Peer Review

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.

September 25, 2025

Posted on by jwilbert

QUESTION:
We use informational letters as a part of our peer review process.  Is it necessary for us to solicit physician input or feedback before issuing an informational letter?

ANSWER FROM HORTYSPRINGER ATTORNEY CHARLIE CHULACK:
The short answer is “no.”  But first, a little context on informational letters (which can also be referred to as “awareness letters”) – these are a tool in the progressive steps continuum that are designed to address minor performance issues and intended to make practitioners aware of expectations or requirements in, for example, the Medical Staff Rules and Regulations.  Much like the other tools you have in the progressive steps continuum, informational letters are non‑punitive and educational, and they aim to get practitioners to self‑correct using feedback.  Informational letters are triggered when a practitioner does not comply with an objective requirement for the Medical Staff.

Ideally, your multi‑specialty peer review committee should approve in advance a list of objective occurrences for when an informational letter will be sent.  By way of example, most Medical Staffs have requirements in the Rules and Regulations that patients have to be seen by the attending physician daily with a progress note recorded describing the visit.  This requirement could be reflected in your peer review policy or manual as a performance issue that triggers an informational letter.  The key here is that the informational letter is triggered by an “objective” occurrence.  Therefore, whether someone did or did not do something that triggers an information letter should be clear on its face and, because of this, there is usually no need to solicit feedback from the practitioner before issuing the informational letter.  However, if you are addressing an issue and considering an informational letter but have questions for the practitioner about the concern, nothing in your policy should prohibit you from asking those questions.

If you have a quick question about this, e‑mail Charlie Chulack at cchulack@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 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.

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.

May 1, 2025

Posted on by Courtney Patterson

QUESTION:
Should we be using specialty-specific triggers as a part of our professional practice evaluation/peer review process?

ANSWER FROM HORTYSPRINGER ATTORNEY CHARLES CHULACK:
Yes.  Specialty-specific triggers give a measure of predictability and transparency to the professional practice evaluation/peer review process (“peer review process”).  These triggers are pre-determined events, organized by specialty or department, that identify a case for review through your peer review process.  Moreover, accreditation entities require the inclusion of these triggers as a part of the review process.  By way of example, The Joint Commission, in MS.08.01.01, instructs that the Medical Staff must “define the circumstances requiring monitoring and evaluation of a physician’s or other licensed practitioner’s professional performance” and requires that “[t]he triggers that indicate the need for performance monitoring are clearly defined.”  The DNV standards have similar language and define, in MS.8, “areas required to be measured [as a part of the peer review process],” including “[s]pecific department indicators that have been defined by the medical staff.”  The triggers should be communicated to members of the specialty or department so that they understand that if a certain event occurs, it is ripe for review, and they will most likely be notified about the case.

Often, the department chairs take the lead in identifying the specialty-specific triggers and the peer review committee is responsible for approving and periodically reviewing them.   For surgery, the triggers could include events such as an unplanned injury or removal of an organ, a retained foreign body, a wrong-site surgery, and a laceration or puncture of a body part.  For medicine, the triggers could include an unplanned transfer to a special care unit, an adverse outcome that is unrelated to the natural course of an illness, the death of a patient in a low mortality DRG, or a critical/abnormal lab result that is unaddressed or misinterpreted.

In addition to specialty-specific triggers, there are numerous other ways that clinical issues may be entered into the peer review process, including through reported concerns, patient complaints, referrals from the serious safety event process, OPPE data that reflects a concerning practice pattern or concern, and utilization issues.  These should also be defined in your peer review policy and will establish a broad net to catch issues for review.

If you have a quick question about this, e-mail Charlie Chulack at cchulack@hortyspringer.com.

April 3, 2025

Posted on by Courtney Patterson

QUESTION:
As a part of our routine peer review process, our multi-specialty peer review committee recently requested a meeting with a physician whose case was under review.  The physician said he would only attend if he was allowed to bring his attorney.  Do we have to allow his attorney to attend this meeting?

ANSWER FROM HORTYSPRINGER ATTORNEY IAN DONALDSON:
You do not, but make sure your peer review policy supports you in making this determination!

We are strong proponents of using “collegial” discussions to address performance concerns.  However, that collegiality can quickly go out the window when attorneys are introduced into the process.  If the physician is allowed to bring their attorney, then an attorney from the hospital side is also likely going to be in attendance.  When this happens, the attorneys end up doing all the talking, instead of having a constructive, peer-to-peer discussion.  Even when the physicians at the meeting find a way to get a word in, the presence of attorneys is likely to cause the committee members to speak less candidly, as they will be worried about whether their comments might be used against them by the adverse attorney.

