EVALUATING CREDENTIALS and GRANTING PRIVILEGES ^57 ^95 ^186

Evaluating credentials and granting privileges are essential to ensure that high-quality, safe care is provided. During the initial application for staff membership at a hospital or other institution, the applicant is responsible for demonstrating his or her qualifications.

Medical Staff Appointments and Credentialing

The institution is responsible for verifying the information in the appli­cant’s credentials from the primary source, whenever feasible. This docu­mentation should include, but may not be limited to, the following infor­mation:

• Education and current curriculum vitae

• Residency and subspecialty training

• Status of American Board of Obstetrics and Gynecology certification or equivalent

• Technical experience and verification of competence and delinea­tion of privileges from previous facilities

• State licensure and history of any disciplinary action either by medi­cal staff or by the state licensing board

• Current cover letter for professional liability insurance indicating limits of coverage

• Letters of recommendation assessing professional judgment and behavior as well as perceived skill levels and clinical competence

• Drug Enforcement Administration certificate

• Any special certificates held (eg, laser)

• Signature sheets for institutional policies (eg, Health Insurance Portability and Accountability Act, compliance program, Code of Conduct, and patient safety)

A credentialing system also should require notification of any mate­rial changes in the credentialed health care provider’s status at any other facilities where the health care provider holds privileges.

Information should be obtained directly from the practitioner’s liabil­ity insurance company and, as required by law, the National Practitioner Data Bank (NPDB) (see Box 1-2). Hospitals must query the NPDB when a health care provider applies for medical staff appointment (courtesy or otherwise) or for clinical privileges at the hospital. This process is ongoing, and the data bank must be queried for all health care providers on the medical staff and those who have clinical privileges at new appointment, every 2 years at the time of reappointment, and at any time within the 2-year cycle if new privileges are requested. Inquiries regarding the training, privileges, behavioral issues, and any negative actions should be directed to any institution where the health care clinician has practiced. Verification also may rely on accepted secondary sources, such as web sites of the American Medical Association (AMA), or even state health departments and national resources, such as the Office of the Inspector General.

For recredentialing, it is reasonable to forego outside peer assessments if the health care provider does enough activity for the institution’s quality assurance and risk management system to oversee the quality of the health care provider’s work. These ongoing peer review data should be considered

Box 1-2. The National Practitioner Data Bank

PO Box 10832

Chantilly, VA 20153-0832 800-767-6732 http://www.npdb-hipdb.hrsa.gov

The National Practitioner Data Bank (NPDB) was established by the Health Care Quality Improvement Act of 1986. The NPDB is an information repository that includes reports of medical malpractice payments and disciplinary actions against physicians, dentists and, in some cases, other licensed health care pro­viders regarding licensure, clinical privileges, and professional society standing.

Practitioners can query the NPDB regarding information about themselves. All queries require payment of a fee. Hospitals are required by law to query the NPDB; other entities that may be eligible to query the NPDB include state boards of medical examiners or state licensing boards, professional societies that follow a formal peer review process, and entities that provide health care services and follow a formal peer review process. Practitioners who are the subject of a report receive notification when a report is submitted. These prac­titioners may add a statement to a report, dispute the report, or contact the reporting entity to make corrections to a report.

The NPDB Help Line number listed provides recorded information 7 days a week, 24 hours a day. Information specialists are available at the same number weekdays from 8:30 am to 6:00 PM (5:30 pm on Fridays) Eastern time. The web site also provides detailed information.

in recredentialing decisions. Current standards from The Joint Commission require hospitals to evaluate physicians on an ongoing basis, rather than just a periodic peer review. This process is referred to as an “ongoing pro­fessional practice evaluation.” The Joint Commission has left it up to each hospital to develop the process and determine which indicators to use.

Many institutions require medical specialty board certification for mem­bership and often accept certification from other countries. A physician may be either board certified or an active candidate, which indicates that the individual has passed the written examination and has not exceeded the limitations of eligibility for the oral examination. Once this period of eligibility has passed without successful completion, the physician is no longer an active candidate and should no longer use this terminology.

As mandated by the American Board of Medical Specialties, all physi­cians with time-limited board certification must participate in maintenance of certification. The four-part maintenance of certification process for obstetrics and gynecology is described in Box 1-3.

