June 2012 Vol. 22, No. 6

­credentials­with­primary­sources,­there­are­several­

considerations­for­medical­staffs­within­a­healthcare­

system­before­any­­documents­are shared.

An argument for centralized credentials

verification

One­of­the­first­steps­is­for­facilities­within­a­­system­

to­determine­whether­to­establish­a­centralized­­CVO,­

says­Christina W. Giles, CPMSM, MS,­president­of­

Medical­Staff­­Solutions­in­Nashua,­N.H.­If­a­system­

decides­to­­establish­

a­­centralized­CVO,­

the­first­step­is­to­

identify­where­the­

CVO­will­be­located­

within­the­organiza-

tion,­both­the­physi-

cal­location­and­

where­the­CVO­will­

report.­Next, the­entire­organization­must­establish­a­fee­

structure­so­that­each­facility­will­contribute­to­covering­

the­cost­of­the­CVO’s­functions,­says­Giles.­

Establishing­a­centralized­CVO­may­not­be­­possible­for­

every­healthcare­system,­however.­Giles­­recommends­

that­organizations­identify­how­many­practitioners­the­

facilities­will­share.­

“Even­though­it’s­a­system,­if­the­hospitals­are­all­lo-

cated­in­different­locations­or­areas,­they­may­not­have­a­

lot­of­common­practitioners.­That’s­just­one­of­the­many­

­considerations,”­says­Giles.­

If­many­specialists­and­subspecialists­will­be­rotat-

ing­through­multiple­­facilities­within­a­system,­it­makes­

sense­for­hospitals­to­accept­PSV­documents­from­a­cen-

tralized­CVO,­she­explains.­

When­authorizing­one­facility­to­act­as­a­CVO­for­an­

entire­system,­it­is­important­for­facilities­to­work­with­

their­legal­counsels­and­sign­an­agreement­stating­that­

Share primary source verification documents with sister hospitalsSave time, money, and resources

Hospital­mergers­and­acquisitions­are­occurring­with­

greater­frequency­than­ever,­and­the­trend­does­not­

show­signs­of­slowing.­With­many­hospitals­forming­

new­partnerships­or­joining­larger­healthcare­networks,­

medical­staffs­are­facing­the­issue­of­granting­privileges­

to­practitioners­from­other­hospitals­within­the­same­

healthcare­system.­

The­question­becomes­whether­it­is­­acceptable­for­

medical­staff­services­departments­to­share­­primary­

source­verification­(PSV)­documents­among­sister­

hospitals.­If­each­medical­staff­has­­different­­policies­

regarding­this­procedure,­the­entire­­process­can­

quickly­become­complicated­and­result­in­­unnecessary­

additional­work­for­each­medical­staff­within­the­

network.­Although­sharing­documents­can­reduce­

the­amount­of­time­medical­staffs­spend­verifying­

IN THIS ISSUE

p. 4 New Mexico law requires medical board reporting for terminated employees What does this new law mean for New Mexico, and what’s the implication for other states?

p. 7 Time’s up!ABMS redefines the term “board eligible” with new time limits between residency and certification.

p. 9 Change management series William K. Cors, MD, MMM, FACPE, discusses how to communicate your medical staff’s change vision to a mixed crowd.

p. 10 Spotlight on physician-patient relationshipThe Bucksbaum Institute is gearing up to research and find ways to improve the physician-patient relationship.

Many primary source

databases can cost

facilities several thousand

dollars, a cost that could

be reduced if only one

hospital within a system

subscribes, says Christina

W. Giles, CPMSM, MS.

Page 2 Medical Staff Briefing June 2012

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each­facility­can­utilize­the­information­obtained­by­the­

facility­that­verifies­credentials,­says­Giles.­“It’s a­legal­

issue,­and­it­would­obviously­depend­on­what­the­state­

law­says,­but­if­there­is­a­formal­written­­agreement­

where­one­organization­is­authorizing­another­to­act­

as­its­agent,­it­would­be­okay­for­them­to­share­the­

­documents,”­she­says.

Giles­adds­that­centralizing­credentialing­­processes­

does­not­necessarily­lead­to­a­reduction­in­staff,­

since each­facility­needs­to­retain­staff­to­administer­

the­process.­

“It’s­just­one­piece­of­the­process.­It’s­the­information­

collection­and­verification­piece,”­she­says.­“There’s­still­

the­need­for­someone­to­assess­the­­information­and­to­

make­recommendations­­concerning­staff­appointments­

and­clinical­competence­and­­privileges,­and­that­would­

most­likely­be­retained­at­the­individual­facility.”

A­hospital­system­does­not­have­to­form­a­central-

ized­CVO­to­benefit­from­document­sharing.­Rather,­it­

can­adjust­its­bylaws­to­allow­facilities­within­the­same­

system­to­share­documents.

Hospitals­looking­to­establish­policies­for­­sharing­

­credentialing­documents­among­facilities­­within­a­

healthcare­system­should­evaluate­existing­­credentialing­

paperwork­and­move­toward­standardized­forms­to­

streamline­the­process.­“We­needed­to­make­sure­that­

our­paperwork­was­the­same­or­very­close­so­that­

­whatever­form­they­may­have­accepted­in­[a­sister­

hospital]­would­be­acceptable­to­us,­and­vice­versa,”­

says Bev  Osborne, CPMSM,­director­of­medical­staff­

services­at­Sacred­Heart­­Medical­Center­in­­Spokane,­

Wash.­Documents­can­be­­redesigned­and­­reformatted­to­

create­a­systemwide­look,­even­if­the­privileging­criteria­

for­each­hospital­are­different.

“You­can­actually­have­one­form­with­multiple­sets­

of­criteria­based­on­where­the­practitioner­is­asking­to­

practice,”­Giles­says.­“It­is­still­specific­to­the­facility,­but­

the­format­and­the­document­itself­could­be­redeveloped­

to­look­like­a­system­document.”­

­

Paving the way for document sharing

Regardless­of­whether­your­organization­chooses­to­

create­a­centralized­CVO­or­a­less­structured­approach,­

­medical­staffs­should­include­stipulations­in­their­bylaws­

about­­sharing­credentialing­documents­between­sister­

­hospitals.­Although­each­facility­within­the­system­may­

have­its­own­bylaws,­appendixes­to­the­credentialing­

and­privileging­process­can­be­added­and­can­be­the­

same­among­all­hospitals,­says­Osborne.­Sacred­Heart­is­

one­of­four­hospitals­that­constitute­­Providence­Health­

Care­(PHC),­part­of­the­larger­Providence­Health­&­Ser-

vices­group.­Example­guidelines­are­included­on­p.­4.