How can your policies help with this dilemma?  We always recommend including language that makes it clear that any collegial meetings will be held in a “no lawyer zone.”  This gives you something to put your finger on to show it is not permitted, should the question ever come up.  More importantly, this allows the invited physician and applicable committee members to have an open and frank “peer‑to‑peer” discussion about whatever issue is on the agenda.

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

February 13, 2025

Posted on by Courtney Patterson

QUESTION:
Our team just attended your seminars in Amelia Island.  The one member who attended the Peer Review Clinic came out of the session with a strong belief we should remove “scoring” from our case review forms.  He’s had some trouble convincing the rest of us, so we wanted to hear it right from the horse’s mouth – why do you recommend against scoring cases?

ANSWER FROM HORTYSPRINGER ATTORNEY IAN DONALDSON:
We are happy to back up your colleague on this one!  The reasons we recommend moving away from using scoring as a part of the peer review process are based on the following issues:

  • We have observed that peer review committees spend a lot of energy on assigning the score, which distracts from the more important issues of whether there is a concern with the care provided and, if so, the appropriate intervention.
  • While scoring gives a perception of being objective, we’ve found that numerical scores don’t necessarily capture the complexity of a case in the same way as a detailed description from a case reviewer.
  • We have found that reviewers may be uncomfortable assigning low scores, which often carry labels indicating that the physician’s care was “inappropriate” or “below the standard.” As a result, the reviewers choose higher scores indicating “care appropriate” even if there are concerns.
  • Negative scores may put physicians on the defensive, especially since most scoring systems don’t allow for the provision of nuanced information.

These characteristics of scoring can undermine efforts to make the peer review process educational rather than punitive.  Accordingly, we recommend having a peer review/professional practice evaluation (“PPE”) system that focuses on actions and performance improvements rather than scoring.

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

Please join Ian Donaldson and Charlie Chulack at an upcoming Peer Review Clinic to learn more about the new approaches Medical Staffs are taking to traditional peer review matters. You can learn more by clicking here.

February 6, 2025

Posted on by Courtney Patterson

QUESTION:
There is a private subreddit discussion group in which only Medical Staff professionals are approved to participate.  Most members of the group seek advice on credentialing, privileging, and peer review issues.  Community guidelines within the group caution against identifying the practitioners involved in their questions.  However, some posts may include specific details about problematic credentialing files or behavior incidents.  In some instances, individuals who post questions may include information such as their name and the hospital at which they work.  A few of our leaders are wondering if joining this group would help to bounce ideas off other Medical Staffs and their leaders.  Is this problematic?

ANSWER FROM HORTYSPRINGER ATTORNEY MARY PATERNI:
While we don’t mean to discourage professional interactions among Medical Staff professionals, there are legal risks to discussing credentialing and peer review issues about individual practitioners on social media.

Let’s be real, it’s social media.  There is never any guarantee that anything posted on platforms like Reddit, Facebook, or Instagram will remain private, even if a group is “closed.”  A member of the group could have a reason for disclosing information outside the group.  All it takes is a screen shot or copy + paste.  Plus, efforts to “de-identify” information do not always work.  Even the smallest bits of supposedly de-identified information can sometimes be pieced together and become identifiable.

There are a variety of legal risks if a post about credentialing or peer review matter gets back to the practitioner who is the subject of the post.  First, the practitioner could claim that the post was defamatory because it disclosed unfavorable information in a public setting.  Also, the practitioner could argue that the post constituted a breach of the confidentiality obligations set forth in the Medical Staff Bylaws, “tortiously interfered” with his employment prospects, or constituted a “breach of contract” under state law.

Social media posts could be problematic even if they are disclosed to individuals other than the practitioner in question.  For example, plaintiffs’ attorneys could use such posts as a reason to look for problems at a hospital.  Also, attorneys representing plaintiffs in malpractice or negligent credentialing cases could argue that the disclosure of peer review information on social media resulted in a waiver of the peer review privilege under state law of any information related to that matter.

So, we want to be careful here.  Again, we don’t mean to discourage professional interactions among Medical Staff professionals.  There are certainly many topics that could be discussed that don’t raise the potential problems discussed above.  However, recognize that there are risks to disclosing practitioner-specific information on social media.

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