Beginning in 2001, all new certificates issued by the American Board of Obstetrics and Gynecology (ABOG) were 6 years in duration. Beginning in 2008, all newly board-certified obstetrician-gynecologists automatically began the annual maintenance of certification process. In addition, as the certifications expire for those physicians with time-limited certification, they too will begin maintenance of certification.

Institutions may decide that certified nurse-midwives (CNMs), nurse practitioners (NPs), and physician assistants (PAs) should be credentialed using the same process as that used for physicians, although the criteria may be different. This process will allow these individuals to function to the full extent of their educational preparation and legal scope of practice. They must be licensed properly and certified by their state, and they should conform to legal requirements and hospital bylaws regarding professional liability insurance.

Institutions also should be aware of the board certification equiva­lents for other health care providers, such as CNMs (American Midwifery Certification Board) and PAs (National Commission on Certification of Physician Assistants). Nurses and NPs have multiple options for certifica­tion. The National Certification Corporation awards certification to NPs in the obstetric, gynecologic, and neonatal nursing specialties as well as vari­ous certificates for nurses, physicians, and other licensed health care per­sonnel. Certification also is awarded to nurses and NPs in specialties, such as family, nurse executive, high-risk perinatal, maternal-child, pediatric, or perinatal, through the American Nurses Credentialing Center. Institutions should ensure that the certification from any accredited certification board is appropriate to the responsibilities and privileges of the respective staff position (see also the “Practice Management” section in Part 2).

Credentialing of noncertified physicians and other health care providers should be performed using the same rigorous standards as those used for physicians.

Box 1-3. Maintenance of Certification

Annual Maintenance of Certification

All obstetrician-gynecologists newly certified by the American Board of Obstetricians and Gynecologists (ABOG) and physicians with time-limited cer­tificates are required to participate in maintenance of certification to continue ABOG certification. Maintenance of certification is a four-part program to be completed over each 6-year maintenance-of-certification cycle:

• Part 1: Professional Standing—Each physician’s license is reviewed by ABOG annually.

• Part 2: Lifetime Education (formerly known as annual board certification, or “ABC”)—Each physician must complete annual article reviews and questions.

• Part 3: Cognitive Expertise—Each physician is required to pass a writ­ten examination. The examination was offered for the first time in 2012. Each physician must complete the examination by the end of the 6-year maintenance-of-certification cycle.

• Part 4: Practice Performance and Self-Assessment/Continuous Quality Improvement—Each physician must complete five self-assessment mod­ules by the end of the 6-year maintenance-of-certification cycle.

Voluntary Recertification

• Voluntary recertification applies only to those diplomates whose certi­fication occurred before 1986 (in general obstetrics and gynecology) or 1987 (in the subspecialties). These individuals have no time limitation on their certificates. Not participating in maintenance of certification will not affect their board certification.

• Even though ABOG does not require these physicians to participate in maintenance of certification, many state licensing boards and hospitals do require them to do so. Requirements vary by state and institution, so individuals in this category need to confirm that they are in compliance.

• Voluntary recertification can be obtained only through the maintenance- of-certification program.

Data from American Board of Obstetricians and Gynecologists (ABOG). Available at: www.abog.org. Retrieved January 3, 2014.

Delineation of Privileges

The authority for granting privileges, including special, temporary, or other appointments, is established by the governing board of an institution or the chief medical officer of the office practice and should be delineated in the institution and medical staff bylaws. Although the criteria and process by which clinical privileges are granted should be outlined in the medical staff bylaws, the actual privileges that may be granted should be stated in the medical staff rules and regulations, where they can be amended more easily. The rules and regulations should delineate which procedures or operations or operative approaches require proctoring and the number of cases that must be proctored before full independence privileges can be granted. The rules and regulations should stipulate who can proctor and whether proctoring must entail consecutive cases.

Privileges should be granted based on the individual’s training, experi­ence, and demonstrated current clinical competence. The department head, after a careful review of the application and all supporting data, should make recommendations for the initial granting of privileges, the renewal of privileges, and the addition or denial of new privileges. The recommenda­tions of the department head regarding appointments and privileges often are reviewed and acted on by designated institutional staff (eg, credentials and medical executive committees) who forward their recommendations to the institution’s governing board. The ultimate responsibility for the quality of medical care rests with the governing board of the institution or chief medical officer of the office practice, with the medical staff respon­sible for effective self-governance. Privileges should be granted only for treating illnesses or performing procedures that can be supported properly by the facilities and the staff.