“We­added­wording­in­our­bylaws­many­years­

ago­that­allowed­us­to­freely­share­among­the­four­

­hospitals,”­says­Osborne.­“Each­hospital’s­bylaws­cur-

rently­say­that­we­can­share­all­information­relative­to­

­credentialing,­­privileging,­and­peer­review,­including­

focused­and­­ongoing­review­between­the­PHC­hospitals.”

Editorial Advisory Board Medical Staff Briefing

Assoc.­Editorial­Director:­­ Erin E. Callahan

Contributing­Editor:­ ­Elizabeth Jonesejones@hcpro.com

Alpesh N. Amin, MD, MBA, FACPExecutive DirectorHospitalist­ProgramVice Chair for Clinical Affairs & QualityDept.­of­Medicine­University­of­California,­Irvine

William K. Cors, MD, MMM, FACPE Chief Medical Quality OfficerPocono­Health­System­East­Stroudsburg,­Pa.

Michael Callahan, Esq.Katten­Muchin­Rosenman,­LLP­Chicago,­Ill.

Sandra Di VarcoMcDermott­Will­&­Emery,­LLP­Chicago,­Ill.

Roger A. Heroux, MHA, PhD, CHEFounding PartnerHospitalist­Management­Resources,­LLC­HMR­ED­Call­Panel­Solutions­Pensacola­Beach,­Fla.

Jonathan Lovins, MD, SFHMHospitalist and Assistant Clinical Professor of MedicineDuke­University­Health­System­Durham,­N.C.

William H. Roach Jr., JDMcDermott­Will­&­Emery­Chicago,­Ill.

Richard E. Rohr, MD, MMM, FACP, FHMDirector of Hospitalist ProgramsGuthrie­Healthcare­System­Sayre,­Pa.

Jodi A. Schirling, CPMSMAlfred­I.­duPont­Institute­Wilmington,­Del.

Richard A. Sheff, MD, CMSLChair and Executive DirectorThe­Greeley­Company­­Danvers,­Mass.

Raymond E. Sullivan, MD, FACSWaterbury­Hospital­Health­Center­Waterbury,­Conn.

Medical Staff Briefing (ISSN: 1076-6022 [print]; 1937-7320 [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: $389/year or $700/two years; back issues are available at $25 each. • MSB, P.O. Box 3049, Peabody, MA 01961-3049. • Copyright © 2012 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email customerservice@hcpro.com. • Visit our website at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of MSB. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

June 2012 Medical Staff Briefing Page 3

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All­credentialing­and­privileging­actions­remain­the­

responsibility­of­each­hospital’s­credentials­committee­

and­medical­executive­committee­and­are­forwarded­to­

the­board.­

“Because­we­are­working­with­the­same­set­of­in-

formation,­it­is­rare­that­the­four­hospitals­vary­in­their­

credentialing­and­privileging­recommendations,”­says­

Osborne.­­

Giles­recommends­that­facilities­compile­a­list­of­ques-

tions­to­consider­when­discussing­systemwide­document­

sharing,­including­the­following:

­➤ What­are­the­current­processes­in­each­facility?

­➤ Which­primary­sources­are­used­and­for­what­

information?

­➤ How­often­do­facilities­access­databases­for­

­credentialing­information?

­➤ What­are­the­costs­associated­with­those­databases?

­➤ How­many­crossover­practitioners­are­present­in­the­

system?

­➤ Will­there­be­buy-in­among­staff­members­for­a­

­common­application­and­privileging­format?

­

“[Medical­staff­leaders]­need­to­talk­it­through­and­

say,­‘Is­this­worth­formulating­such­an­agreement,­or­

should­we­just­let­everybody­continue­to­do­their­own­

thing?’­”­says­Giles.­

Many­organizations­may­find­a­compelling­argument­

in­favor­of­sharing­confidential­credentialing­documents­

among­sister­facilities—it­minimizes­the­amount­of­time­

and­money­spent­verifying­credentials­with­primary­

sources.­

However,­whether­your­hospital­can­benefit­from­

these­perks­depends­on­whether­state­law­allows­docu-

ment­sharing.

Giles­notes­that­access­to­many­primary­source­

­databases­can­cost­facilities­several­thousand­dollars,­

a cost­that­could­be­reduced­if­only­one­hospital­within­a­

system­subscribes.

“Each­PHC­hospital­is­a­table­within­our­shared­

database,­which­allows­us­to­easily­create­hospital-spe-

cific­or­PHC-wide­reports.­Expirables,­such­as­license,­

DEA,­insurance,­and­board­certifications­are­verified­

once­and­housed­in­the­database,”­says­Osborne.­This­

allows­the­medical­staff­to­spend­more­time­on­value-

added­tasks,­such­as­privileging­and­ongoing­review,­

although­NPDB­reports­must­continue­to­be­done­by­

each­hospital.­

“By­having­all­the­same­­requirements­and­having­the­

ability­to­freely­share­back­and­forth,­we­keep­honing­

our­processes­to­avoid­duplicative­work,”­says­Osborne.­

“Nobody­can­afford­to­duplicate­these­days.”­

Medical­staff­leaders­should­take­into­consideration­

the­comfort­level­of­the­entire­medical­staff­when­decid-

ing­whether­to­consolidate­processes.­

“If­the­hospitals­and­medical­staffs­were­in­favor­of­the­

merger­or­the­acquisition,­then­the­road­is­already­paved­

for­looking­for­ways­to­consolidate­and­save­money,”­

Giles­notes.­“But­if­the­merger­or­acquisition­isn’t­­being­

­accepted­and­isn’t­being­supported­by­the­medical­staff,­

then­you’re­going­to­have­to­look­at­enhancing­educa-

tion­and­communication­with­the­medical­staff­if­you’re­

going­to­suggest­changing­the­way­credentialing­and­

privileging­are­done.”

