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Reporting Clinical Privileges Webcast

The webcast occurred on October 29, 2019.

Q&As

  1. Professional Review Action
    The following definition of a professional review action (from the NPDB Guidebook Glossary) is important to many of these FAQs and for reporting adverse clinical privileges actions to the NPDB. (Physicians and dentists must be reported for clinical privileges actions, while entities may report other health care practitioners, such as advanced practice registered nurses and physician assistants, for clinical privileges actions.)
    A professional review action is:
    Defined in NPDB regulations as "an action or recommendation of a health care entity:
    "(1) Taken in the course of professional review activity;
    "(2) Based on the professional competence or professional conduct of an individual health care practitioner which affects or could affect adversely the health or welfare of a patient or patients; and
    "(3) Which adversely affects or may adversely affect the clinical privileges or membership in a professional society of the health care practitioner.
    "(4) This term excludes actions which are primarily based on:
    "(i) The health care practitioner's association, or lack of association, with a professional society or association;
    "(ii) The health care practitioner's fees or the health care practitioner's advertising or engaging in other competitive acts intended to solicit or retain business;
    "(iii) The health care practitioner's participation in prepaid group health plans, salaried employment, or any other manner of delivering health services whether on a fee-for-service or other basis;
    "(iv) A health care practitioner's association with, supervision of, delegation of authority to, support for, training of, or participation in a private group practice with, a member or members of a particular class of health care practitioner or professional; or
    "(v) Any other matter that does not relate to the competence or professional conduct of a health care practitioner."

  2. What if a physician wants to limit or discontinue certain privileges that has been granted in between the normal reappointment cycle. Is this reportable?
    The limitation should not be reported to the NPDB if the physician did not surrender clinical privileges while under investigation by a health care entity relating to possible professional incompetence or improper professional conduct, or in return for not conducting such an investigation. However, if an investigation was under way when the physician limited privileges, even if the physician was not aware of the investigation, the limitation should be reported, even if the physician claimed the surrender of privileges was for unrelated personal reasons. The limitation or discontinuance also would be reportable if it was done in return for not conducting an investigation.

  3. If a physician appeals a restriction of privileges once an action by a hospital's governing board has concluded, and the restriction lasts more than 30 days, is the action reportable, or does the appeal pause the process?
    An appeal of the governing board's decision does not affect the reportability of an adverse clinical privileges action that lasts more than 30 days. The action is reportable even if there is an appeal. If an appeal is successful and the original action is overturned, the action must be voided by the hospital.

  4. Would calling a physician to meet with the medical executive committee to discuss an issue be considered an investigation? For instance: there is a patient care concern, the MEC interviews the provider at its meeting, and it then discusses next steps without taking an immediate action. The next day the provider resigns. Would that meeting be considered an investigation, making the resignation reportable?
    Yes. The NPDB considers an investigation to run from the start of an inquiry until a final decision on a clinical privileges action is reached. In other words, an investigation is not limited to a health care entity's gathering of facts or limited to the manner in which the term "investigation" is defined in an organization's by-laws or policy. An investigation begins as soon as the health care entity begins an inquiry. In this case, the MEC had begun fact-finding, which is part of an investigation, when it interviewed the physician. Therefore, the resignation is reportable.

  5. A physician is being investigated for a professionalism issue and decides to relocate, so he resigns. Is this reportable?
    Yes. If a physician resigns, for any reason, while under investigation for issues related to professional competence or professional conduct, the resignation is reportable to the NPDB. The NPDB considers an investigation to run from the start of an inquiry until a final decision on a clinical privileges action is reached. In other words, an investigation is not limited to a health care entity's gathering of facts or limited to the manner in which the term "investigation" is defined in an organization's by-laws or policy. An investigation begins as soon as the health care entity begins an inquiry.

  6. If a physician has been suspended for more than 30 days for not completing medical records, is this reportable?
    It depends. A hospital must report the suspension if the suspension is a result of a professional review action and the hospital determines that the failure to complete medical records is related to the physician's professional competence or conduct and adversely affects or could adversely affect a patient's health or welfare. If the suspension of the physician's clinical privileges is the result of an automatic or administrative action, and not the result of a professional review action, the suspension should not be reported.

  7. If an organization finds that a report was missed (not reported in time), and then reports it, does the organization set itself up for possibly being fined or punished for not having reported in a timely manner?
    Organizations must submit reports to the NPDB, even if the 30-day reporting window was missed. Entities are not excused from reporting simply because they missed a reporting deadline. The NPDB encourages good faith reporting of all missing reports as soon as possible.

  8. Is a leave of absence while under investigation considered to be a resignation of privileges that is reportable?
    If a leave of absence while under investigation restricts privileges, it is reportable. NPDB regulations state that "[a]cceptance of the surrender of clinical privileges or any restriction of such privileges" is reportable. To the extent a leave of absence restricts a practitioner's ability to exercise privileges, it is considered a surrender that is reportable. If a practitioner can take a leave of absence without affecting his or her privileges, and his or her privileges remain intact during the leave of absence, the leave of absence is not reportable to the NPDB.

  9. If the clinical privileges of a physician who is employed by a hospital are not renewed by the physician during a focused evaluation of his or her practice, is this reportable?
    If the practitioner does not apply for renewal of medical staff appointment or clinical privileges while under investigation by the health care entity for possible professional incompetence or improper professional conduct, or in return for not conducting such an investigation or not taking a professional review action, the event is considered a surrender while under investigation and must be reported to the NPDB. This nonrenewal must be reported regardless of whether the practitioner was aware of the investigation at the time he or she failed to renew the staff appointment or clinical privileges. A practitioner's awareness that an investigation is being conducted is not a requirement for filing a report with the NPDB.

  10. When is proctoring considered a restriction on privileges? What determines whether proctoring is reportable?
    A restriction begins at the time a physician or dentist cannot practice the full scope of his or her privileges and is reportable to the NPDB once that restriction has been in place for more than 30 days. Proctoring may or may not be reportable depending on the type of proctoring and the length of time it is in effect. If a physician or dentist cannot perform certain procedures without proctor approval or presence, this is considered a restriction of privileges. The inability to practice the full scope of privileges without a proctor's presence or approval is a restriction. Once the physician or dentist is prohibited from performing the procedure without a proctor, his or her privileges are adversely affected. The number of cases required to be proctored at the time of imposition, or the expectation that a restriction will be concluded within 30 days, is irrelevant for reporting purposes. The reportability of the action hinges on whether the restriction, is in, fact in effect for a period longer than 30 days. Note, however, that if the proctor does not have to approve procedures in advance or be present while procedures are being performed — for example, the proctor merely reviews the physician's or dentist's performance once a procedure is completed — this is not considered a restriction of privileges. Such an arrangement would not be reportable to the NPDB, no matter how long it lasts.

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