Investigating physician behavior complaints

When a practitioner may have behaved outside of quality practice guidelines (e.g., an event that caused a negative patient outcome, a procedure that was allegedly performed incorrectly, a behavioral issue that was reported, etc.), there must be an investigation to determine whether the complaint can be substantiated. Such investigations are most often documented and submitted as incident reports.

First, the medical staff bylaws should clearly define what an investigation is, as it is directly associated with specific timelines and requirements for National Practitioner Data Bank reporting. A hospital’s legal counsel should be involved in creating the definition that resides in the bylaws to appropriately protect the organization, ensure fairness to the practitioner, and clearly determine reporting requirements.

Because the chief of staff oversees the medical staff, and department chairs are responsible for continual surveillance of the performance of all members of their department, both the chief and corresponding department chair need to be notified when an incident report is received. In hospitals without departments, this responsibility falls on the chief of staff. The medical staff bylaws should outline the first steps of an investigation. When conducting an investigation, follow the bylaws to ensure that timelines and reporting requirements are met, guarantee unbiased treatment of the practitioner, and protect the organization from any legal ramifications.

Incidents involving privileges and negative patient outcomes often require creating a subcommittee (i.e., an ad hoc committee) that includes members of the department in which the practitioner specializes. For example, if the practitioner is a surgeon, members of the surgery department (often including the department chair) are key committee members, as they have the knowledge and training to appropriately review the processes and outcome of the incident.

If the incident is behavioral and particularly egregious or if repeated episodes are documented, then the complaint rises to another level. In these instances, the bylaws dictate the path forward, and either the bylaws or a policy should require that an ad hoc committee be appointed to address these situations. One model is a medical executive subcommittee called the well-being committee.

The chief of staff, vice chief of staff, appropriate department chair, credentials committee chairperson, and CEO should be involved in the well-being committee. This committee, along with the credentials and medical executive committees, provides rehabilitation options or any other recommendations. The committee also provides support to the practitioner and follows his or her progress until the options/recommendations are met. If the practitioner chooses not to comply with those recommendations, the discussion then moves forward, according to the procedure outlined in the bylaws, to a discussion of whether the provider should continue to be granted medical staff membership and clinical privileges.