Sharing­credentialing­documents­within­a­­system­

of­hospitals­could­save­time,­money,­and­resources.­

­However,­for­some­healthcare­systems,­a­limited­

number­of­crossover­practitioners­or­a­lack­of­­staff­buy-

in­may­make­the­effort­of­­establishing­new­policies­

for­sharing­documents­more­trouble­than­it’s­worth.­

­Ultimately,­each­healthcare­system­must­­examine­the­

similarities­and­differences­of­the­­facilities­within­its­

group­and­determine­which­­approach­will­best­suit­the­

needs­of­its­organization­and­its­community.­n

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Sharing PSV documents between sister hospitals: Sample guidelines

If a practitioner is currently credentialed at a sister hospi-

tal and wishes to apply to your hospital, provided there is a

shared database, obtain the following:

➤ Copy of credentials information from the sister hospital

➤ Original application

➤ Primary source verifications (PSV) from medical school,

training programs, initial peer/competency reference letters

➤ Last reappointment documentation, including

attestation page

➤ Current licenses/insurance/DEA (if not scanned into

database)

➤ Original approval letter

➤ Most recent approval letter with copy of current

privileges

➤ Documentation (proctoring/lists of cases, etc.) as

required for specific privileges

➤ Special notice if any disciplinary actions, known lawsuits

pending, complaints pending, actions against state

license or known pending actions

Requesting hospital will need to obtain the following:

➤ AMA profile

➤ Medicare attestation statement (physicians only)

➤ Privilege delineation request (Note: If practitioner

requests additional privileges not held at the sister

hospital, the requesting hospital must request a

competency reference for the additional privileges.)

➤ NPDB query

➤ Office of Inspector General/Excluded Parties List System

checks

➤ Criminal background check

➤ Confirmation of good standing from sister hospital

(obtained via MD query plus email confirmation)

➤ Run current hospital “privileges performed” report; this

will be reviewed by the department/credentials chair

who may inquire regarding specific competencies

➤ Temporary privileges may be granted pending the

next credentials/medical executive committee/board

meeting upon the recommendation of medical staff

leadership

Emergency privileges may be granted if there is an ur-

gent patient care need for a practitioner from a sister hospital

to see a patient at your hospital. Per The Joint Commission,

emergency privileges may be granted based on documenta-

tion of current licensure and competency, which may be ob-

tained from accessing the sister hospital’s database.

One-time privileges to assist in a surgery at a sister hospi-

tal may be granted by a letter request from the practitioner,

confirmation of good standing from the “home” hospital,

and an NPDB query done at the site where the surgery will

be performed. The “site” hospital will confirm current li-

censure, DEA, and insurance in the home hospital’s data-

base. Any member of the administrative team may sign the

approval.

Credentialed staff agree that all information relative to

their credentialing, privileging, and peer review (including

FPPE and OPPE) may be shared among the hospitals.

Source: Bev Osborne, CPMSM. Reprinted with permission.

Recent New Mexico law requires hospitals to report terminated employees to the state medical board

At­the­beginning­of­2012,­New­Mexico­expand-

ed­its state­laws­regarding­reporting­settlements,­

­judgments,­adverse­actions,­and­credentialing­ac-

tions­to­the­state­medical­board­to­include­employed­

physicians.

Prior­to­this­change,­hospitals­could­terminate­

­contracted­or­employed­physicians­at­any­time­without­

having­to­initiate­the­peer­review­process,­and­without­

reporting­the­action­to­the­state­medical­board­or­the­

NPDB.­With­the­change,­New­Mexico­became­the­first­

state­to­adopt­reporting­requirements­for­employed­

physicians.

June 2012 Medical Staff Briefing Page 5

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The­state­already­requires­healthcare­facilities­to­

­report­“adverse­events,”­defined­as­“reducing,­­restricting,­

suspending,­revoking,­denying,­or­failing­to­renew­clini-

cal­privileges,”­but­the­law­change­added­the­­following­

language:­

... terminating employment for cause, or without cause

when based on incompetency or behavior affecting patient

care and safety, or physician being allowed to resign rather

than being terminated for such reasons. This does not include

those instances in which a peer review entity requires super-

vision of a physician for purposes of evaluating that physi-

cian’s professional knowledge or ability.

Cynthia Grubbs, JD, RN,­director­of­the­Division­

of­Practitioner­Data­Banks­for­the­Bureau­of­Health­

­Professionals­at­the­U.S.­Department­of­Health­and­

­Human­Services,­says­New­Mexico­is­the­first­state­that­

she­knows­of­to­take­such­action.­“We­don’t­know­all­of­

the­states’­new­laws­that­have­happened,­but­this­is­the­

first­I’ve­heard­of­any­state­taking­this­action.”

Although­this­law­only­applies­to­healthcare­­facilities­

in­New­Mexico,­it­could­affect­other­states­in­the­future,­

especially­as­the­number­of­employed­physicians­contin-

ues­to­rise.

Creating the law

The­New­Mexico­Medical­Board­began­pushing­for­

a­law­change­in­May­2011,­after­receiving­complaints­

from­patients­and­physicians­about­other­physicians­who­

were­providing­substandard­care,­says­Becky Cochran,

CPMSM, CPCS,­director­of­medical­staff­services­at­San­

Juan­Regional­Medical­Center­and­vice­chair­of­the­New­

Mexico­Medical­Board.

The­board­quickly­realized­that­employed­physicians­

were­being­terminated­or­asked­to­resign­because­of­

quality­issues,­which­saved­the­hospital­from­initiating­

the­peer­review­process­and­reporting­adverse­incidents­

to­the­state­medical­board­or­the­NPDB.

“All­of­a­sudden­all­of­these­hospitals­or­healthcare­

clinics­were­getting­rid­of­doctors­that­weren’t­measuring­

up,­and­there­was­no­mechanism­to­let­the­board­know­

so­we­could­step­in­and­take­action­on­their­license­or­

send­them­for­more­training,”­Cochran­says.

Additional­reporting­requirements­are­currently­

out­for­public­comment.­If­they­are­accepted,­hospitals­

would­have­to­report­adverse­actions­within­30­days­of­

the­adverse­action,­rather­than­within­30­days­of­the­

final­action.

“Before,­the­wording­was­a­‘final­decision’­or­a­‘final­

adverse­action,’­and­we­know­that­can­take­months,­

maybe­years­to­reach­a­final­action,”­Cochran­says.­

“There­wasn’t­anything­to­flag­the­medical­board­about­

an­adverse­action,­so­we­took­out­the­language­for­final­

action;­that­way­it­gives­the­board­the­opportunity­to­

know­if­there­are­problems­with­the­physician­so­we­can­

protect­the­public.”

