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Chapter 10 Medical Staff Organization and Malpractice Medical Staff Privileges

▸ MEDICAL STAFF PRIVILEGES Medical staff privileges are restricted to those professionals who fulfill the

requirements as described in an organization’s medical staff bylaws. Although

cognizant of the importance of medical staff membership, the governing body must

meet its obligation to maintain standards of good medical practice in dealing with

matters of staff appointment, credentialing, and the disciplining of physicians for

such things as disruptive behavior, incompetence, psychological problems, criminal

actions, and substance abuse.

Appointment to the medical staff and medical staff privileges should be granted

only after there has been a thorough investigation of the applicant. The delineation

of clinical privileges should be discipline-specific and based on appropriate

predetermined criteria that adhere to national standards. The appointment,

privileging, and credentialing process are discussed below.

Application The application should include information regarding the applicant’s medical school;

internship; residency program; license to practice medicine; board certification;

fellowship; medical society membership; malpractice coverage; unique skills and

talents; privileges requested and specialty; availability to provide on-call emergency

department coverage where applicable; availability to serve on medical staff and/or

organization committees; medical staff appointments and privileges at other

healthcare organizations; disciplinary actions against the applicant; unexplained

breaks in work history; voluntary and/or involuntary limitations or relinquishment of

staff privileges; and office location (geographic requirements should not be

unreasonably restrictive; if the applicant does not meet the organization’s

geographic requirements for residence and office location, provision should be

available in the bylaws for exceptions that might be necessary to attract high-quality

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consulting staff). Board certification alone is generally not acceptable criteria for

determining eligibility for medical staff appointment.

The primary function of physician board certification is to provide a platform for

physician specialists to demonstrate a mastery of the core competencies

required to provide the best possible care in a given medical specialty. The

American Board of Physician Specialties (ABPS) governs 18 specialty boards that

allow physicians to prove they possess the skill and experience necessary to

practice their chosen specialties.

Fellowship training and medical society membership are also not normally required

for medical staff appointment.

Medical Staff Bylaws The medical staff bylaws should be approved by the medical executive committee

and governing body. All applicants for medical staff privileges should be required to

sign a statement attesting to the fact that the medical staff bylaws have been read

and understood and that the physician agrees to abide by the bylaws and other

policies and procedures that may be adopted from time to time by the organization.

Physical and Mental Status An applicant’s physical and mental status should be addressed prior to the granting

of medical appointments and staff privileges. Credentialed members of the medical

staff should undergo a medical evaluation prior to reappointment to the medical

staff.

Consent for Release of Information Consent for release of information from third parties should be obtained from the

applicant.

Certificate of Insurance The applicant should provide evidence of professional liability insurance. The

insurance policy should provide minimum levels of insurance coverage, with limits

(e.g., $1 million to $3 million) determined by the organization.

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State Licensure A physician’s right to practice medicine is subject to the licensing laws contained in

the statutes of the state in which the physician resides. The right to practice

medicine is not a vested right, but is a condition of a right subordinate to the police

power of the state to protect and preserve public health. Although a state has the

power to regulate the practice of medicine for the benefit of the public health and

welfare, this power is restricted. Regulations must be reasonably related to public

health and welfare and must not amount to arbitrary or unreasonable interference

with the right to practice one’s profession. Health professions commonly requiring

licensure include chiropractors, dentists, nurses, nurse practitioners, pharmacists,

physician assistants, optometrists, osteopaths, physicians, and podiatrists. A statute

mandating that the Medical Board of California disclose to the public information

regarding its licensees (Cal. Bus. & Prof. Code, § 803.1) and the statute mandating

that the board post on the Internet information pertaining to its licensees (Section

2027) did not prohibit the board from posting on its website information regarding a

licensee’s completion of probation with a listing of the case number of the case from

which the probation arose. Grounds for the revocation of a license to practice

medicine include: a clear demonstration of the lack of good moral character,

deliberate falsification of a patient’s medical record (to protect one’s own interests at

the expense of the patient), intentional fraudulent advertising, gross incompetence,

sexual misconduct, substance abuse, performance of unnecessary medical

procedures, billing for services not performed, and disruptive behavior.

National Practitioner Data Bank Healthcare organizations must query the National Practitioner Data Bank (NPDB) for

information on applicants seeking medical staff privileges and every 2 years on the

renewal of appointments. The NPDB’s principal purpose is to facilitate a more

comprehensive review of professional credentials.

References References should be checked thoroughly. Failure to do so can lead to corporate

liability for a physician’s negligent acts. Both written and oral references should be

obtained from previous organizations with which the applicant has been affiliated.

An action was brought against the hospital in Rule v. Lutheran Hospitals & Homes Society of America for birth injuries sustained during an infant’s breech delivery.

The action was based on allegations that the hospital negligently failed to

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investigate the qualifications of the attending physician before granting him

privileges. The jury’s verdict of $650,000 was supported by evidence that the

hospital failed to check with other hospitals where the physician had practiced. The

physician’s privileges at one hospital had been limited in that breech deliveries had

to be performed under supervision.

Interview Process Prior to interviewing the applicant, the following questions should be answered:

Have all documents been received prior to the interview?

Are there any unaccounted-for breaks or gaps in education or employment?

Has any disciplinary action or misconduct investigation been initiated or are any

pending against the applicant by any licensing body?

Has the applicant’s license to practice medicine in any state ever been denied,

limited, suspended, or revoked?

Have the applicant’s medical staff privileges ever been suspended, diminished,

revoked, or refused at any healthcare organization?

Has the applicant ever withdrawn an application or resigned from any medical staff

to avoid disciplinary action prior to a decision being rendered by an organization

regarding application for membership?

Has the applicant ever been named as a defendant in a lawsuit?

Has the applicant ever been named as a defendant in a criminal proceeding?

Is the applicant available for emergency on-call coverage?

Does the applicant have back-up and cross-coverage?

Does the applicant have any special skills or talents?

Has the applicant reviewed medical staff bylaws, rules, and regulations, and, where

applicable, departmental rules and regulations?

Does the applicant agree to abide by the medical staff bylaws, rules, regulations, and

other policies and procedures set by the organization?

Is the applicant a team player? Can he or she work well with others?

Has the applicant ever been restricted from participating in any private or

government (e.g., Medicare, Medicaid) health insurance program?

Has the applicant’s malpractice insurance coverage ever been terminated by action

of an insurance carrier?

Has the applicant ever been denied malpractice insurance coverage?

Have there been any settlements and/or judgments against the applicant?

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Does the applicant have any physical or mental impairments that could affect his or

her ability to practice the privileges requested?

Delineation of Clinical Privileges The delineation of clinical privileges is the process by which the medical staff

determines precisely what procedures a physician is authorized to perform. This

decision is based on predetermined criteria as to what credentials are necessary to

competently perform the privileges requested, including education and supervised

practice to verify the skills necessary to perform the privileges being requested.

Limitations on Privileges Requested

Dr. Warnick, a pediatrician, obtained associate staff privileges at the Natchez

Community Hospital in 1997. She later applied for full privileges through the

hospital’s credentials committee. Concern was raised about her alleged difficulty

with the intubation of children. As a result, action on Warnick’s request for full

privileges was deferred. In May of 1998, the credentials committee recommended

full privileges with the exception of neonatal resuscitation. After several in-hospital

appeals, Warnick filed a lawsuit. The court determined that there was substantial

evidence to support the hospital’s suspension of Warnick’s resuscitation privileges

and her right to due process was not violated.