knowledge of the entity as a whole, rather than the knowledge contained in an individual hospital.  The standard is the law – when it comes to doling out liability – that the credentialers “knew or should have known” the relevant information that came from the sister facility.

April 28, 2016

QUESTION:        We have an applicant who, technically, does not satisfy our threshold criteria.  But, we’re wondering if it’s really a big enough deal to justify keeping this physician off of our staff.  Specifically, this applicant had his license suspended six months ago, for 37 days, due to failure to comply with the tax code.  The physician disclosed the suspension on his application and included a narrative explanation, which basically stated that:

  • His wife failed to file the family’s tax returns for three years, without his knowledge. This resulted in him getting further behind in filing and caused tax penalties to add up.
  • He did not realize he had any tax delinquencies or that there was any problem with his license until his employer was notified that his license was suspended. He said mail delivery at his home has a history of being unreliable.
  • He resubmitted all ten years of tax returns that were requested by the taxing authority and was fully compliant with their investigation into the matter, once he knew there was a problem.
  • He paid the outstanding taxes and penalties due.
  • His license was reinstated after 37 days.

Our primary source verification of his license indicates the suspension and that it was due to failure to comply with the tax code.  Do we really need to make a “thing” out of this?  After all, how relevant is tax compliance to the practice of medicine?

ANSWER:            While you do need to make a “thing” out of this, that does not necessarily mean that this individual will not be able to join your medical staff.  A few things to consider when faced with an applicant like this, who does not satisfy your threshold criteria:

First, remember that the threshold criteria were developed through a process of careful deliberation by medical staff leaders and hospital representatives.  So, the legwork in determining whether an issue is a “big deal” with respect to medical staff membership and/or clinical privileges has already been done.  That decision need not be made on a case-by-case basis by those responsible for processing individual applications.

Further, the threshold criteria are part of the Bylaws or Credentials Policy and those documents should be followed.  Relatedly, the threshold criteria should be waived only if there is a waiver process set forth in the Bylaws or Credentials Policy (such provisions usually require a recommendation by the Credentials Committee and MEC and a final decision by the Board with respect to a waiver, before the application is then considered – if the waiver is granted).

As a general rule, waivers should be granted only if there are exceptional circumstances justifying the grant of a waiver.  The burden should be placed on the applicant to show that his or her qualifications are the same as or exceed those of individuals who satisfy the threshold criteria.  You do not need to show that you have good cause to keep an applicant out.  The applicant needs to show he or she is qualified to join your medical staff.  For example, failure to file tax returns and pay delinquent taxes calls into question an individual’s responsibility, veracity in documentation, honesty, and ability or willingness to comply with the rules.  And, so, the burden should be placed on the applicant to show that these things are not an issue before any waiver is granted.

Finally, just because you may not view tax noncompliance as a “big deal” does not mean you should not look at this issue with scrutiny, because it could raise other issues.  It may not.  But, you won’t know for sure until you look closely.  Consider the following issues, which you may wish to resolve before making a decision about a waiver:

  • Why did the applicant tell you that he did not know about the suspension of his license until his employer was notified? Is he preemptively explaining away the fact that he continued to practice on a suspended license – after notification from the state?
  • Is the applicant’s explanation reasonable and consistent? He says that he had no knowledge that his wife failed to file tax returns – and was not aware of the tax delinquency until his employer notified him that his license had been suspended.  But, he also stated that the wife’s failure to file tax returns caused him to “get behind” in filing.  If he did not know that his wife did not file returns, how could that have affected his filings in future years?
  • The applicant states that he was asked to provide 10 years of returns as part of the taxing authority’s investigation – but he stated that his wife only failed to file during three years. Why the inconsistency?
  • The applicant says that he was unaware of the problems with his taxes and license because of poor mail delivery at his address. That is very unusual and warrants additional follow-up.  Can the applicant provide any evidence that he has complained on prior occasions to the postmaster?  Does he have any evidence that mail and packages are returned to sender without delivery?  Does the applicant live in a very rural area, outside the bounds of normal civilization, where it may be reasonable to presume mail service is less consistent?

This may all seem like a lot of rigamarole for what looks like a simple, administrative oversight of a regular physician.  And, it may turn out to be.  But, sometimes, when situations like this arise, a little bit of scrutiny and digging reveals that the seemingly simple issue that was voluntarily revealed is actually a bigger issue than was being concealed.  It pays to do your homework up front.  So, put the burden on the applicant to fully explain and document his or her side of the story and then, given that information, consider whether his or her situation is so extraordinary that it justifies waiving your criteria.

March 26, 2015

QUESTION:   Can advanced practice clinicians and other non-physicians be appointed to the medical staff?

ANSWER:   Yes, as long as your state hospital licensure regulations and medical staff bylaws allow them to be medical staff members. The Interpretive Guidelines of the Medicare Conditions of Participation for Hospitals, at §482.12(a)(1), say:

  • The governing body has the authority, in accordance with state law, to grant medical staff privileges and membership to non-physician practitioners.
  • The regulations allow hospitals and their medical staffs to take advantage of the expertise and skills of all types of practitioners who practice at the hospital when making decisions concerning medical staff privileges and membership.
  • Granting medical staff privileges and membership to non-physician practitioners is an option available to the governing body; it is not a requirement.

Practitioners who can be on the medical staff may include any of the following:

  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • CRNAs
  • Certified nurse-midwives
  • Clinical social workers
  • Clinical psychologists
  • Anesthesiologist assistants
  • Registered dieticians or nutrition professionals
  • Physical therapists
  • Occupational therapists
  • Speech language therapists

Mind you: you don’t have to appoint any of these categories of practitioners to the medical staff, but unless your state law says otherwise, you can.