After an applicant’s credentials have been verified, the specific privileges that have been requested should be considered carefully. Physicians who are trained appropriately, have sufficient experience, and have demon­strated current clinical competence should be granted privileges accord­ingly. Assessment for granting privileges may vary according to the type of procedure and the risks associated with it. For example, the assessment for dilation and curettage privileges will require less observation and preceptor time than the assessment for laparoscopic hysterectomy. New technology and procedures require training and demonstration of competence before privileges are granted. Also essential to this review is the capacity of the institution to meet the requirements for the privileges granted.

Blanket approval for all aspects of patient care under the designation “obstetric and gynecologic privileges” fails to recognize the reality of ter­tiary care issues and variations in training in technical procedures. The institution should have in place a policy that allows for differentiation of privileges. There are various approaches to differentiating privileges, including the following:

• “Laundry list”—An applicant can specifically request procedures and conditions from a checklist.

• Categorization—Major procedures or treatment areas are identified and classified based on complexity or the level of training.

• Descriptive—An applicant describes the requested privileges in nar­rative form.

• Delineation by codes—Privileges are requested based on diagnoses codes (from the current edition of the International Classification of Diseases, Clinical Modification system), current procedural terminol­ogy codes, or diagnosis-related group codes.

• Combination—A hybrid of two or more of the methods previously described.

Core privileging, an alternative to the methods previously described, groups together privileges that might require similar education, training, or skill to be performed. Privileges also can be related by organ systems, pathophysiology, diagnostic or therapeutic principles, anatomic relation­ships, or surgical approach and technologies (eg, robotic surgery or assisted reproduction). This method assumes that anyone who has completed an approved residency has sufficient knowledge and technical skills to per­form competently within the specialty. Procedures or privileges that require special training, such as radical hysterectomy, would be listed separately, not in a core group. A sample list of specific procedures for which privileges may be granted as a group follows:

• General core privileges in obstetrics and gynecology

• Maternal-fetal medicine

• Gynecologic oncology

• Major surgical procedures

• Reproductive endocrinology and infertility

• Assisted reproduction

• Operative laparoscopy

• Robotic surgery

• Urogynecologic procedures

• Pelvic floor reconstructive surgery

• Diagnosis and treatment of breast disease

Cosmetic procedures (eg, laser hair removal, tattoo removal, and lipo­suction) are not considered gynecologic procedures. As with other surgical procedures, privileging for cosmetic procedures should be based on educa­tion, training, experience, and demonstrated competence.

Privileges often are formatted by levels (eg, Level I, Level II, and Level III gynecologic privileges) as shown in Appendix B. As new technologies evolve, processes for granting privileges for them will need to be formu­lated. Appendix C includes a sample application for privileges, which out­lines such areas as the provisional period, emergency situations, and the performance of new procedures.

Whether licensed or not, residents ordinarily do not have independent admitting privileges. Fellows (eg, those in subspecialty training who usually have completed basic specialty requirements) may have admitting privi­leges if allowed by the institution’s bylaws; however, their privileges and appointments should be regarded as time limited for the term of training. Institutions should develop specific policies governing dual employment (moonlighting) for residents that adhere to state requirements. The institu­tion’s policy regarding dual employment should be articulated clearly in residents’ contracts.

Certified nurse-midwives and NPs are licensed independent practitio­ners and may have delineated clinical privileges or may function under a job description. In either case, specific requirements established by The Joint Commission and state regulatory and licensing authorities govern the scope and independence of their practice. Physician assistants are regarded as supervised clinical practitioners, whereas the requirements for CNM and NP collaboration with physicians vary by state. Certified nurse-midwives and NPs generally operate under guidelines, developed collaboratively and subject to institutional approval, that define their roles in the institution and protocols that govern their practice. These documents should define conditions that require referral and include guidelines for physician col­laboration and supervision.

Institutions initially may grant medical staff membership to physi­cians and licensed independent practitioners for a limited period with the understanding that at the end of that time, privileges may be withdrawn or reduced. Periods requiring proctoring, probationary periods, temporary privileges, as well as any combination of these are also common.