­

Effect on the NPDB

If­hospitals­restructure­how­they­take­action­and­

push­more­cases­toward­peer­review­rather­than­

s­imply­­reporting­terminations­to­the­state­medical­

board,­it might­improve­protection­for­both­the­physi-

cian­and­the­hospital.­If­there­is­an­adverse­decision­or­­

a­suspension­of­privileges,­that­would­be­reported­to­

the­NPDB.

If­hospitals­decide­instead­to­simply­report­termina-

tions,­the­medical­board­may­decide­to­take­additional­

action.­”The­medical­board­may­have­an­increase­in­

their­investigations­and­sanctions­that­they­take­against­

practitioners,­which­would­then­increase­the­licensure­

activity­within­the­National­Practitioner­Data­Bank,”­

Grubbs says.

The­NPDB­recently­implemented­a­new­process­so­

that­hospitals­can­send­an­electronic­report­to­their­

state­medical­board­when­they­file­an­NPDB­report.­

­Previously,­hospitals­had­to­mail­separate­reports.

“It’s­more­streamlined­and­it­has­a­little­bit­more­

checks­and­balances­to­ensure­the­medical­board­actu-

ally­receives­it,”­Grubbs­says.­“Each­state­is­independent­

and­gets­to­make­their­own­laws,­but­I’m­sure­that­there­

will­be­plenty­of­other­legislative­bodies­seeing­what­the­

response­is­to­this­new­law­in­New­Mexico.”­

Page 6 Medical Staff Briefing June 2012

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The rising number of employed physicians

The­reason­for­this­law­change­hinges­on­the­number­

of­physicians­employed­by­hospitals,­a­figure­that­has­

grown­rapidly­in­the­last­decade.

A­survey­published­by­the­AHA­at­the­beginning­

of­the­year­indicated­that­hospitals­employed­211,500­

physicians­in­2010,­a­34%­increase­since­2000.­Addi-

tionally,­nearly­38%­of­hospitalists­on­the­medical­staff­

are­employed­by­the­hospital.­Nearly­60%­of­hospitals­

are­using­hospitalists­in­2010,­according­to­the­AHA­

survey.

Since­1990,­the­NPDB­has­been­a­key­source­of­

­information­for­MSPs.­In­the­early­years­of­the­Data­

Bank,­most­physicians­worked­independently,­but­those­

numbers­have­gradually­shifted,­and­more­physicians­

want­the­perks­of­being­employed­by­the­hospital,­says­

Carol Cairns, CPMSM, CPCS,­president­of­PRO-CON,­

a­medical­staff­consulting­company­in­Plainfield,­Ill.­

In­past­years,­MSPs­could­be­confident­that­the­NPDB­

would­have­appropriate­information­on­reduction­of­

privileges­or­behavioral­issues­affecting­patient­care,­

but­with­­employed­physicians,­the­reporting­of­this­

­information­may­not­occur.

“As­we­begin­to­employ­more­and­more­physicians,­

the­percentages­are­changing­quite­a­bit.­A­lot­of­times­

quality­and­behavioral­issues­are­managed­through­the­

contract­or­employment,­so­the­hospital­just­simply­

terminates­or­dismisses­the­practitioner,­or­they­don’t­

renew­the­contract,”­Cairns­says.­“That’s­fine,­but­there­

is­probably­no­reporting­to­the­Data­Bank.”

The­downside­is­that­most­contracts­have­language­

that­allows­the­hospital­to­terminate­a­physician­for­any­

reason.­This­gives­hospitals­a­loophole­where­they­can­

terminate­or­request­that­a­physician­resign­because­

of­behavioral­or­quality­issues,­avoiding­a­peer­review­

process.

Subsequently,­the­law­change­offers­additional­

­protection­for­employed­physicians.­Cochran­believes­

the­change­will­challenge­HR­departments­to­rethink­

their­process­of­terminating­a­physician.­If­they­think­

there­is­a­concern­with­competency,­instead­of­simply­

­terminating­the­doctor­or­letting­a­doctor­resign,­they­

will­turn­the­case­over­to­the­medical­staff­process,­which­

would­allow­that­employee­to­be­evaluated­by­his­or­

her­peers­and­have­the­right­to­a­hearing­if­the­outcome­

­affected­the­employee’s­privileges.

“What­we­are­really­asking­for­is­transparency,”­

­Cochran­says.

­

Legal implications

It­may­be­too­early­to­determine­how­the­l­egislative­

change­will­affect­legal­cases­going­forward.­In­one­

sense,­there­may­be­more­information­available­from­the­

state­medical­board­if­hospitals­abide­by­the­law.

“There­is­a­risk­that­hospitals­who­avoided­reporting­to­

the­NPDB­all­along­will­also­try­to­continue­on­that­path­

even­if­there­is­a­state­law,­because­reporting­is­some-

thing­organizations­would­prefer­to­avoid,”­Cairns­says.­

“There­is­a­real­dichotomy­regarding­reporting­to­the­

Data­Bank.­Some­organizations­will­try­to­sidestep­taking­

action­and­thus­reporting,­but­interestingly­enough­those­

same­organizations­want­accurate­information­from­the­

Data­Bank­on­practitioners­at­the­time­of­appointment­

and­reappointment.­So,­the­same­issues­that­have­made­

organizations­hesitant­to­report­in­the­past­are­potentially­

the­same­issues­even­with­this­state­law.”

Cochran­notes­that­there­will­be­a­fine­from­the­state­

medical­board­for­healthcare­facilities­that­fail­to­report­

terminated­physicians.­

The­new­change­will­require­additional­advice­from­

hospital­attorneys­on­how­to­terminate­a­physician­or­

revoke­privileges,­since­it­also­mixes­employment­law­

into­potential­claims.

“To­me,­the­complexity­is­going­to­require­more­ad-

vice­from­knowledgeable­healthcare­attorneys­to­inform­

organizations­because­it’s­not­just­simple­employment­

law,­it’s­also­the­Data­Bank­regulations­as­well­as­state-

specific­requirements.­Not­all­attorneys­are­familiar­with­

medical­staff­processes,”­Cairns­says.­n

­

Editor’s note: This article originally appeared in the May

Credentialing & Peer Review Legal Insider.

