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.