Sharing competency data

In addition to requiring competency information from practitioners, organizations should develop a policy and procedures specifying which data they will share, and how, and the healthcare entities with which the data will be shared. An important early step is to evaluate the state peer review confidentiality statutes to determine if the information to be disclosed is protected as confidential peer review. If it is, the facility should work with its legal counsel to determine under what circumstances the information may be disclosed without losing the peer review privilege. Bylaws also may need to be amended to include specific language authorizing the sharing and receipt of such information.

Facilities seeking competency data may need to amend their policies or medical staff bylaws. The following samples can be customized for most facilities, but consult with counsel first.

For obtaining information from other facilities:

Each practitioner, as a condition for obtaining and maintaining staff appointment and/or privileges at [Hospital name], must authorize the disclosure of restrictive action taken, peer review information, results of focused and ongoing professional practice evaluations, and quality assessment/performance improvement activities by the medical staffs of hospitals where the practitioner has privileges or to which the practitioner has applied or is employed.

For releasing information to other facilities:

Each practitioner, as a condition for obtaining and maintaining staff appointment and/or privileges at [hospital name], must authorize the disclosure of restrictive action taken pursuant to [Hospital name] Bylaws section _____ [refer to bylaws definition of “restrictive action,” i.e. suspension, termination, mandatory consultation, agreement by a practitioner to withdraw his/her application, etc.], peer review information, results of focused and ongoing professional practice evaluations, and results of quality assessment/performance improvement activities to the medical staffs of hospitals where the practitioner has privileges or to which the practitioner has applied or is employed.

—Kathy Matzka, CPMSM, CPCS, from the April 2015 issue of Credentialing Resource Center Journal.