June 13, 2019

QUESTION:         A registrant at our April Complete Course for Medical Staff Leaders in New Orleans submitted a question about waiver of threshold eligibility criteria for an applicant  (a general practitioner who did an internship in 1985 but not a residency and so cannot even sit for the boards, who has been doing only outpatient primary care since).  The criteria specify that grandfathering is possible for those who finished training before 1985; after 1985, a physician must achieve board certification within three years of appointment.  All references are excellent. What can we do?

ANSWER:            The question does not reveal why this physician wants to be on the medical staff or whether privileges would be sought in addition to appointment.  In order to be eligible for any privileges, regardless of medical staff category, any applicant must be able to demonstrate current competence, according to CMS. Often, the eligibility criteria require that a candidate has practiced in at least two of the preceding four years in a hospital setting. Many organizations have a category for office-based practitioners, without any privileges. Some physicians wish to have a connection with the hospital for purposes of continuity of care when they refer patients for inpatient care to hospitalists.  Possibly this physician wants appointment to be on health plan panels.  (The latter is not a reason, in itself, to grant appointment.) When a physician is appointed to any category of the medical staff, even a category that does not carry with it any privileges, the public (and health plans) may rely on the hospital’s imprimatur.

The courts have upheld grandfathering in certain circumstances, but usually that is limited to individuals who have been on a medical staff for a number of years who have a track record that can be evaluated, when new policies require board certification for all applicants after a certain date. The hospital is not required to process an application for initial appointment from those who are not eligible.  In the questioner’s situation, the only option other than declining to process the application based on ineligibility may be to consider appointing this individual to a membership-only category with no privileges. To consider even that type of appointment, many organizations would obtain evaluations from physicians to whom the outpatient practitioner has referred patients, to be sure that this outpatient practitioner is referring patients for the right reasons and doing the right pre-referral assessment.

As a final point on waivers generally, an occasional waiver in exceptional circumstances is usually preferable to modifying standards to fit a particular unusual situation and risking opening the door to others. Anytime a waiver is to be considered, it’s best to follow a process, specified in the Credentials Policy, and include a statement that the waiver is not intended to set a precedent for anyone else.  And, any waiver should be based on exceptional qualifications of the applicant and the best interest of the hospital and community.

February 9, 2017

QUESTION:        Our Credentials Committee recently considered a request for a waiver, submitted by a physician who does not satisfy our threshold criteria for appointment.  A few years back, this physician pled guilty to a felony battery charge, which ultimately led to a downward spiral in which he violated a restraining order and had his probation revoked.  The physician was forthcoming about his criminal background when he submitted his application, though his explanation largely deflected blame for the matters leading up to his arrest, guilty plea, and probation violation.

Before processing the physician’s request for a waiver, the Chief of Staff and CMO have recommended that the physician be required to provide substantial information (including arrest and/or court records) regarding these matters.  The Chair of the Credentials Committee disagrees and believes that the Credentials Committee, which has the responsibility pursuant to the Medical Staff Credentialing Policy to consider and make recommendations regarding waivers, should simply talk with the physician to get his side of the story and, if any questions remain after that, decide whether to ask for additional information.  Who is right?

ANSWER:            Most Medical Staff Bylaws or Credentialing Policies call on the Credentials Committee to consider and make a recommendation on requests for waivers of threshold eligibility criteria.  Often, the Credentials Committee is given broad discretion regarding what information to consider when reaching its recommendation.  And, as the individual charged with planning the agenda and activities of the Credentials Committee, the Chair would have the ability to exercise much discretion in determining how the committee would go about considering any request for a waiver.

The Credentials Committee may wish to review the application (or preapplication) submitted by the individual or any explanation submitted by the individual in conjunction with his or her request for a waiver.  It may also wish to speak with the individual regarding the waiver request and the circumstances that led to the individual being ineligible.  Therefore, the Chair’s expressed preference for talking with the individual is not totally out of line.

However, in almost any circumstance where a waiver is to be granted, the Credentials Committee is going to want to also verify the facts with third parties – to corroborate the story that is being told by the individual requesting a waiver.  The only exceptions to this would be when the circumstance is so obvious that no verification is required.  This may be the case, for example, if the individual does not have a coverage arrangement with another member of the medical staff, but explains that this is because no one else is practicing in the subspecialty in which he or she is requesting privileges.  Another example would be an individual whose office or residence is farther from the hospital than required by Hospital policy, in which case the individual may simply be providing the relevant addresses and explaining why the small discrepancy in distance will not affect his or her ability to respond appropriately to patients.

In the case at hand, where the individual is requesting a waiver related to his criminal history, it is hard to imagine any scenario where the Credentials Committee, MEC, or Board could proceed in processing the request for a waiver without verifying the facts of the matter from third party sources.  If the medical staff leaders or hospital failed to conduct this verification, how could they later justify such inaction (for example, in a court case brought by a patient or staff member who alleged to have been harmed by the physician’s conduct)?  Merely taking the physician’s word for it seems especially unreasonable in light of the fact that his original explanation deflected blame.

So, who is right in this situation – the Chief of Staff and CMO (who want to request written documentation) or the Chair of the Credentials Committee (who wants to talk with the individual requesting the waiver)?  In the end, the answer is that both of them are right in some ways.  It is the Chair of the Credentials Committee who ultimately decides whether the matter gets placed on the Credentials Committee’s agenda and, if so, the information that is gathered in advance of the meeting to assist the Credentials Committee as it talks with the applicant.  But, the committee will not be able to do its job properly without obtaining substantial information to corroborate the physician’s story – and so the Chair would be wise to take the advice of the Chief of Staff and CMO and gather the relevant documents from the individual prior to the Credentials Committee meeting.