Editor's pick: Free medical staff policy: Placing the burden on the applicant

Your medical staff should have a policy that places the burden on the applicant to prove his or her clinical competence and provide all the information the medical staff leaders, credentials committee, MEC, and governing body need to make evidence-based decisions regarding membership and privileges. Below is sample policy language you can adapt to meet your facility’s needs:

Policy
Each practitioner who either applies for or maintains medical staff membership and/or privileges has the burden of providing evidence that demonstrates, in the sole discretion of the hospital, that he or she meets the hospital’s established criteria for membership and privileges. This policy applies at the time of initial appointment, reappointment, application for clinical privileges, employment, or at any time during a practitioner’s affiliation with the institution.

Procedure
To fulfill this responsibility, the practitioner has the burden of producing any information requested by the hospital or its authorized representatives that is reasonably necessary, in the sole discretion of the hospital, to evaluate whether or not the practitioner meets the criteria for medical staff membership and privileges.

If there is delay in obtaining such required information, or if the hospital requires clarification of such information, the medical staff services department will request the applicant’s assistance. Under these circumstances, the medical staff may modify its usual and customary time periods for processing the application or reapplication. The hospital has sole discretion for determining what constitutes an adequate response.

If, during the process of initial application or reapplication, the applicant fails to respond adequately within 30 days to a request for information or assistance, the hospital will deem the application or reapplication as being withdrawn voluntarily. The result of the withdrawal is automatic termination of the application or reapplication process. The hospital will not consider the termination an adverse action. Therefore, the applicant or reapplicant is not entitled to a fair hearing or appeal consistent with the medical staff’s fair hearing plan. The hospital will not report the action to any external agency.

This policy and other helpful tools and tips to help you manage low- and no-volume providers are included in Assessing the Competency of Low-Volume Providers, Second Edition, by Mark A. Smith, MD, MBA, CMSL, and Sally Pelletier, CPMSM, CPCS. Pre-order your copy today!