Temporary Privileges

On occasion there arises a need to provide access to the facilities for a practitioner who, although fully qualified, is not a member of the institu­tion’s medical staff. The reasons for providing temporary access should be reviewed for appropriateness and to ensure that they serve the best interests of patient care, the medical staff, and the community. The practitioner’s credentials and qualifications and the adequacy of the practitioner’s profes­sional liability insurance, if required, should be verified before privileges are granted. The institution’s bylaws should specify who has authority to award such privileges, which should be granted for a period not to exceed 120 days.

Provisional Status

An initial appointment to the medical staff should be based on a thorough review of the individual’s credentials and proctoring. The classification of privileges should be designated and the provisional period limited. Medical staff bylaws may provide for an extension of the provisional period if the volume of work or the opportunity for observation has not been sufficient to satisfy the requirements for active staff eligibility.

At the end of the provisional period, an appointee found to be profes­sionally competent and ethical should be granted active staff membership with an appropriate classification of privileges. If, however, at the end of or during the provisional period there is objective and documented evidence that the individual is not professionally competent or ethical, the depart­ment head should make a recommendation to the appropriate committee and the institution’s governing board that privileges be restricted or denied. There should be detailed documentation of the problems and difficulties to support such a recommendation. Any such action is subject to the provi­sions of applicable medical staff bylaws. Professional review actions based on reasons related to professional competence or conduct that adversely affect clinical privileges of a physician for a period longer than 30 days must be reported to the state licensing board and the NPDB.

Itinerant Surgeons

Surgeons who occasionally commute as needed to perform surgery (eg, to rural areas) often are referred to as itinerant surgeons. Itinerant surgeons sometimes can provide a community with services it would not otherwise have. If the services of itinerant surgeons are used, the hospital should fol­low its own policy to verify the physicians’ credentials. In addition, when itinerant surgery is an appropriate option for the community and the patient, the physician should provide the following:

• A written and complete preoperative workup

• A written plan for postoperative care

The hospital should provide the following:

• Regular review of the medical records and outcomes

• Appropriate preoperative and postoperative support services for safe patient care

• Appropriate technical support and equipment

Added Skills or Qualifications

Physicians may request privileges for new skills or emerging technology that has been introduced subsequent to an individual’s residency or fellow­ship training. New equipment or technology usually improves health care, provided that practitioners and other hospital staff understand the proper indications for usage. Problems can arise when staff perform duties or use equipment for which they are not trained. Privileges for new skills should only be granted when the appropriate training has been completed and documented and the competency level has been achieved with adequate supervision. Proof of attendance at a postgraduate training course in a new technology or procedure is not sufficient evidence to demonstrate compe­tence in the performance of such procedures. In addition, the NPDB must be queried whenever physicians request new privileges outside of the nor­mal reappointment credentialing process.

Each physician requesting additional privileges for new equipment or technology should be evaluated by answering the following questions:

• Does the hospital have a mechanism in place to ensure that neces­sary support for the new equipment or technology is available?

• Has the physician been adequately trained, including hands-on experience, to use the new equipment or to perform the new tech­nology?

• Has the physician adequately demonstrated an ability to use the new equipment or perform the new technology?

Institutional departments should establish documented requirements for assessing competence in performing new procedures or technologies, and these requirements should be forwarded ultimately to the governing board. This may require that the physician undergo a period of proctor- ing, supervision, or both. If no one on staff can serve as a proctor, the hospital may either require reciprocal proctoring at another hospital or grant temporary privileges to someone from another hospital to supervise the applicant. Specifically, if the procedures for which new privileges are requested were not included in residency training, the applicant must do the following:

• Complete a preceptorship with a physician already credentialed to perform the procedures of that skill level; the preceptorship should require the applicant to perform the designated surgery, with the preceptor acting as first assistant.

• Provide a list of cases satisfactorily completed under supervision at each skill level, as defined by the local institution.

• Submit a letter from the preceptor documenting that the procedures were completed in a satisfactory manner and that the applicant is competent to perform the procedures independently at the desig­nated skill level.