June 2012 Medical Staff Briefing Page 7

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New policy lays the term ‘board eligibility’ to restABMS establishes time limits between residency and certification

Gone­are­the­days­when­physicians­could­claim­they­

were­board­eligible,­even­if­they­finished­residency­

­training­30­years­ago.­Effective­January­1,­the­ABMS­has­

put­limits­on­the­time­between­when­a­physician­finishes­

residency­training­and­when­he­or­she­passes­the­board­

certification­examination.­MSPs­are­welcoming­the­

policy­change­with­open­arms­because­it­defines­a­once­

hazy­term­that­made­the­task­of­determining­a­physi-

cian’s­eligibility­to­join­a­medical­staff­a­difficult­one.­

“We­made­the­change­because,­despite­our­efforts,­

physicians­can­claim­to­be­board­eligible­for­decades,­and­

we­think­that­link­between­residency­training­and­when­

you­get­certified­is­important.­It­shouldn’t­go­on­for­

decades­because­it­is­a­system—training­and­certification­

are­linked,”­says­Sheldon D. Horowitz, MD,­senior­

advisor­of­professional­and­scientific­affairs­at­the­ABMS.

As­a­result­of­the­policy­change,­physicians­must­

achieve­initial­board­certification­between­three­and­

­seven­years­after­completing­Accreditation­Council­for­

Graduate­Medical­Education–accredited­­residency­train-

ing.­Horowitz­notes­that­the­three-year­minimum­is­

simply­an­estimate­given­that­some­boards­require­physi-

cians­to­get­hands-on­practice­experience­before­com-

pleting­the­certification­exam,­while­other­boards­allow­

physicians­to­take­the­exam­immediately­after­complet-

ing­residency­training.­After­seven­years,­a­physician­

can­no­longer­claim­to­be­board­eligible;­to­do­so­would­

breach­medical­ethics.

Each­of­the­24­ABMS­member­boards­has­established­

a­specific­time­period­for­physicians­to­pass­their­certi-

fying­exam­depending­on­the­exam­requirements­and­

schedules.­For­example,­some­boards­require­written­and­

oral­examinations­spaced­apart,­while­others­only­re-

quire­a­written­examination.­Thus,­the­ABMS­could­not­

apply­a­single­timeline­across­all­member­boards.­

Member­boards­may­choose­to­waive­time­restrictions­

for­physicians­under­extenuating­circumstances,­such­as­

acute­illness­or­military­deployment.

Physicians­who­have­completed­residency­train-

ing­but­have­not­yet­achieved­board­certification­must­

pass­their­certifying­examinations­in­accordance­with­

the­time­limits­of­their­member­board.­Each­member­

board­will­specify­its­time­limits­going­forward­and­will­

choose­a­year­by­which­physicians­currently­in­process­

must­achieve­certification.­The­year­chosen­must­occur­

between­2015­and­2019.

Each­member­board­is­in­the­process­of­developing­a­

reentry­process­for­physicians­who­fall­outside­of­the­time­

limit.­Physicians­may­be­required­to­participate­in­addi-

tional­education,­training,­testing,­self-evaluation,­or­per-

formance­evaluation­before­becoming­eligible­to­­recertify.­

“They­can’t­just­be­board­eligible­for­seven­years,­

miss­the­end­date,­and­then­just­start­again.­There­will­

have­to­be­a­reentry­plan­if­they­want­to­get­back in,”­

says­Horowitz.

­

Policy change makes credentialing clear-cut

So­what­does­all­of­this­mean­for­the­credentialing­

process?­“It’s­good­news,”­says­Kathy Matzka, CPCS,

CPMSM,­a­medical­staff­consultant­in­Lebanon,­Ill.­“If­

everyone­has­to­be­certified­in­seven­years,­we­can­write­

that­language­into­the­bylaws.­Historically,­it­has­been­a­

moving­target­because­people­can­remain­board­eligible­

for­a­pretty­long­time,­and­some­boards­have­limits­but­

others­do­not,­so­now­we­have­a­clear­line­in­the­sand.”

For­hospitals­that­do­not­require­physicians­to­be­

board­eligible,­the­ABMS­policy­change­may­spark­a­dis-

cussion­as­to­whether­it’s­time­to­add­that­requirement­

to­the­bylaws­now­that­it­is­a­more­meaningful­achieve-

ment.­For­hospitals­that­already­require­physicians­to­be­

board­certified­or­board­eligible,­the­ABMS­policy­change­

helps­define­the­term­“board­eligible”­and­makes­the­task­

of­determining­a­physician’s­eligibility­to­join­the­medical­

staff­simpler.­

“It­will­help­simplify­the­credentialing­process­because­

it­helps­define­the­parameters­of­what­board­­eligibility­

Page 8 Medical Staff Briefing June 2012

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means,”­says­Michael Coyne,­director­of­business­

development­at­ABMS.­“The­limits­give­medical­staff­

professionals­the­ability­to­find­out­if­board­eligibility­

is­being­reported­inappropriately.­If­there­are­limits,­it­

will­be­obvious­when­there­has­been­a­breach­of­ethical­

­standards­with­physicians­reporting­board­eligibility.”

Medical­staffs­should­look­through­their­rosters­of­

medical­staff­members­to­see­who­is­board­eligible­under­

the­policy.­Matzka­says­that­most­medical­staffs­will­elect­

to­grandfather­in­physicians­who­joined­the­staff­before­

the­policy­change­took­effect.

“I­think­if­a­physician­has­been­working­all­this­time­

without­being­board­certified,­I­doubt­the­hospital­is­

going­to­require­them­to­be­board­certified.­Usually,­if­

they­have­the­requirement­in­the­bylaws,­it­is­for­when­

someone­new­comes­on­staff,”­Matzka­says.

Medical­staffs­that­require­physicians­to­be­board­

­certified­or­eligible­must­also­review­their­bylaws­

­language­to­ensure­that­it­complies­with­the­policy­

change.­According­to­Matzka,­because­each­board­has­

determined­its­own­time­frame,­it’s­not­wise­to­include­

a­blanket­seven-year­provision­for­all­physicians­on­staff­

because­each­board­has­its­own­time­limit,­which­falls­

anywhere­between­three­and­seven­years.­

“I­would­make­sure­the­language­is­generic­enough­

to­accommodate­each­board’s­requirements.­It­may­

say,­‘Each­physician­must­be­board­eligible­or­qualified­

within­the­appropriate­number­of­years­according­to­the­

specific­board.’­If­you­leave­it­open,­you­can­simply­refer­

back­to­that­board­for­the­time­frame,”­says­Matzka.

