Fair Hearing Triggers

Dear medical staff leader:

In the early 1980's the medical community increased its efforts to limit the practice of incompetent practitioners through the implementation of professional peer review and credentialing procedures for practitioners with or trying to obtain hospital membership and privileges. However, as the decade progressed, the success of the peer review process became threatened by an increase in lawsuits filed by the disciplined physician against the individual review committee members and the hospital.

In response to this increase in litigation, the Health Care Quality Improvement Act (HCQIA) of 1986 was passed by Congress with the expectation that it would help protect hospitals and individual practitioners participating on medical peer review committees from potential liability in the form of monetary damages after the denial, revocation, or reduction of a practitioner's privileges. The Act established standards for hospital peer review committees, provided immunity for those involved in peer review, and created the National Practitioner Data Bank.

In order to obtain immunity under the HCQIA of 1986, medical staff bylaws must state an exact process that will be followed whenever an adverse recommendation with regard to clinical competence or professional conduct has been made by the MEC or the Board. The details as to the timetable, how a fair hearing should proceed, and the rights of the affected practitioner must be specifically stated.

In addition, The Joint Commission requires an appeal process to the Governing Board in place. You should have a bright line definition of what actions will trigger the fair hearing and appeal due process. Your bylaws should state clearly that hearings would be triggered only by the following actions:

• Denial of medical staff appointment or reappointment
• Revocation of medical staff appointment
• Denial or restriction of requested clinical privileges
• Involuntary reduction or revocation of clinical privileges
• Application of a mandatory concurring consultation requirement, or an increase in the stringency of a pre-existing mandatory concurring consultation requirement, when such requirement only applies to an individual medical staff member and is imposed for more than 14 days
• Suspension of staff appointment or clinical privileges, but only if the suspension is for more than 14 days and is not caused by the member's failure to complete medical records or any other reason unrelated to clinical competence or professional conduct.

Joseph Cooper, MD
The Greeley Company