If there is no experienced surgeon on the hospital staff who is able to serve as a preceptor for advanced or new surgical procedures, a supervised preceptorship must be arranged. This may be done by scheduling a number of cases from physicians who require privileging and inviting a creden­tialed surgeon from another institution to serve as a surgical consultant.

After a Period of Inactivity

The AMA defines physician reentry as “a return to clinical practice in the discipline in which one has been trained and certified following an extended period of inactivity.” Inactivity that results from disciplinary action or impairment is addressed later in this section.

There are several reasons why a physician might take a leave of absence from clinical practice, such as family leave (maternity and paternity leave and childrearing); personal health reasons; career dissatisfaction; alterna­tive careers, such as administration; military service; academic pursuits; or humanitarian leave. Traditionally, women were more likely to experience career interruptions; however, recent research shows that younger cohorts of male physicians also take on multiple roles and express intentions to adjust their careers accordingly.

It is extremely important for physicians considering a leave of absence or major change in practice activities to think in advance about options should they wish to return. At a minimum, licensure and continuing medi­cal education activities should be maintained. Working at least part-time during an absence to maintain competency should be considered.

When physicians request reentry after a period of inactivity, a general guideline for evaluation would be to consider the physician as any other new applicant for privileges. This would include evaluation of the following:

• Demonstration that a minimum number of hours of continuing medical education has been earned during the period of inactivity. It is also important to meet any board certification requirements (ie, maintenance of certification) during the absence.

• In accordance with the medical staff bylaws, supervision by a proc­tor (who evaluates and documents proficiency) appointed by the department head for a minimum number and defined breadth of cases during the provisional period.

• A time-sensitive, focused review of cases as required by the depart­mental quality and safety improvement committee may be com­pleted as appropriate.

The area of skills assessment may prove challenging if the proctored supervision and review of cases are not felt to be adequate. The Joint Commission also requires a focused professional practice evaluation for all physicians who initially request privileges and those existing practitioners who request new privileges. Options to consider are as follows:

1. Residency training programs

Benefits: More locations are available, providing structured didactic programs and implementing competency assessment. Participating in these programs can provide a source of manpower to help com­pensate for restricted residency work hours.

Drawbacks: Many hospitals with residency programs have only a lim­ited number of cases available for training. Reentry programs must not negatively affect the residency training program (ie, if someone is being brought into a reentry program in an institution that has a resi­dency program, the Residency Review Committee must be notified with an explanation of why it will not negatively affect the residents).

2. Simulation centers

Benefits: These centers can help supplement hands-on clinical experi­ence and may be more geographically accessible. The use of simula­tion centers for reentry into practice is a new concept. This training may precede and supplement proctored clinical experience.

Drawbacks: Currently there are few functioning simulation centers, although this number continues to increase. Cost is another drawback.

3. Physician reentry program

Benefits: Well-designed physician reentry program systems should be consistent with the current continuum of medical education and meet the needs of the reentering physician.

Drawbacks: Only a few physician reentry program systems are offered nationally; thus, cost and location are considerable obstacles in using these programs. An underlying assumption is that physicians do not necessarily lose competence in all areas of practice with time. Competencies such as patient communication and professionalism may not decline. Therefore, a reentry program should target those areas in which physicians are more likely to have lost relevant skills or knowledge or in which skills and knowledge need to be updated.

Evaluation for Continuing Competence

The performance of each staff member and documentation of continu­ing competence should be reviewed continuously (more than annually) through a clearly defined process as required by The Joint Commission Standards for Ongoing Professional Practice Evaluation (which can be found in The Joint Commission publication, Credentialing and Privileging Your Hospital Medical Staff, Second Edition; see Resources). Institutions should establish objective criteria for evaluation of care that can be equally applied to all licensed independent practitioners, including CNMs, NPs, family physicians, and obstetrician-gynecologists. Evaluation criteria may include the following:

• Additional medical education for new skills

• Continuing education

• Professional recognition

• Untoward outcomes and cases reviewed by the quality and safety improvement committee

• Professional behavior

• Maintenance of certification for board-certified physicians

• Results of ongoing departmental assessment of quality of care

The ongoing quality improvement program requires data collection based on objective criteria (eg, measure specifications) and should delineate which outcomes of clinical practice will be monitored for each practitioner. This delineation of areas to be monitored often is referred to as a “dash­board” of indicators and should be transparent to credentialed physicians being monitored. The standards require an evaluation of all practitioners, not just those with performance issues. This evaluation may include peri­odic chart review; direct observation; monitoring of diagnostic and treat­ment techniques; and discussion with other individuals involved in the care of each patient, including consulting physicians, nurses, and administrative personnel.