At­Baystate­Health­in­Springfield,­Mass.,­the­ABMS­pol-

icy­change­will­not­likely­change­the­medical­staff­bylaws,­

says Roxanne Chamberlain, MBA, CPMSM, CPCS,

director­of­medical­staff­services­and­provider­enrollment.­

The­medical­staff­bylaws­already­require­physicians­to­be-

come­board­certified­within­five­years­of­joining­the­staff,­

which­falls­nicely­in­the­middle­of­the­three-­to­seven-year­

period­ABMS­requires.

Matzka­also­notes­that­the­ABMS­policy­change­will­

be­helpful­when­it­comes­to­recruiting­and­contracting­

with­physicians.­“If­the­hospital­requires­board­certifi-

cation,­they­can­put­a­finite­number­of­years­on­each­

physician­contract,”­she­says.­“People­who­are­recruiting­

need­to­look­at­the­contractual­language.”

­

The bigger picture

Horowitz­explains­that­the­policy­change­is­part­of­

a­bigger­initiative­to­make­board­certification­a­more­

meaningful­endeavor­for­physicians­that­will­­ultimately­

result­in­better­patient­care­and­outcomes.­The­mainte-

nance­of­certification­(MOC)­initiative­that­the­ABMS­

rolled­out­in­2006­is­part­of­the­same­initiative.­

There­has­been­much­debate­in­recent­years­as­

to­the­value­of­board­certification.­Until­recently,­

becoming­certified­usually­required­a­physician­to­

take­an­exam­every­10­years,­which­did­not­speak­to­

his­or­her­current­competence.­Many­medical­staffs­

stopped­requiring­physicians­to­be­board­certified­

because­they­found­that­a­larger­percentage­enjoyed­

­successful­­practices­without­ever­having­taken­a­board­

­certification­exam.­

Thanks­to­MOC,­instead­of­merely­taking­a­periodic­

­examination,­physicians­are­required­to­participate­in­

ongoing­education­and­assessment,­which­may­include­

self-assessments,­participation­in­practice­performance­

evaluation,­reading­assignments,­and­other­activities.­

The­recent­policy­change­putting­time­limits­on­board­

eligibility­help­assure­medical­staffs­that­when­a­physi-

cian­claims­to­be­board­eligible,­he­or­she­will­be­taking­

the­examination­within­a­specified­time­frame,­and­after­

certification­will­be­demonstrating­current­competence­

during­the­MOC­process.­For­medical­staffs­tasked­with­

verifying­applicants’­qualifications,­the­ABMS­policy­

change­is­a­gift.­n

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by William K. Cors, MD, MMM, FACPE, chief medical

quality officer, Pocono Health System, East Stroudsburg, Pa.

At­Better­Times­Hospital’s­­medical­staff­redesign­

retreat,­the­guiding­coalition­emerged­with­a­model­

called­“3-6-9.”­The­model­calls­for­three­key­medical­staff­

committees:­the­medical­executive­committee­(MEC),­

credentials­committee,­and­a­single­multispecialty­peer­

review­committee.­It­allows­up­to­six­clinical­service­lines­

and­nine­members­on­the­MEC.­

Carl,­the­chair­of­the­department­of­medicine,­explod-

ed­in­a­tirade­about­the­new­plan­on­Monday­morning.­

At­Better­Times­Hospital,­under­the­existing­medical­staff­

model,­Carl’s­­department­had­more­than­200­members­

and­thus­was­ensured­four­seats­on­the­MEC.­He­did­not­

want­to­give­that­up.­

Joe,­the­medical­staff­president,­quickly­­conferred­with­

Bill,­the­senior­statesperson­serving­on­the­­guiding­coali-

tion.­They­quickly­diagnosed­their­missteps­in­communi-

cating­this­model­to­the­medical staff:

­➤ First,­clearly­someone­on­the­coalition­ran­into­Carl­

with­news­from­the­retreat.­Thus,­they­should­nev-

er­have­assumed­that­the­information­would­remain­

confidential.

­➤ Second,­and­more­importantly,­the­coalition­should­

have­developed­a­list­of­probable­naysayers­and­their­

concerns.­Before­the­retreat,­the­­coalition­should­

have­invited­these­naysayers­to­a­series­of “beer­and­

pizza”­meetings­to­hear­them­out­and to­explain­why­

the­change­process­was­needed.

Unfortunately,­Joe­and­Bill­are­in­the­awkward­

position­of­damage­control­and­trying­to­communicate­

significant­issues­to­a­less­than­receptive­audience.­They­

make­plans­to­meet­with­Carl­that­night­for­­dinner.­They­

also­develop­a­short­list­of­other­potential­“hostile”­par-

ties­and­make­similar­arrangements­for­private­conversa-

tions­as­soon­as­possible.

A medical staff leader’s guide to change managementPart 5: Communicating the change vision to a mixed crowd

Joe­has­been­referencing­John­Kotter’s­work­­Leading

Change to­frame­this­initiative.­The­book­lays­out­the­

­effective­communication­of­vision­that­the­guiding­coali-

tion­would­benefit­from:

­➤ Express­ideas­simply,­using­clear,­declarative­

­sentences.­Eliminate­all­jargon.­

­➤ Use­metaphors,­analogies,­and­examples­to­make­

concepts­clear­and­understandable.­

­➤ Use­many­different­forums­to­communicate­ideas:­

­– A­physician­portal­on­the­hospital’s­website,­

­possibly­linked­to­the­EMR

­– Text­messaging,­email,­and­social­media

­– Written­memos­in­physicians’­mailboxes

­– Explanatory­posters­in­the­medical­staff­lounge

­– In-person­meetings­

­– One-on-one­conversations­with­potential­

naysayers

­➤ Repeat­key­ideas.­Rare­is­the­person­who­­understands­

a­new­concept­the­first­time.­

­➤ Listen­first­and­then­be­listened­to.­Two-way­

­communication,­although­time-consuming,­has­no­

substitute.­

The­guiding­coalition­divides­up­the­beer­and­pizza­

meetings­with­potential­naysayers.­After­that­night’s­

dinner,­Carl­is­not­yet­convinced­but­is­­willing­to­listen­

and­participate­in­the­process.

Joe­and­Bill­further­work­with­the­­hospital’s­mar-

keting­and­public­relations­department­to­­develop­the­

message,­the­communication­plan,­and­the­methods­for­

broad­and­repeated­­dissemination­of­the­“3-6-9”­plan.­

The­work­of­the­guiding­coalition­has­just­begun,­

yet­multiple­barriers­have­already­been­identified:­The­

entrenched­medical­staff­structures­makes­it­difficult­to­

act;­several­key­physicians­still­discourage­change;­and­

the­guiding­coalition,­although­well­chosen,­still­lacks­

needed­skills,­which­impedes­action.­

Next­month­the­guiding­coalition­tackles­all­this­and­

more.­Until­then,­be­the­best­that­you­can­be.­n

Page 10 Medical Staff Briefing June 2012

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Travel­back­100­years,­and­you­will­find­William­

­Osler,­the­“father­of­modern­medicine,”­writing­about­

the­physician-patient­relationship.­The­topic­isn’t­new,­

but­it­has­come­into­the­spotlight­in­recent­years­thanks­

to­patients’­demands­for­a­more­personalized­approach­

to­medicine­and­physicians’­search­for­a­more­effective­

way­to­keep­patients­well.­

To­address­the­need­for­better­relationships­between­

patients­and­physicians,­the­University­of­Chicago­has­

created­the­Bucksbaum­Institute­for­Clinical­Excellence­

with­a­healthy­$42­million­donation­from­Matthew­and­

Carolyn­Bucksbaum.­

According­to­Matthew Sorrentino, MD, FACC,

FASH,­professor­of­medicine­at­the­University­of­

­Chicago­and­associate­director­of­the­Bucksbaum­

­Institute,­Matthew­and­Carolyn­Bucksbaum­received­

care­at­the­University­of­Chicago­Hospital­and­wondered­

why­they­couldn’t­receive­the­same­level­of­care­and­

personalized­attention­elsewhere.­

“Can­this­be­taught­to­students­better?­How­about­

physicians­early­in­their­practice—can­they­be­taught­

better­ways?­[Matthew­and­Carolyn]­thought­all­the­way­

through­the­physician’s­career.­That­sparked­the­idea­of­

studying­the­patient-physician­relationship­in­a­more­

­rigorous­way­and­coming­up­with­ways­of­disseminating­

and­teaching­best­practices,”­says­Sorrentino.

Eliminate the barriers

According­to­Sorrentino,­medical­students­have­

­always­studied­medical­ethics,­but­there­is­increasing­

focus­on­it­now­because­the­physician-patient­relation-

ship­has­been­put­in­jeopardy­thanks­to­a­barrage­of­

­technological­advances.­The­more­the­medical­commu-

nity­relies­on­technology,­the­harder­it­is­for­caregivers­to­

connect­with­patients.­

“I­think­the­impersonalization­of­medicine­and­the­

technological­advances­have­put­a­barrier­between­

the doctor­and­patients.­A­lot­of­patients­come­in­to­

the­­office,­and­the­doctor­doesn’t­look­at­the­patient;­

Institute shines spotlight on physician-patient relationshiphe­or­she­looks­at­the­computer.­There­has­been­this­

­technological­growth­that­has­taken­away­the­major­

healing­aspect­of­medicine,­which­is­the­laying­on­of­

hands,­the­empathy,”­says­Sorrentino.

Rather­than­cut­technology­out­of­their­practices,­

which­isn’t­an­option,­physicians­must­learn­how­to­

interact­with­patients­in­the­midst­of­the­­technological­

buzz.­Physicians­also­need­to­learn­how­to­manage­

their­patient­relationships­in­an­increasingly­hectic­

environment.­

“Today,­the­typical­office­visit­is­10­minutes.­When­

I­was­in­medical­school,­the­typical­office­visit­was­a­

half­hour­or­an­hour.­How­can­we­restore­the­patient-­

physician­relationship­into­the­10-minute­patient­visit?”­

Sorrentino­says.

The­patient-physician­relationship­isn’t­just­about­

making­the­process­of­receiving­care­more­pleasant­for­

the­patient,­although­that­is­a­large­piece­of­the­pie.­In­

addition­to­researching­how­to­re-personalize­medicine,­

the­Bucksbaum­Institute­also­hopes­to­find­ways­to­cut­

costs­and­improve­medical­outcomes­by­improving­the­

patient-physician­relationship.­Studies­show­that­when­

patients­have­a­strong­relationship­with­their­physicians,­

they­are­more­likely­to­have­positive­outcomes,­comply­

with­their­medical­plans,­and­experience­fewer­com-

plications­from­surgeries.­“This­is­not­‘we­want­people­

to­be­nice­to­each­other.’­This­is­improving­healthcare,”­

says­Sorrentino.

Although­the­institute­focuses­on­the­patient-­

physician­relationship,­it­recognizes­that­the­patient­

experience­extends­beyond­the­physician­and­includes­

nurses,­medical­staff­and­hospital­leadership,­and­cleri-

cal­staff.­

“We­want­to­incorporate­all­of­that­into­the­insti-

tute.­We­have­a­board­of­advisors­to­help­us­figure­out­

ways­to­go­beyond­the­physician.­The­idea­is­to­look­at­

all­aspects­of­the­patient­relationship,­what­the­barriers­

are,­and­how­we­can­improve­them.­All­of­these­things­

should­improve­patient­outcomes,”­Sorrentino­says.

June 2012 Medical Staff Briefing Page 11

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The Bucksbaum structure

The­Bucksbaum­Institute­is­still­in­its­formative­years;­

it­is­currently­hiring­faculty­and­organizing­its­structure.­

Sorrentino­expects­it­to­be­up­and­running­at­full­speed­

within­three­to­five­years.­The­institute­is­separate­from­

the­University­of­Chicago,­with­its­own­funding­and­body­

of­advisors­and­trustees.­A­physical­space­has­been­desig-

nated­and­is­currently­under­construction,­“but­we­don’t­

consider­it­a­brick-and-mortar­institute,”­says­Sorrentino.­

Three­major­groups­are­involved­with­the­institute:­

the­University­of­Chicago­Medical­School­students,­

University­of­Chicago­faculty,­and­internal­and­external­

practicing­physicians.­

Each­year,­the­institute­will­select­a­minimum­of­three­

medical­students­whose­careers­up­to­that­point­exem-

plify­the­qualities­the­institute­is­trying­to­promote.­All­

second-year­medical­students­can­apply­for­the­position.­

A­tuition­stipend­goes­along­with­the­honor.­

“We­expect­the­students­to­become­involved­with­

our­faculty­scholars­in­research­projects­and­teaching­

programs.­They­will­also­serve­as­a­liaison­to­the­entire­

student­body­to­promote­Bucksbaum­programs­and­get­

other­students­­involved­in­research­and­teaching­oppor-

tunities,”­explains­Sorrentino.