The quality improvement process should be designed to detect varia­tions from the established or recommended patterns of care for clinical practice in areas that are considered important aspects of care. The process should determine, in each instance, whether a variation is acceptable or unacceptable. Unacceptable variations are considered deficiencies. A defi­ciency found through this process should be entered in the credentials file for each practitioner. When a pattern is identified, it should be reviewed by a quality assessment committee or similar body. The absence of unaccept­able variations based on preselected indicators for any practitioner is not sufficient to meet the requirement for performance data on every practitio­ner. The Joint Commission requires hospitals to evaluate physicians on an ongoing basis rather than just a periodic peer review, using these indicators deemed appropriate by the respective facility.

If a practitioner’s performance profile indicates that the standards of the department have not been met, corrective action may need to be insti­tuted and documented. The severity of the problem will dictate the steps that need to be taken. Remedial action and its outcome, if necessary, also should be recorded. This information forms an important basis for the recommendations made for the renewal of privileges.

Established policies and procedures should be followed, in consulta­tion with legal counsel whenever privileges are to be modified, restricted, or revoked. When a negative action is recommended, all applicable bylaw procedures must be followed. The final authority for such action resides with the institution’s governing board. Professional review actions based on reasons related to professional competence or conduct that adversely affect clinical privileges of a physician for a period longer than 30 days must be reported to the state licensing board and the NPDB. If a physi­cian voluntarily surrenders or restricts his or her privileges while under investigation (or to avoid it), this information also must be reported. These actions may be, but are not required to be, reported when taken against practitioners who are not physicians.

Reappraisal of privileges should occur at least every 2 years and include verification of current licensure and proof of professional liability cover­age. Information regarding professional performance, including clinical and technical skills and information from hospital performance improve­ment activities, also should be considered. A decision should be made as to whether privileges are to be continued in full, modified, restricted, or revoked. Expansion of privileges should come through formal application and appropriate review.

Impairment and Disruptive Behavior

The following discussion provides practical guidance for the management of physicians and licensed independent practitioners who abuse substances or who exhibit disruptive behavior.

Impairment

Impairment presents a sensitive problem in all settings in which physi­cians and licensed independent practitioners practice, including hospitals, clinics, and medical groups. Practitioners are considered impaired if they are unable to practice medicine with reasonable skill and safety because of physical or mental illness (including alcohol or other chemical drug dependencies) and mood disorders. Any condition that may affect deci­sion-making capabilities, medical judgment, and competence—including diseases of an organic nature—may contribute to impairment. (For infor­mation on the ethical obligations of impaired physicians and their col­leagues, see also the “Human Resources” section later in Part 1.)

Early recognition of chemical dependency or other impairment can be difficult. Denial is common. The following are some of the manifestations of impairment:

• Failure to monitor patients appropriately

• Poor quality of medical care

• Incomplete or poor-quality medical records

• Frequent absences

• Increased isolation from colleagues and other staff members

• Self-prescribing of drugs

To assist in the management of a health care provider who may be impaired, consider the following:

• Is there evidence of impaired ability to practice?

• Is there imminent danger to patients?

• Is there a history of previous treatment for impairment?

• Is the practitioner motivated to enter a treatment program for impairment?

• Should privileges be suspended?

It is often difficult to deal directly with an impaired physician. However, there is a responsibility to recognize, assess, and report impairment. The department head or other responsible person should be informed and should consult personally with the health care provider involved. In an emergency situation, physicians should know whom they should ask to address a problem related to an impaired colleague. The chief medical officer and on-call administrator often are the designated authorities, but staff members should know who the appropriate on-call contact person is for all types of health care providers at an institution.

Legal requirements applicable to the impaired physician vary from state to state. It is important to consult the institution’s legal counsel before ini­tiating any disciplinary or other type of action regarding an impaired physi­cian. Each state has specific laws that outline the reporting requirements to the respective licensing board. The institution’s legal counsel should have information on the individual state’s “duty to report” laws, and departmen­tal members should be aware of the content of these laws. Many states have programs that allow for anonymous reporting.