The­institute­will­also­name­two­to­four­junior­fac-

ulty­scholars­each­year.­The­junior­faculty­members­will­

receive­a­salary­stipend­to­help­support­their­research­or­

program­development.­The­junior­scholars­are­expected­

to­work­with­the­students­in­forwarding­the­student­

research­and­programs.­

Master­clinicians­will­be­expected­to­mentor­the­

junior­faculty­and­help­direct­research­endeavors­and­

program­development.­“We­expect­the­master­clini-

cians­to­be­key­speakers­and­teachers­at­all­levels­of­the­

medical­school­and­the­university.­We­feel­that­a­strong­

collaborative­­effort­will­ensure­success­of­this­program,”­

Sorrentino says.­

Any­faculty­member­who­is­interested­in­participating­

will­be­considered­an­associate­member­of­the­institute,­

and­the­institute­expects­to­announce­a­grant­program­

that­would­give­seed­money­to­individuals­who­con-

duct­research­to­promote­the­goals­of­the­institute.­“We­

hope­for­five­to­six­grants.­It­doesn’t­have­to­be­scholarly­

research;­it­might­be­an­educational­program­that­might­

help­improve­patient­care,”­says­Sorrentino.

The­institute­will­also­hold­a­symposium­annually­to­

highlight­the­research­that­the­Bucksbaum­scholars­and­

junior­faculty­have­developed.­Although­the­institute­is­

still­in­its­organizational­phase,­it­is­ambitious­and­opti-

mistic­enough­to­hold­its­first­symposium­this­year.

Medical­staff­leaders­should­keep­an­eye­on­research­

developed­by­the­Bucksbaum­Institute­and­other­orga-

nizations­that­study­medical­ethics,­as­the­findings­may­

make­all­the­difference­in­strong­patient­satisfaction­

scores,­better­outcomes,­patient­compliance,­and­lower-

cost­healthcare.­n

Page 12 Medical Staff Briefing June 2012

© 2012 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978-750-8400.

by Mary J. Hoppa, senior consultant at

The Greeley Company, a division of HCPro,

Inc., in Danvers, Mass.

Reporting­a­physician­to­the­NPDB­

is­not­to­be­taken­lightly,­and­­hospitals­

must­understand­when­it­is­appropriate­to­do­so.­In­

some­cases,­a­hospital­can­mar­a­physician’s­career­by­

reporting­him­or­her­for­a­non-reportable­event,­such­

as­failing­to­meet­the­requirements­for­­initial­privi-

leges.­Other­times,­physicians­who­should­be­­reported­

to­the­NPDB­for­quality­issues­fall­through­the­cracks­

because­hospitals­don’t­fully­understand­reporting­

guidelines.

The­NPDB­was­created­under­Title­IV­of­Public­

Law­99-660,­also­known­as­the­Health­Care­Quality­

­Improvement­Act­of­1986­(HCQIA).­This­law­man-

dates­public­reporting­of­certain­events­to­the­NPDB.­It­

also­mandates­fair­hearing­rights­for­other­events­that­

involve­the­denial­or­restriction­of­privileges­of­suf-

ficient­time­period­when­done­for­reasons­of­a­physi-

cian’s­competence­or­professional­conduct.­In­addition,­

HCQIA­provides­immunity­to­those­involved­in­the­

peer­review­process­as­noted­below.

A­professional­review­action­is­reportable­if­both­of­

the­following­occur:

­➤ A­medical­staff’s­decision­adversely­affects­a­physi-

cian’s­clinical­privileges­or­panel­membership­for­a­

period­of­more­than­30­days,­including­reduction,­

restriction,­suspension,­or­revocation­of­privileges;­

denial­of­privileges­based­on­professional­review­

(excluding­denials­based­on­failure­to­meet­specific­

criteria­or­an­initial­application­withdrawal­prior­to­

a­final­professional­review­decision);­the­decision­

not­to­renew­privileges;­and­summary­suspension­

that­­results­from­a­professional­review­action,­even­

if­the­­action­is­not­final

Under what circumstances should the medical staff report a physician to the NPDB?

­➤ The­medical­staff’s­decision­is­based­on­the­

­professional­competence­or­professional­conduct­

of­the­physician/dentist­that­adversely­affects,­or­

could­adversely­affect,­the­health­or­welfare­of­a­

patient

Another­circumstance­that­warrants­­mandatory­

­reporting­is­when­a­physician­or­dentist­­voluntarily­

surrenders­privileges,­accepts­a­restriction­on­privileges,­

or­withdraws­a­renewal­application­while­under­­

(or­to­avoid)­investigation.

Although­the­HCQIA­is­not­explicit­about­who­

should­receive­fair­hearing­rights,­it­is­explicit­about­

who­does­not­warrant­fair­hearing­rights.­Fair­hear-

ing­and­appeal­rights­are­not­mandated­when­there­

is­no­adverse­professional­review­action­taken,­or­

in­the­case­of­a­suspension­or­restriction­of­clinical­

privileges,­for­a­period­of­not­longer­than­14­days,­

during­which­an­investigation­is­being­conducted­­

to­determine­the­need­for­a­professional­review­

action.

HCQIA­also­provides­immunity­protections­to­indi-

viduals­and­bodies­involved­in­the­peer­review­process­

when­it­is­performed:

­➤ In­the­reasonable­belief­that­the­action­was­in­the­

furtherance­of­quality­healthcare­

­➤ After­a­reasonable­effort­to­obtain­the­facts­of­the­

matter

­➤ After­adequate­notice­and­hearing­procedures­are­

afforded­to­the­physician­involved­or­after­such­

other­procedures­as­are­fair­to­the­physician­under­

the­circumstances­

­➤ In­the­reasonable­belief­that­the­action­was­war-

ranted­by­the­facts­known­after­such­reasonable­

effort­to­obtain­facts­and­after­meeting­the­re-

quirement­of­the­previous­bullet­point­n