Intervention as soon as impairment is suspected or before professional performance is impaired is encouraged. If intervention is to succeed, the following steps are important:

• Obtain specific, well-documented evidence. The hospital’s com­mittee on physician well-being (or the group serving this function) should be involved from the beginning, and bylaws addressing impairment should be followed.

• Consider using a group approach for the intervention. This group should include respected peers, a representative of the county or state physician diversion program, and a family member, if possible.

• Use a nonjudgmental and direct approach. This approach may result in an admission of impairment by the health care provider. Less direct efforts are more likely to result in denial.

An impaired health care provider should be obligated to enter a treat­ment program, with the specific type of program dependent on state legal requirements, the requirements of the state licensure board, and the preferences of the impaired practitioner. Impaired physician or diversion programs, usually operated through the state medical licensing board, are an excellent source of information regarding the evaluation and treatment of impaired health care providers and any applicable legal requirements. Most state medical societies have a committee on physicians’ health that serves as an advocate and referral resource for physicians at risk of alcohol and drug dependence. Successful treatment plans, either inpatient or out­patient, must address the type and severity of the problem.

The voluntary entrance of an impaired practitioner into a rehabilita­tion program is not reportable to the NPDB if no professional review action was taken and the practitioner did not relinquish clinical privileges. Furthermore, when a health care provider takes a leave of absence and clinical privileges have not been taken away, no report to the NPDB is required. However, if a professional review action requires an impaired physician to enter a rehabilitation program involuntarily, that review action is reportable to the NPDB if it is based on the physician’s compe­tence or professional conduct and adversely affects the physician’s clinical privileges for more than 30 days. Throughout the process, it is important to respect the physician’s right to privacy and confidentiality wherever possible.

The AMA has recommended that institutions develop a policy on reporting and investigating suspected impairment. In addition, The Joint Commission has specific requirements regarding the institution’s method for identifying and managing matters of individual health for licensed independent practitioners, including physicians (see Resources).

Disruptive Behavior

Physicians exhibiting disruptive behavior pose special problems. According to the AMA, disruptive behavior may be defined as personal conduct, whether verbal or physical, that affects or that may affect patient care negatively. The AMA suggests that “each medical staff should develop and adapt bylaw provisions or policies for intervening in situations where a physician’s behavior is identified as disruptive.” Hospitals may consider adopting a code of conduct with which all medical staff members agree to comply. Conduct that poses imminent danger to patient safety should be referred to the department chair or appropriate leader for immediate action. Offenses of a less serious nature may be referred to the hospital’s committee on physician well-being or a similar group. In either case, a mechanism for reporting disruptive behavior should be in place, and medical staff mem­bers should be aware of the procedures. It is important to remember that the ultimate goals for any intervention regarding a clinician with impairment or disruptive behavior are to help (rather than discipline), restore the practitio­ner to optimal professional functioning, and protect patients.

Revoking Privileges

Revoking privileges, including summary suspension, is an extreme step ordinarily not taken unless all other measures have failed or the behavior of the health care provider is so egregious that the safety of patients is jeopardized. The legal implications of such action require that the pro­cesses identified in the institution’s administrative documents be reviewed carefully by legal counsel and followed with precision. Such actions must be taken in accordance with the institution’s bylaws and applicable legal requirements. Careful documentation is of critical importance. Due pro­cess procedures must be documented in the medical staff bylaws before initiating the review process that could result in disciplinary action.

A follow-up evaluation of the practitioner’s quality of care is necessary to document the effectiveness of the actions. The findings, actions, and outcomes of the quality improvement process should be reported in a timely manner to the appropriate institutional governing board. When the initial intervention does not result in the anticipated improvement, the problem must be reassessed. A second effort should be made to provide a solution, and the result of this effort must be evaluated. Results should be recorded in the individual’s quality improvement file and reported to the institution’s governing board, as appropriate. If the second attempt does not result in the anticipated improvements, further steps may be necessary. The department head and the quality improvement committee may need to recommend disciplinary action against a practitioner who fails to com­ply or improve. Because such action has important legal ramifications, it is critical that legal counsel, usually provided by the institution, be consulted in advance.

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